Hernias (GI) Flashcards
Define hernia.
Part of an organ is displaced and protrudes through the wall of the cavity containing it
What are some different types of hernia? (8)
- inguinal - superomedial to pubic tubercle
- femoral - inferolateral to pubic tubercle
- umbilical - umbilicus (symmetrical)
- paraumbilical - asymmetrical, above/below umbilicus
- epigastric - midline between umbilicus and xiphisternum
- incisional
- obturator - passes through obturator foramen
- Richter - only the antimesenteric border of the bowel herniates through the fascial defect –> strangulation without obstruction
Define an epigastric hernia.
Midline, through linea alba, between umbilicus and xiphisternum
Define umbilical hernia.
Midline, through anterior abdominal fascia, usually bowel/fat
Define inguinal hernia.
Abdominal or pelvic contents protrude through inguinal canal - most common hernia (75%)
Who are inguinal hernias more common in?
M>F due to larger and more prominent inguinal canal
What are the two types of inguinal hernias?
Direct and indirect
What is a direct inguinal hernia?
Protrusion DIRECTLY through posterior wall of inguinal canal and MEDIAL to inferior epigastric vessels
How are direct inguinal hernias developed?
Acquired - occur over time due to weakness and straining in abdominal muscles
(Increased abdominal Pa –> degeneration and weakening of transversalis fascia)
Who does direct inguinal hernias occur in?
Older men, rare in children
What is an indirect inguinal hernia?
Protrusion into inguinal canal through deep inguinal ring LATERAL to inferior epigastric vessels
INDIRECTLY protrudes inguinal canal (does not protrude directly through wall)
How are indirect inguinal hernias acquired?
Congenital - defect in abdominal wall typically present since birth
Who does indirect inguinal hernias occur in?
May occur in infants
How do direct and indirect inguinal hernias differ on palpation?
When reduced and pressure is applied to deep inguinal ring (occluding it), indirect hernia will remain reduced but direct hernia reappears
What are some risk factors for inguinal hernias? (10)
- male
- older age (direct hernia)
- Fx
- prematurity (indirect)
- AAA
- Marfan syndrome
- Ehlers-Danlos syndrome
- defective transversalis fascia (direct)
- lathyrism - neurotoxic disease by ingestion of certain legumes
- increased intra-abdominal Pa - chronic bronchitis/emphysema, pregnancy, ascites, obesity, BPH, urethral stricture, constipation
What are femoral hernias?
- contents pass through femoral canal (inferolateral to pubic tubercle)
- most common in women
- only 5% of hernias
Define incisional hernia.
Contents herniate through scar from previous surgery
Define incarcerated hernias.
Hernias that cannot be reduced and no systemic features (complicated hernia)
Define strangulated hernias.
Blood supply cut off to hernia leading to ischaemia - more common with femoral hernias
How may patients with a strangulated hernia present? (5)
- tender, distended abdomen with guarding
- absent bowel sounds
- systemic features
- bowel obstruction e.g. distension, N&V
- bowel ischaemia e.g. bloody stools
What is the difference between an uncomplicated vs complicated hernia?
- uncomplicated - reducible (can push it back in)
- complicated - irreducible, incarcerated (cannot push it back in)
- reduced blood and lymphatic flow –> oedema –> strangulation (cut off blood supply) –> ischaemia and necrosis
- untreated –> perforation –> localised peritonitis –> generalised peritonitis
What is the most common hernia type in men vs women?
- men - inguinal hernia
- women - femoral hernia
What are the clinical features of inguinal hernias? (5)
- lump in groin (belly button, tummy = other type)
- groin discomfort/pain - dull, heaviness, dragging
- pain improves when hernia does not bulge
- bowel obstruction - N&V, constipation, acute abdomen
- reducible / irreducible
What are the clinical features of a femoral hernia? (2)
- typically non-reducible
- cough impulse more likely to be absent than inguinal, but can still be +ve
What might you find on examination of hernias? (4)
- visible or palpable mass - soft and pliable, may enlarge with standing/Valsalva manoeuvre (forced expiration through closed airway)
- incarcerated: painful, tender and erythematous
- strangulated: systemic Sx (pyrexia, tachycardia)
- reducible?
- press down on deep inguinal ring with 2 fingers to occlude + ask patient to cough/stand
- if hernia reappears –> direct
- if hernia does not reappear –> indirect
How are hernias usually diagnosed?
Clinical diagnosis via observation and palpation
What scans may be useful to diagnose a hernia? (3)
- ultrasound of groin when diagnostic uncertainty
- CT useful in very obese patients; do if complicated (irreducible), obstructed or strangulated
- MRI of groin
What do we look for in bloods when suspecting a strangulated hernia? (2)
Leukocytosis + raised lactate
What special tests can we do to investigate a hernia?
Valsalva manoeuvre (forced expiration through a closed airway) + cough impulse
What are some differential diagnoses for hernias? (7)
- undescended testis
- lymphadenopathy
- femoral aneurysm
- psoas abscess
- hydrocoele
- spermatocele
- lipoma of spermatic cord
What is the main method of hernia management?
Surgical mesh repair (even in medically fit patients if asymptomatic):
- herniotomy: use mesh patches to repair the defect/wall through which herniation occurred
- herniorrhaphy: stitch the healthy ends of tissue/muscle together using a mesh
How do we manage a small, asymptomatic inguinal hernia?
Watchful waiting
How do we manage a large/symptomatic uncomplicated inguinal hernia?
- unilateral inguinal hernia - open-mesh approach
- bilateral/recurrent inguinal hernia - laparoscopic mesh repair
How do we manage incarcerated/strangulated inguinal hernias?
- surgical repair + supportive + consider prophylactic Abx
- not strangulated: laparoscopic
- strangulated: open (as bowel may necrose)
- mesh repair if bowel viable, non-mesh repair if gangrenous bowel
When can inguinal hernias be left?
If patient not fit for surgery - can use Truss support belt
What type of hernia definitely needs repair?
Femoral hernia due to risk of strangulation
How do we manage umbilical hernias?
- small asymptomatic - observation until 4/5y, spontaneous reduction in 80%
- incarcerated - surgical repair following attempted reduction
- large symptomatic OR small asymptomatic but no spontaneous reduction - surgical repair due to risk of incarceration
How do we manage obstructed/strangulated hernias?
Emergency laparotomy
What are some post-operative complications of hernias? (6)
- urinary retention
- wound seroma (fluid collection)
- inguinal wound haematoma
- wound infection
- bowel obstruction
- vas deferens division or vascular injury (fertility issues)
What are some complications of hernias? (4)
- incarceration
- strangulation (Maydl’s hernia - strangulated W-shaped loop of small bowel)
- bowel obstruction
- perforation –> peritonitis
Describe the prognosis of hernias.
Excellent after surgical repair
