Hernias pt.1

Question 1

What is word hernia derived from?

Answer 1

From the Latin word for rupture

Question 2

What is a hernia?

Answer 2

An abnormal protrusion of an organ or tissue through a defect in its surrounding walls

Question 3

Where do hernias most commonly occur?

Answer 3

Although a hernia can occur at various sites of the body, these defects most commonly involve the abdominal wall, particularly the inguinal region

Question 4

Where do abdominal wall hernias occur?

Answer 4

• Abdominal wall hernias occur only at sites at which the aponeurosis and fascia are not covered by striated muscle.
• These sites most commonly include the inguinal, femoral, and umbilical areas; linea alba; lower portion of the semilunar line; and sites of prior incisions
• These hernias occur at areas of intrinsic weakness in the layers of the abdominal wall, whereas incisional hernias are a common postoperative complication of surgery and can occur at any location in the abdominal wall

Question 5

What can hernias be divided into?

Answer 5

• Etiology: Either congenital or acquired
• Characteristic: Reducible, irreducible, incarcerated, strangulated

Question 6

What is the difference between reducible and irreducible hernias?

Answer 6

• A hernia that can disappear either spontaneously or on
  manipulation, i.e. its contents can be replaced within the surrounding musculature
• A hernia that cannot be manipulated or reduced to its original cavity.

Question 7

What is a strangulated hernia?

Answer 7

A hernia in which blood supply to its content has been compromised and its contents become ischaemic, which is a serious and potentially fatal complication

Question 8

What is an incarcerated hernia?

Answer 8

An irreducible, painful hernia that requires surgical intervention

Question 9

In which situations does a strangulated hernia occur?

Answer 9

• Strangulation occurs more often in large
  hernias that have small orifices.
• In this situation, the small neck of
  the hernia obstructs arterial blood flow, venous drainage, or both
  to the contents of the hernia sac

Question 10

In which sex are hernias more common?

Answer 10

Males

Question 11

What causes abdominal hernias?

Answer 11

All conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones:
- Chronic lung disease – coughing
- Constipation
- Urinary retention (enlarged prostate)
- Obesity
- Exercises
- Ascites

Question 12

Things to look for in a patient with hernia when asking about history

Answer 12

• Ask the patient! Self- diagnosis of a swelling is common.
• Where is the swelling?
• Is it reducible/ irreducible? Is it painful? If suspecting incarceration, ask
  about symptoms of bowel obstruction (any vomiting?).
• Is it a 1° or recurrent hernia? Any previous surgery?
• Patient risk factors? Recent heavy lifting, history of coughing or
  constipation/ difficulty in micturition?

Question 13

Physical examination of a patient with hernia

Answer 13

• Confirm swelling and characteristics (reducible/ irreducible, cough
  impulse, anatomical location).
• Examine the patient lying down and standing. Ask them to cough or
  strain (to elicit reducible hernias).
• Any skin changes or overlying cellulitis?
• Any previous surgical scars?
• General examination, including signs of bowel obstruction (distended
  abdomen).

Question 14

Investigations to perform in a patient with hernia

Answer 14

• Diagnosis is usually clinical.
• Plain X- ray is of little value in hernia diagnosis (may show signs of
  bowel obstruction in strangulated hernias).
• USS may be useful for simple hernias or ruling out other causes of
  abdominal wall swellings.
• CT is used in complex hernias to determine size and defect location
  and in the acute situation.

Question 15

What is the most common type of abdominal hernias? Percentage?

Answer 15

Inguinal hernias (account for 75% of all abdominal wall hernias)

Question 16

What can inguinal hernias be divided into? Difference between each?

Answer 16

• Classified as indirect (lateral) and direct (medial), according to its relationship to the inferior epigastric artery
• A pantaloon-type hernia occurs when there is both an indirect and a
  direct hernia component

Question 17

Importance of distinguishing between direct and indirect inguinal hernias?

Answer 17

This distinction is of little importance because the operative repair of these types of hernias is similar.

Question 18

What is the inguinal canal?

Answer 18

• An oblique passage through the lower abdominal wall
• A short passage that extends inferiorly and medially through the inferior part of the abdominal wall.

