Hernias (femoral, inguinal, miscellaneous) Flashcards
What is a hernia?
Hernia = protrusion of part/all of a viscus through the wall of the compartment in which it is usually contained
Femoral hernia = protrusion of intra-abdominal contents through the femoral canal
Inguinal hernia = protrusion of intra-abdominal contents through the inguinal canal
What is the aetiology of hernias?
Inguinal hernias may be due to a congenital or acquired defect in the inguinal canal structure
Congenital - Processus vaginalis fails to undergo regression
Acquired defect - Degeneration and fatty changes to the wall
Connective tissue disorders predispose to hernia formation
Femoral hernias are more common in multiparous females - Elevated intra-abdominal pressure dilates the femoral vein which then stretches the femoral ring
What are the risk factors for femoral hernias?
Women
Increased intra-abdominal pressure: COPD Obesity Heavy lifting Straining – constipation, occupation Peritoneal dialysis
What are the risk factors for inguinal hernias?
Male Old age Smoking Family history Prematurity Arterial aneurysm Previous lower RHS quadrant incision Connective tissues disorder: Marfan’s syndrome, Ehlers-Danlos syndrome
Increased intra-abdominal pressure Chronic bronchitis Heavy lifting Pregnancy Chronic bowel obstruction Obesity
What is the epidemiology of hernias?
Groin hernias
Different hernia types are more common in different ages/genders
Male children - Indirect > direct > femoral
4% of male infants have an indirect
Female children - Indirect > direct > femoral (All Rare)
Male adults - Direct > indirect > femoral
Female adults - Femoral = indirect > direct (rare)
All hernias more common on right (later descent of testicle/previous appendicectomy)
Lifetime risk of inguinal herniation is 27% for men and 3% for women
92% of all inguinal hernias occur in men
What are the symptoms of hernia?
Lump in groin
Pain (on straining +/- constant)
What are the signs of misc or femoral hernias?
Miscellaneous
Pain
Visible/palpable lump
Spigelian – linea semilunaris – inferior and lateral to umbilicus
Obturator – inner thigh pain + Howship-Romberg sign = pain when internally rotate hip
Femoral hernias
Small, firm, non-reducible lump inferior and lateral to the pubic tubercle
Dull on percussion
Rare to hear bowel sounds
No cough impulse
IF strangulated - Nausea, vomiting and severe abdominal pain
What are the signs of inguinal hernias?
Direct
Reducible, soft groin lump superior and medial to the pubic tubercle
Rarely extends to scrotum
Reduced by pushing straight back
Resonant on percussion
Bowel sounds can be heard on auscultation
Cannot be controlled by pressure to the internal ring
Indirect
Reducible, soft groin lump superior and medial to the pubic tubercle
Often extends to scrotum
Reduced by pushing up and laterally
Resonant on percussion
Bowel sounds can be heard on auscultation
Can be controlled by pressure to the internal ring
IF strangulated -Nausea, vomiting and severe abdominal pain
What are the appropriate investigations for hernias?
First line - Examination/clinical diagnosis
Other investigations:
Ultrasound scan
CT
What is the management of hernias?
Non-mandatory (watch and wait) -Small, easily reducible, non-painful direct hernias
Symptomatic hernias - Elective surgery
Irreducible inguinal hernias - Prompt surgery
Femoral hernias - Urgent surgery
Painful, irreducible hernias - Emergency surgery
What are the complications of hernias?
Complications of hernias Incarceration Obstruction Strangulation (Ricters hernia = strangulation without obstruction) - Reduced blood supply leads to ischaemia Systemic sepsis Peritonitis without perforation Perforation
Complications of hernia repair Urinary retention post-op Haematoma Seroma (fluid filled tissue spaces created by surgical procedures) Infection
Scrotal complications
Division of the vas deferens
Ischaemic orchitis
Testicular atrophy
Incisional hernia
Reoccurence
Nerve injury leading to persistent pain or numbness
What is the prognosis of hernias?
With mesh-repair, the incidence of recurrent hernia is 1-2%
Potential complications (~5%) Haematoma Seroma Paresthesias in groin Numbness in groin
Chronic groin pain described in 0.5-6%
Strangulated hernias carry a 10% mortality
