Hernias ( femoral, inguinal, miscellaneous) Flashcards
where does the inguinal ligament run?
between the ASIS and the pubic tubercle
Describe the anatomy of the inguonal ligament and the inguinal canal?
inguinal igament runs between the ASIS and pubic tubercle
within inguinal ligament runs the inguinal canal- provides a passage way for the spermatic cord in males and round ligament in females and carries inguinal nerve in both sexes
entry point of inguinal canal is the deep inguinal ring ( lies just above midpoint of inguinal ligament and the exit point is the superifical inguinal ring ( lies just above and medial to pubic tubercle)
what is the entry and exit point of the inguinal canal?
entry= deep inguinal ring ( lies just above midpoint of inguinal ligament)
exit= superificial inguinal ring ( lies just above and medial to pubic tubercle)
what does the inguinal canal provide a passage for?
spermatic cord in males and round ligament in females
carries the ilioinguinal nerve in both sexes
what is a hernia?
protrusion of a viscus or part of a viscus through a defect of the wall of its containing cavity into an abnormal position
what are th emost common types of hernias?
inguinal
where are femoral hernia found?
infero-lateral to pubic tubercle ( and medial to femoral pulse)
where are inguinal hernias found?
superomedial to pubic tubercle?
can inguinal and femoral hernias be differentiated clinically?
NO ONLY IN SURGERY
what is the cause of inguinal and femoral hernias?
Occur due to inc intra-abdominal pressure i.e. due to chronic cough, smoking causing cough, constipation, pregnancy, weight-lifting, or weakened abdominal muscles.
what does it mean if hernias are irreducible?
they cannot be pushed back into the right place
what does incarceration of hernias mean?
contents of hernia sack are stuck inside by adhesions
what is an amyand hernia?
contains the appendix within its sac
what is a gluteal hernia?
protrudes through the greater sciatic foramen
what is a littre hernia?
contains a Meckel diverticulum
what is an obturator hernia?
protrudes through the obturator canal
what is a sciatic hernia?
protrudes through the lesser sciatic foramen
what is a spligelian hernia?
protrudes through the semilunar line
what are the 2 types of lumbar hernia and what do they pass through?
Petit herniapasses through the inferior lumbar triangle of the posterolateral wall, which is bounded by external oblique, latissimus dorsi and the iliac crest below.
Grynfeltt herniapasses through the superior lumbar triangle, a space bounded by the 12th rib above, sacrospinalis muscle medially and the internal oblique muscle laterally.
define inguinal hernia and what are the two types of inguinal hernia?
Most common type of hernia
The abnormal protrusion of a peritoneal sac through a weakness of the abdominal wall in the inguinal region – both types emerge at the superficial inguinal ring
DIRECT AND INDIRECT INGUINAL HERNIAS
what is the cause of a direct inguinal hernia and descirbe its location?
caused by weakness in posterior wall of inguinal canal
Abdominal contents ( fatty tissue, sometimes with bowel) are forced through this defect and enter inguinal canal
therefore contents emerge medial to deep inguinal ring
arises medial to inferior epigastric vessels
appears through Hesselbach’s triangle
what are the borders of hesselbach’s triangle?
- lateral border of rectus abdominis
- inferior epigastric vessels
- inguinal ligament
describe how an indirect hernia arises?
does not pierce the abdominal wall
abdominal contents pass through the deep inguinal ring-> Passing through inguinal canal and exiting via the superficial ring
what is it known as if indirect and direct hernias coexist?
pantaloon hernia
outline the aetiology of inguinal hernias?
congenital- abnormal contents enter the inguinal canal through a patent processus vaginalis
acquired- due to increased intra-abdominal pressure along with muscle and transversalis fascia weakness
what are the risk factors for inguinal hernias?