Question 19

Where does the inguinal take its course?

Answer 19

It runs from the deep to the superficial ring (i.e. from the internal to the external inguinal ring)

Question 20

What runs through the inguinal canal?

Answer 20

The inguinal canal transmits the spermatic cord (round ligament in females) and the ilioinguinal nerve

Question 21

What is the spermatic cord made of?

Answer 21

Contents of the spermatic cord are:
- Three vessels (testicular artery, cremasteric artery, artery to the vas
deferens).
- Three nerves (genital branch of genitofemoral, autonomic supply to
the testicle, ilioinguinal nerve).
- Three structures (vas deferens, pampiniform venous plexus, testicular
lymphatics).
- Three coverings (external spermatic fascia, cremasteric fascia, internal
spermatic fascia).

Question 22

What is the deep inguinal ring and where is it found?

Answer 22

Formed through the transversalis fascia (TVF) and lies 1– 2cm above the inguinal ligament, midway between the symphysis pubis and the anterior superior iliac spine

Question 23

What is the superficial inguinal ring and where is it found?

Answer 23

The superficial (external) inguinal ring is a V- shaped defect in the aponeurosis of the external oblique, above, and medial to the pubic tubercle

Question 24

Clinical features of the inguinal hernia

Answer 24

• Many have no symptoms until a lump is noticed in the groin.
• Most patients present with a bulge in the groin area, or pain in the groin
• Some will describe the pain or bulge that gets worse with physical activity or coughing, or to a specific activity (e.g. lifting).
• Symptoms may include a aching, dragging, burning or pinching sensation in the groin, especially towards the end of the day. These sensations can radiate into the scrotum or down the leg
• At times an inguinal hernia can present with severe pain or obstructive symptoms caused by incarceration or strangulation of the hernia sac contents

Question 25

At which age do inguinal hernias occur?

Answer 25

The incidence of inguinal hernias has a bimodal distribution, with peaks around age 5 and after age 70

Question 26

Which is more common. direct or indirect inguinal hernias?

Answer 26

Two-thirds of these hernias are indirect, making an indirect hernia the most common groin hernia in both males and females

Question 27

In which sex are inguinal hernias most common?

Answer 27

Males account for about 90% of all inguinal hernias and females about 10%

Question 28

How common are femoral hernias and sex distribution?

Answer 28

Femoral hernias account for only 3% of all inguinal hernias and are more commonly seen in women with females accounting for about 70% of all femoral hernias.

Question 29

How many people will experience and inguinal hernia in their lifetime?

Answer 29

An inguinal hernia will affect nearly 25% of men and less than 2% of women over their lifetime

Question 30

Which side do indirect inguinal hernias most often occur?

Answer 30

• An indirect hernia occurs more often on the right.
• This is believed to be attributed to the slower closure of a patent processus vaginalis on the right side compared to the left

Question 31

How to perform a physical examination for inguinal and femoral hernias?

Answer 31

• The exam is best performed with the patient standing.
• Visual inspection of the inguinal area is conducted first to rule out obvious bulges or asymmetry in groin or scrotum.
• Next, the examiner palpates over the groin and scrotum to detect the presence of a hernia.
• The palpation of the inguinal canal is completed last.
• The examiner palpates through the scrotum and towards the external inguinal ring.
• The patient is then instructed to cough or perform a Valsalva maneuver
• If a hernia is present, the examiner will be able to palpate a bulge that moves in and out as the patient increases intraabdominal pressure through coughing or Valsalva.
• Examination of the contralateral side is essential as this allows the clinician to compare right versus left for symmetry and/or abnormalities.
• In cases when there is high suspicion but no hernia can be detected on physical exam, a radiologic investigation may be warranted to elicit the diagnosis

Question 32

Where would a femoral hernia be felt when examining a patient?

Answer 32

A femoral hernia should be palpable below the inguinal ligament and just lateral to the pubic tubercle.

Question 33

In which patients can a femoral hernia be missed?

Answer 33

Femoral hernias can easily be missed in an obese patient.

