Hernias are cool

Question 1

Where do femoral hernias occur? Do any other hernias occur here?

Answer 1

femoral canal- 
anteriorly- inguinal ligament
medial- lacunar ligament
lateral- femoral vein
posterior- pectineal ligament

only part of the intestinal wall folds through (imagine pinching a hose)

Richter’s hernias occur here too

Question 2

Are femoral hernias common?

Answer 2

they are the most common

more common in women

Question 3

Symptoms of a femoral hernia?

Answer 3

intestinal obstruction,
if there’s strangulation: ‘‘Strangulation and ischaemia will be associated with the four signs of inflammation (pain, redness, swelling, warmth) and tenderness’’.

Question 4

Is strangulation a common occurence in femoral hernias?

Answer 4

yes bc the femoral ring is tight

Question 5

Most common type of hernia in women?

Answer 5

inguinal (despite femoral hernias being more common than in men)

Question 6

Compare direct and indirect hernias..

Answer 6

Indirect: the viscus traverses the entire length of the canal, entering at the deep ring and leaving at the superficial ring. the deep ring is lateral to the inferior epigastric vessels

Direct: viscus breaks through weakness in the transversalis fascia, and passes through the superficial ring. Breach commonly medial to inferior epigastric vessels

Question 7

What pre-disposes you to a direct inguinal hernia??

Answer 7

weakness in the transversalis fascia: previous hernia, age), and increases in intra-adbominal pressure- chronic cough, obsesity, squats, pregnancy

Question 8

If a patient history points to an inguinal hernia, what would you expect upon physical examination?

be wary of what complications?

Answer 8

ask the patient to cough, feel it against your hand :P
‘reducing’ the hernia may allow for control at the deep inguinal ring if it’s an indirect hernia.
scrotal continuation can occur more commonly in indirect hernias

bowel obstruction
strangulation: hot, painful, swollen, red, tender.

Question 9

What does incarcerated mean in the context of hernias??

Answer 9

it receives blood supply, but its lumen is occluded, denying contents’ passage

Question 10

What are the different forms of umbilical hernia? Include their potential complications

Answer 10

Exomphalos- rare (midgut)–> fatal peritonitis

Congenital- results from failure to completely close the umbilical cicatrix –> asymptomatic, neck so wide it rarely obstructs, and it goes away by 2 years old

Acquired para-umbilical: above or below the umbilicus due to weakening –> neck less wide, risk of strangulation, perhaps some obstructive symptoms and adhesions may develop

Question 11

What pre-disposes umbilical hernias?

Answer 11

genetics: exomphalmos
prematurity and/or being male: exompalmos, congenital
black ethnicity: congenital
women, multi-parity, obesity, age: para-umbilical

Question 12

which umbilical hernias are reducible?

Answer 12

para-umbilical hernias less likely to be reducible; congenital ones are

Question 13

What are incisional hernias?

Answer 13

due to a defect in the scar from prv abdo surgery. common with midline laparotomy scars

Question 14

what pre-disposes an incisional hernia??

Answer 14

obesity, chronic cough, cachexia, protein or vit-c deficiency, infection, distension, haematoma, steroids
poor closure during the operation

Question 15

Symptoms of incisional?

Answer 15

usually asymptomatic but there might be a lump. watch for intestinal obstruction

Question 16

complications of incisional hernias?

Answer 16

wide neck, therefore strangulation is rare. but contents can accumulate (incarceration) to form an irreducible hernia that is more likely to obstruct the bowels or strangulate.
if there is a gaping wound, obv the intestine protruding isn’t pretty

Question 17

What’s a midline ventral hernia?

Answer 17

elongated gap between rectus muscles in the elderly, and wasted patients ((divarication of the recti))

Question 18

How do you estimate the size of the defect in patients with reducible hernias?

Answer 18

by reducing it, and feeling for its borders

Question 19

Epigastric hernias? What are they?

Answer 19

they are a particular variety of ventral hernia in the linea alba above the umbilicus, consisting of one or more small protrusions through which extraperitoneal fat herniates.

Question 20

Are epigastric hernias harmful?

Answer 20

No, despite being v painful. Surgery becomes an option when the pain is too much.

Question 21

how would you differentiate between epigastric hernias and diverication of the rectus abdominus??

Answer 21

epigastric: between the xiphoid process and the umbilicus
divarication: along the linea alba due to stretching and weakness, causing L/R muscles to separate.
Use Uss if necessary

Question 22

Why might asking the patient to sit up be a useful assessment? Does coughing have the same effect?

Answer 22

sitting up employs the rectus muscles exclusively- therefore a midline bulge shows a midline ventral hernia, either epigastric or due to divarication

Coughing doesn’t- because all abdominal muscles are used, not as useful as an exercise.