Male
Prematurity
Age
Smoking – generalised defect in connective tissue turnover in the groin
Obesity
FHx
AAA
Prev RLQ incision (e.g. for appendectomy)
Defectiver transversalis fascia
Chronic cough e.g. COPD emphysema- chronic cough increases intra-abdominal pressure
Marfan’s – CT disorder
Ehlers-Danlos syndrome – CT disorder
summarise the epidemiology of inguinal hernias?
COMMON
Peak age in adults: 55-85 yrs
9 x more common in MALES
what are the presenting symptoms of inguinal gernias?
Asymptomatic
Patient notices a ‘lump in the groin’
May cause discomfort and pain
May be irreducible
May present because it has increased in size
May present because of complications (e.g. bowel obstruction => N+V, constipation)
what are the signs of inguinal hernias on physical examination?
Look for previous scars and check both sides – more common on R side
Can’t get above lump
Groin lump that extends to the scrotum (males) or labia (women)
If lump visible, ask patient to reduce it. If he cannot, make sure it is not a scrotal lump. If no lump visible, go straight to cough impulse.
Distinguishing inguinal and femoral hernias:
- Inguinal - superior and medial to the pubic tubercle
- Femoral - inferior and lateral to the pubic tubercle
Check for cough impulse
Auscultation- there may be bowel sounds over the hernia
Hernia may be irreducible
Check for signs of complications
- Bowel obstruction and systemic upset (pyrexia, tachycardia etc.)
- Tenderness if strangulated
Repeat examinationwith patient standing
Distinguish direct and indrect hernias
- Reduce the hernia and occlude the deep internal ring with two fingers. Ask patient to cough/stand. If hernia is restrained, it is indirect. If not, it is direct
- Gold standard: surgery – direct hernias are medial to inferior epigastric vessels, indirect are latera
How are inguinal and femoral hernias distinguished?
inguinal- superior and medial to pubic tubercle
femoral- inferior and lateral to pubic tubercle
where do both direct and indirect hernias exit via?
superifical inguinal ring and emerge within the testes
hwo do you distinguish between a direct and indirect clinically
Locate the deep inguinal ring (midway between the anterior superior iliac spine and pubic tubercle).
Manually reduce the patient’s hernia by compressing it towards the deep inguinal ring starting at the inferior aspect of the hernia.
once hernia is reduced-> occlude the deep inguinal ring with 2 fingers and ask patient to cough
if hernia is restrained= INDIRECT
If hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point and is, therefore= DIRECT
How are direct and indirect hernias distinguished in surgery?
direct hernias are medial to inferior epigastric vessels, indirect are lateral
What are the appropriate investigations for inguinal hernias?
CLINICAL DIAGNOSIS
what investigations should you consider for inguinal hernias?
ABGs- may show lactic acidosis from bowel ischaemia
imaging
- USS- exclude other causes of groin lump
- Herniography ( erect Xray)- rarely performed- requires intraperitoneal injection of non-ionic contrast admin beforehand
- MRI of groin- only if unsure if there is herniation clinicallly
outline a management plan for inguinal hernias?
watchful waiting is small and symptomatic hernia
surgical- only done if symptomatic
- Elective repair is uncomplicated
- if hernial contents become strangulated or obstructed it is a surgical emergency and operation must be done within 24 hours
describe the surgical management of hernias?
open or laproscopic mesh repair
hernia is strangluated reduced and mesh is inserted to reinforce defect in the transversalis fascia
what advice should be given before a hernia operation?
diet advice if overweight
stop smoking pre-op
what is a herniotomy, herniorraphy, hernioplasty?
hermniotomy= sugical excision of hernial sac
herniorrhaphy= repair of hernia using locally available tissue
Hernoplasty= repair of hernia using synthetic material eg mesh
What are the possible complications of inguinal hernias?
inaceration
strangulation
bowel obstruction
Maydl’s hernia (image on the right - strangulated W-shaped loop of small bowel)
Richter’s hernia(strangulation of only part of the bowel circumference)
surgical complications
what are the surgical complications
Pain and numbness
Wound infection
Haematoma
Penile/scrotal oedema
Mesh infection
Urinary retention for 24hrs after
Wound seroma for a week after (don’t drain routinely as may introduce an infection)
Osteitis pubis
summarise the prognosis for patients with inguinal hernias?
