hernias and post-op complications Flashcards
What is an epigastric hernia?
a hernia that occurs in the upper midline through the fibres of the linea alba
typically secondary to raised chronic intrabdominal pressure such as obesity, pregnancy, ascites
what is a paraumbilical hernia?
herniation through the the linea alba around the umbilical region that occurs due to defect in the anterior abdominal wall fascia that occurs when the umbilical ring fails to close following birth
Generally contain pre-peritoneal fat but can occasionally contain bowel
they do not normally stangulate
what is an inguinal hernia ?
a protusion of abdominal or pelvic contents through a dilated internal inguinal ring or attenuated inguinal floor into the inguinal canal and out of the external inguinal ring, causing a visible or palpable mass
how are inguinal hernias classified?
Direct = bowel enters the inguinal canal “directly” through a weakness in the posterior wall of the canal, termed Hesselbach’s triangle
medial to inferior epigastric artery
Indirect = bowel enters the inguinal canal via the deep inguinal ring
lateral to inferior epigastric artery
what are the S&S of an inguinal hernia?
dull, heavy, dragging groin discomfort
visible/palpable mass in the groin that may/may not be reducible. Can enlarge on coughing
Acute abdomen in strangulation
how can you tell if an inguinal hernia is direct or indirect on examination?
Theoretically, to differentiate a direct from an indirect inguinal hernia, the examiner must reduce the hernia and then place pressure over the deep inguinal ring (located at the mid-point of the inguinal ligament), before asking the patient to cough.
If the hernia protrudes despite occlusion of the deep inguinal ring, this indicates a direct hernia, whereas if the hernia does not protrude, this indicates an indirect hernia. However, this assessment is often seen as unreliable and the only definite method to differentiate them is at the time of surgery.
how can inguinal hernias be managed?
Hernia repairs can be performed via open repair (Lichtenstein technique most commonly used) or laparoscopic repair (either total extraperitoneal (TEP) or transabdominal pre-peritoneal (TAPP)).
Open mesh repairs are preferred for those with primary inguinal hernias and are deemed the most cost-effective technique in this patient group. They can be performed under general, spinal or local anaesthesia, dependent on patient fitness and surgeon preference.
what are emergency presentations of hernia?
incarcerated - hernial contents unable to return to original cavity
obstruction - bowel lumen is obstructed, leading to the clinical features of bowel obstruction
Strangulation - compression of the hernia has lead to compromised blood supply and bowel ischaemia
what are the signs of hernial strangulation ?
pain out of proportion
symptoms of bowel obstruction
sepsis (hypotension, tachycardia)
erythematous dusky skin at hernia site
what is an incisional hernia?
An incisional hernia is the protrusion of the contents of a cavity (usually the abdomen) through a previously made incision in the compartment’s wall.
They occur (by definition) after an operation, and are an extremely common complication of abdominal surgery, with recent data reporting a prevalence after 1 year at 5.2% and 2 years of approximately 25%.
what are the clincial features of incisional hernia?
The characteristic clinical feature of an incisional hernia is a non-pulsatile, reducible, soft and non-tender swelling at or near the site of a previous surgical wound.
If the hernia is incarcerated, it can become painful, tender, and erythematous. In cases of bowel obstruction, the patient may also present with symptoms of abdominal distention, vomiting, and/or absolute constipation.
On examination, a mass is palpable at or near the site of the surgical incision, which may be reducible (depending on its severity). Assess the patient for any signs of bowel ischaemia (strangulation), such as rebound tenderness or involuntary guarding.
how can an incisional hernia be managed?
Incisional hernias can be repaired using a variety of techniques, including suture repair (for very small hernias), laparoscopic mesh repair, and open mesh repair.
The common complications of incisional hernia repair are pain (particularly after laparoscopic surgery due to the tacks used to hold the mesh in place), bowel injury and seroma formation (after open surgery; this may take several weeks or months to settle)
what is wound dehiscence?
Wound dehiscence is where a wound fails to heal, often re-opening a few days after surgery (most common in abdominal surgery).
what are the types of wound dehiscence ?
Superficial dehiscence – the skin wound alone fails, with the rectus sheath remaining intact
Often occurs secondary to local infection, poorly controlled diabetes mellitus, or poor nutritional status
Full thickness dehiscence – the rectus sheath fails to heal and bursts, with protrusion of abdominal content (often termed a “burst abdomen”)
This may occur secondarily to raised intra-abdominal pressure (e.g. patients with an ileus), poor surgical technique (e.g. poor suture technique or poor suture choice), or if the patients is critically unwell
how is wound dehiscence managed?
Superficial dehiscence usually just requires washing out the wound with saline and then simple wound care (e.g. packing the wound with absorbent ribbon gauze).
Management of Full Dehiscence
In the event of a sudden full dehiscence of a wound (or “burst abdomen”), provide suitable analgesia and start broad spectrum intravenous antibiotics as a priority.
Cover the wound in saline-soaked gauze and arrange urgent return to theatre for re-closure of the wound.