Question 34

Diagnosis and investigations in inguinal hernias

Answer 34

• Often a clinical diagnosis.
• Physical examination is the best way to diagnose a hernia
• Thorough history is important too
• Radiological investigations may be utilised if diagnosis is uncertain, particularly if history strongly suggests hernia, but none can be elicited through physical examination or situations where body hiatus makes physical examination limited

Question 35

Imaging modalities for inguinal hernias

Answer 35

Radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI)

Question 36

Ultrasound in inguinal hernia

Answer 36

• Least invasive
• Largely dependent on skill of the examiner
• examination should be conducted with a Valsalva maneuver to increase intra-abdominal pressure
• An ultrasound can detect an inguinal hernia with a sensitivity of 86% and a specificity of 77%

Question 37

CT imaging in inguinal hernia

Answer 37

• Beneficial when the diagnosis is obscure
• can better delineate groin anatomy and help to detect other etiologies of groin mass or in cases of complicated hernias
• CT scan can detect inguinal hernias with a sensitivity of 80% and specificity of 65%

Question 38

MRI imaging in inguinal hernia

Answer 38

• MRI has a sensitivity of 95% and specificity of 96% in the detection of an inguinal hernia. However,
• MRI is costly and rarely used for diagnosis of an inguinal hernia due to its limited access.
• When indicated, MRI can be used to assist in the differentiation of sports-related injuries versus inguinal hernias

Question 39

Treatment and management of inguinal hernia

Answer 39

• Surgical repair is the definitive treatment for an inguinal hernia
• All patients with symptoms or have had episodes of irreducibility or bowel
  obstruction documented should be offered repair promptly
• In some asymptomatic or minimally bothersome hernias, watchful waiting can be an option.
• Elderly, immobile patients or those with high morbidity for operation may be safely observed if asymptomatic or mildly symptomatic (annual risk of incarceration is 2– 3 per 1000 patients per year)

Question 40

Which category are inguinal hernias included in?

Answer 40

Groin hernias

Question 41

What can groin hernias be divided into?

Answer 41

2 main categories: inguinal and femoral

Question 42

Types of surgery for inguinal hernia repair and anesthesia used

Answer 42

• Open or laparoscopic under GA or LA
• Tension- free reinforcement of the TVF layer (usually with nonabsorbable
  mesh); in open repairs, this lies in front of the TVF and in laparoscopic repairs, behind it).
• Mesh may be fixed in place by sutures (open) or ‘tacking’ devices
  (laparoscopic approach).
• Laparoscopic approach is recommended for recurrent and bilateral hernias and should be carried out by experienced surgeons in well equipped units

Question 43

Advice following inguinal hernia surgery

Answer 43

Patients should be advised to avoid heavy lifting and straining for at least 1– 2 weeks post- op.

Question 44

Lifetime recurrence of inguinal repairs

Answer 44

Recurrence with mesh repair is lower compared to recurrence with suture repair with rates of 3% to 5% and 10% to 15% respectively

Question 45

Differential diagnosis of inguinal hernia

Answer 45

The differential diagnoses for a groin bulge includes a hernia, lymphadenopathy, lymphoma, metastatic neoplasm, hydrocele, epididymitis, testicular torsion, abscess, hematoma, femoral artery aneurysm, and/or an undescended testicle

Question 46

Surgery vs non surgery for inguinal hernias

Answer 46

• It has generally been accepted that all inguinal hernias should be repaired; although, this idea has recently come into question.
• Recent articles suggest that watchful waiting is a safe and acceptable option for men in asymptomatic or minimally symptomatic cases.
• Watchful waiting is considered an acceptable treatment option as the risk of incarceration and strangulation in the studies was minimal.
• It is generally accepted that all hernia patients who are medically cleared for surgery, as well as patients with symptomatic inguinal hernia, should be offered elective surgery.

Question 47

Should femoral hernias be repaired?

Answer 47

Femoral hernias should always be repaired as they have a high risk of incarceration

Question 48

Complications of inguinal repair

Answer 48

• Reports of complications after elective inguinal hernia repair are approximately 10% overall.
• The most commonly reported complications are similar to those seen in other operations and include seroma, hematoma, urinary retention, and surgical site infection.
• Two serious complications directly related to an inguinal hernia are hernia recurrence and chronic pain (CP in 10% of cases).