Slowly enlarge if left alone
Excellent after surgical repair
describe an open inguinal hernia repair?
An open technique explores the inguinal canal, identifies the important structures within it (which need to be carefully protected), reduces the hernial contents back into the abdominal cavity and places a mesh that strengthens the posterior wall to prevent further herniation. It is a simple operation with excellent results and can be done with either general or local anaesthetic.
describe laproscopic inguinal hernia repair ? what are the advantages and for what type of hernias is it performed?
benefit of less post-operative pain and quicker recovery
preferred for bilateral hernias
basic steps of the operation involve visualising the defect from within the abdominal cavity, reducing or pulling back the contents of the hernia, and repairing the defect from within the abdomen.
describe open inguinal hernia repair?
open technique explores the inguinal canal, identifies the important structures within it (which need to be carefully protected), reduces the hernial contents back into the abdominal cavity and places a mesh that strengthens the posterior wall to prevent further herniation
simple operation with excellent results and can be done with either general or local anaesthetic.
preferred unilateral hernia
define femoral hernias?
abdominal contents pass through a naturally occuring weakness in the femoral canal- presenting as mass in upper medial thigh ( ELDERLY WOMEN)
summarise the epidemiology of femoral hernias?
Less common than inguinal but these are more likely to get incarcerated as they are situated in a tighter place.
More commen in women – especially in middle age and elderly
Account for 5% of abdominal hernias
what are the risk factors for femoral hernias?
Female
Increasing age- elderly woman
Pregnancy – higher incidence in multiparous compared to nulliparous
Increased intra-abdominal pressure e.g. heavy lifting, chronic constipation
what are the presenting symptoms of a femoral hernia?
Lump in the groin
Usually asymptomatic at presentation
Around 30% present as an emergency due to obstruction or strangulation
what are the signs of femoral hernias on physical examination
Abdominal examination
Look for lump and compare both sides
Ask patient to reduce lump, ask patient to cough
Check if below and lateral to pubic tubercle
If no lump visible, feel for a cough impulse
Likely to be irreducible and to strangulate due to rigidity of the canal’s borders
Repeat examination with patient standing
what are the appopriate investigations for femoral hernias?
ultrasound scan
describe the management of femoral hernias?
Should all be referred for as there is a risk of strangulation
Should be repaired urgently, as there is a 50% risk of strangulation within a month.
Surgical repair
- Herniotomy: ligation and excision of the sac
- Herniorrhaphy: repair of the hernial defect
what are the possible complications of a femoral hernia?
Strangulation
Risk of becoming irreducible or obstructed
Bowel resection
Wound infection
describe the anatomy of femoral canal, the femoral artery, vein and nerve and inguinal canal?
passing beneath inguinal ligament= femoral artery, femoral vein, femoral nerve ( NAVY structures lateral to medial as Y is the crease in the groin)
femoral artery and vein are enclosed in a sheath
medial to femoral vein is femoral canal
what is the function of the femoral canal and what does the femoral canal contain?
allow expansion of femoral vein in order to increase venous return
small amount of fatty tissue and a lymph node ( known as lymph node of cloquet)
Why is there a high risk of strangulation and obstruction in femoral hernias?
femoral canal space is quite tight and is brodered medially by the sharp edge of the lacunar ligament
compare the strangulation, how common and reducibl of indirect, direct hernias and femoral hernias?
Indirect hernias
- common (80%)
- can strangulate
Direct hernias
- less common (20%)
- reduce easily
- rarely strangulate
Femoral hernias
- more frequent in females
- frequently irreducible
- frequently strangulate
