Hernias -abdominal and hiatus Flashcards
RF for abdominal wall hernia
- High BMI
- Multiparous
- Poor nutritional state
- Male
- Older age
Emergency repairs and mesh choice
- Level of contamination factors into decision of which mesh will be used
Types of abdominal wall hernias
What is an epigastric hernia?
- Occurs in upper abdominal region
- Through fibres of linea alba
- Often asymptomatic but present as reducible lump
Epigastric hernia surgery
- If symptomatic - surgery
- Via open or laparoscopic
- Mesh used to repair depending on size (if more than 1cm needs mesh)
What is Divararification of the recti?
- Stretching of linea alba
- Widening gap between rectus abdominus muscles
- As there is not a defect in abdo wall - this is not a hernia
- RF inc older age and multiparity
- Just need physio, surgery is purely cosmetic if done
What is a spigelian hernia? What is it associated with?
- Rare form of abdo hernia
- Level of arcuate line at semilunaris
- Lump at lower lateral edge of rectus abdominus
- Associated with higher rates of undescended teste (cryptochidism) - failure of gubernaculum
- Open or laparoscopic repair
Obturator hernia - what is it? And who is at risk
- Hernia of pelvic floor through obturator foramen into obturator canal
- More common in women (wider pelvis) and frail older pts (lack of fat in canal)
- Lump in upper medial thigh
Sign of obturator hernia
- Positive Howship-Romberg sign
- Hip and knee pain exacerbated by thigh extension, medial rotation and abduction
- Due to compression of obturator nerve
Management obturator hernia
- Risk of strangulation high
- Repair urgently
What is a Richters hernia?
- Often surgical emergency
- Partial herniation of bowel where only the antimesenteric (part of bowel opposite side to mesentery) border becomes involved
- Only part of bowel lumen is within hernial sac
- Risk of ischaemia is high due to compormise to blood supply
What is a lumbar hernia?
- Rare posterior hernia
- Occur spontaneously or iatrogenic following surgery - often open renal surgery
- Present as posterior lump, associated with back pain
Rare abdominal wall hernias
- Littre - hernia containing meckels diverticulum
- Amyand - contains vermiform appendix
- De Garengeot - femoral hernia containing appendix
What is hiatus hernia?
- Protrusion of organ from abdominal cavity into thorax through oesophageal hiatus (where oesophagus passes through diaphragm)
- Typically stomach
- VERY COMMON - often asymptomatic
Anatomical classification of hiatus hernia
- I - sliding hernia
- II - rolling hernia
- III - mixed type
- IV - other structures
Sliding hernia
Involving:
* GOJ - gastrooesophageal junction
* Abdominal part of oesophagus
* Cardia of stomach
* These 3 move/slides upwards through diaphragm hiatus into thorax
* MOST COMMON
Rolling hernia
- Upward movement of the gastric fundus
- Lies alongslife GOJ = bubble of stomach in thorax
- True hernia with peritoneal sac
Mixed type hiatus hernia
- Gastric fundus and GOJ herniate above hiatus
- Fundus lies above GOJ
Other structures
- Structures other than stomach herniate through oesophageal hiatus
Type of hiatus hernia and associations
- Sliding –> GORD
- II-IV = paraoesophageal hernias, higher risk of gastric ischaemia/volvulus
Gastric volvulus
- Stomach twists on itself by 180 degrees
- = obstruction of gastric passage and tissue necrosis
- Needs urgent surgery
Triad for gastric volvulus
Borchardts:
* Sudden severe epigastric pain
* Retching without vomitting
* Inability to pass NG tube
Need urgent CT and emergency surgery
RF for hiatus hernia
- Age related loss of diaphragmatic tone
- Increase intra-abdo pressure - coughing lots
- Increased size of diaphragmatic hiatus
- Pregnancy, obesity and ascites –> increased pressure
- Previous oesophageal and stomach surgery
Presentation of hiatus hernia
- Majority asymptomatic
- GORD
- Epigastric pain - worse lying flat
- Less common - hiccups, palps (irritated diaphragm/pericardial sac) vomitting, dysphagia, anaemia (due to ulceration and bleeding)
Investigations for hiatus hernia
- Upper GI endoscopy - OGD
- Shows upwards displacement of GOJ
- Oesophagitis, gastritis or Barretts too
Management hiatus hernia
- Asymptomatic, incidental finding - nothing
- Conservative - PPI, weight loss, altered diet (low fat, avoid meals before bedtime, smaller portions)
- Surgical if ongoing, increased risk of complications, nutritional failure
Further investigations for surgical management for hiatus hernia
- Oesophageal manometry - pressure in oesophagus during swallowing, assess for achalasia
- Ambulatory 24hr oesophageal pH monitoring - level of reflux quantified, assess reflux episodes and symptoms relationship
- Contrast swallow/meal - rule out strictures/motility disorders and diagnose hernia
Surgery for hiatus hernia
- Cruroplasty - hernia reduced back into abdomen, hiatus resized using sutures or mesh
- Fundoplication - gastric fundus wrapped around lower oesophagus and stitched (can be full 360 wrap or partial)
Complications of hiatus hernia surgery
- Recurrence of hernia
- Abdominal bloating/increased flatulence due to inability to belch from tightness of wrap
- Dysphagia - wrap too tight or crural repair too narrow (often transient post op due to oedema)
- Fundal necrosis - blood supply via left gastric artery and short gastric vessels disrupted
