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Year 3 > Hernias (GI) > Flashcards

Hernias (GI) Flashcards

1
Q

Define hernia.

A

Part of an organ is displaced and protrudes through the wall of the cavity containing it

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2
Q

What are some different types of hernia? (8)

A
  • 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
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3
Q

Define an epigastric hernia.

A

Midline, through linea alba, between umbilicus and xiphisternum

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4
Q

Define umbilical hernia.

A

Midline, through anterior abdominal fascia, usually bowel/fat

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5
Q

Define inguinal hernia.

A

Abdominal or pelvic contents protrude through inguinal canal - most common hernia (75%)

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6
Q

Who are inguinal hernias more common in?

A

M>F due to larger and more prominent inguinal canal

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7
Q

What are the two types of inguinal hernias?

A

Direct and indirect

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8
Q

What is a direct inguinal hernia?

A

Protrusion DIRECTLY through posterior wall of inguinal canal and MEDIAL to inferior epigastric vessels

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9
Q

How are direct inguinal hernias developed?

A

Acquired - occur over time due to weakness and straining in abdominal muscles

(Increased abdominal Pa –> degeneration and weakening of transversalis fascia)

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10
Q

Who does direct inguinal hernias occur in?

A

Older men, rare in children

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11
Q

What is an indirect inguinal hernia?

A

Protrusion into inguinal canal through deep inguinal ring LATERAL to inferior epigastric vessels

INDIRECTLY protrudes inguinal canal (does not protrude directly through wall)

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12
Q

How are indirect inguinal hernias acquired?

A

Congenital - defect in abdominal wall typically present since birth

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13
Q

Who does indirect inguinal hernias occur in?

A

May occur in infants

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14
Q

How do direct and indirect inguinal hernias differ on palpation?

A

When reduced and pressure is applied to deep inguinal ring (occluding it), indirect hernia will remain reduced but direct hernia reappears

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15
Q

What are some risk factors for inguinal hernias? (10)

A
  • 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
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16
Q

What are femoral hernias?

A
  • contents pass through femoral canal (inferolateral to pubic tubercle)
  • most common in women
  • only 5% of hernias
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17
Q

Define incisional hernia.

A

Contents herniate through scar from previous surgery

18
Q

Define incarcerated hernias.

A

Hernias that cannot be reduced and no systemic features (complicated hernia)

19
Q

Define strangulated hernias.

A

Blood supply cut off to hernia leading to ischaemia - more common with femoral hernias

20
Q

How may patients with a strangulated hernia present? (5)

A
  • tender, distended abdomen with guarding
  • absent bowel sounds
  • systemic features
  • bowel obstruction e.g. distension, N&V
  • bowel ischaemia e.g. bloody stools
21
Q

What is the difference between an uncomplicated vs complicated hernia?

A
  • 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
22
Q

What is the most common hernia type in men vs women?

A
  • men - inguinal hernia
  • women - femoral hernia
23
Q

What are the clinical features of inguinal hernias? (5)

A
  • 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
24
Q

What are the clinical features of a femoral hernia? (2)

A
  • typically non-reducible
  • cough impulse more likely to be absent than inguinal, but can still be +ve
25
Q

What might you find on examination of hernias? (4)

A
  • 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
26
Q

How are hernias usually diagnosed?

A

Clinical diagnosis via observation and palpation

27
Q

What scans may be useful to diagnose a hernia? (3)

A
  • ultrasound of groin when diagnostic uncertainty
  • CT useful in very obese patients; do if complicated (irreducible), obstructed or strangulated
  • MRI of groin
28
Q

What do we look for in bloods when suspecting a strangulated hernia? (2)

A

Leukocytosis + raised lactate

29
Q

What special tests can we do to investigate a hernia?

A

Valsalva manoeuvre (forced expiration through a closed airway) + cough impulse

30
Q

What are some differential diagnoses for hernias? (7)

A
  • undescended testis
  • lymphadenopathy
  • femoral aneurysm
  • psoas abscess
  • hydrocoele
  • spermatocele
  • lipoma of spermatic cord
31
Q

What is the main method of hernia management?

A

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
32
Q

How do we manage a small, asymptomatic inguinal hernia?

A

Watchful waiting

33
Q

How do we manage a large/symptomatic uncomplicated inguinal hernia?

A
  • unilateral inguinal hernia - open-mesh approach
  • bilateral/recurrent inguinal hernia - laparoscopic mesh repair
34
Q

How do we manage incarcerated/strangulated inguinal hernias?

A
  • 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
35
Q

When can inguinal hernias be left?

A

If patient not fit for surgery - can use Truss support belt

36
Q

What type of hernia definitely needs repair?

A

Femoral hernia due to risk of strangulation

37
Q

How do we manage umbilical hernias?

A
  • 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
38
Q

How do we manage obstructed/strangulated hernias?

A

Emergency laparotomy

39
Q

What are some post-operative complications of hernias? (6)

A
  • urinary retention
  • wound seroma (fluid collection)
  • inguinal wound haematoma
  • wound infection
  • bowel obstruction
  • vas deferens division or vascular injury (fertility issues)
40
Q

What are some complications of hernias? (4)

A
  • incarceration
  • strangulation (Maydl’s hernia - strangulated W-shaped loop of small bowel)
  • bowel obstruction
  • perforation –> peritonitis
41
Q

Describe the prognosis of hernias.

A

Excellent after surgical repair

Year 3 (175 decks)

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