Hernias - Surgery Flashcards
What is a hernia?
Protrusion of a viscus or part of a viscus through the wall of its containing cavity into an abnormal position.
What is a reducible hernia?
Sac can return to the abdominal cavity either spontaneously or with manipulation
What is a irreducible hernia?
Sac cannot be reduced despite pressure or manipulation
Strangulated hernia?
Blood supply of contents is compromised due to pressure at the neck of the hernia
Risks ar 3% and more common in indirect hernias.
Sliding hernia?
Part of sac is formed by bowel (caecum or sigmoid) Take care when excising the sac.
What is Maydl’s hernia?
Herniating double loop of bowel. Strangulated portion may reside as a single loop inside the abdomen
What is Littre’s hernia?
Hernial sac containing strangulated Meckel’s diverticulum
What is Amyand’s hernia?
Inguinal hernia containing strangulated appendix
What is Richter’s hernia?
Only part of circumference of bowel is within the sac.
Most commonly seen with femoral hernia
Can strangulate without obstructing.
What is a pantaloon hernia?
Direct + indirect hernia
Herniotomy?
Excision of hernial sac
Heniorrhaphy?
Suture repair of hernial defect
Hernioplasty?
Mesh repair of hernial defect
What is the epidemiology of an inguinal hernia?
- 3% of adults will require hernioplasty
- 4% of male neonates have hernia (higher in prems)
- M»F (:1 (descent of testes
- Majority present in 50s
Pathology of inguinal hernia?
Commoner in R (damage to ilioinguinal N @ appendicectomy –> muscle weakness).
5% bilateral
8-15% present as emergency with strangulation/obstruction.
Aetiology of inguinal hernia?
Congenital: patent processus vaginalis. This requires immediate repair.
- Processus vaginalis should obliterate following descent of testes
- If it stays patent it may fill with
Fluid – hydrocele
- Bowel/omentum –> Indirect hernia
Acquired inguinal hernia?
Mainly things with increased the intra-abdominal pressure
- Chronic cough: COPD, asthma
- Prostatism
- Constipation
- Severe muscular effort: heavy lifting
- Previous incision/repair
- Ascites/obesity
- Appendicectomy
Classification of inguinal hernias?
Indirect or direct
What is an indirect hernia?
- 80%: commoner in young
- Congenital patent processus vaginalis
- Emerge through the deep ring
- Same 3 coverings as cord and descend into the scrotum
Can strangulate.
What is an direct hernia?
20%: common in elderly
Acquired
- Emerge through Hesselbach’s triangle (passes medial to the inferior epigastric artery). Rectus abdominis is medial. Inguinal ligament inferior. INferior epigastric vessels.
- Can acquire internal and external spermatic fascia
Rarely descend into scrotum
Rarely strangulate
What are the clinical features in children of an inguinal hernia?
- Lump in groin which may descend into scrotum
- Exacerbated by crying
- Commonly obstruct
Clinical features in adults of an inguinal hernia
- Lump in groin, exacerbated by straining/cough.
- May be clear ppting event: e.g heavy lifting
- Dragging pain radiating to groin.
May present with obstruction/strangulation.
Difference between direct and indirect inguinal hernia?
Direct
- Protrudes through Hesselbach triangle - medial to the inferior epigastric artery.
- Weakness in transversalis fascia area of the HEsselbach triangle
- Low risk of strangulation
- Seen in adults
- Much more in males.
Indirect
- Protrudes through the inguinal ring
- Passess lateral to the inferior epigastric artery
Failure of the processus vaginalis to close.
Low risk of strangulation
Internal ring test?
- Ask patient to reduce the hernia.
- Feel the abductor longus. Bony prominence and pubic tubercle.
- Internal ring surface anatomy is midway between pubicle tubercle and ASIS.
- then ask patient to stand. Then to cough. The hernia does not exit.
Mid-inguinal point
BEtween ASIS and Pubic Symphysis
Midpoint of the inguinal ligament
Pubile tubercule and ASIS
What is the inguinal canal consisting of?
- Anterior: External oblique + internal oblique for lateral 3rd
- Posterior: transversalis fascia + conjoint tendon for medial 3rd
- Floor: Inguinal ligament
- Roof: arching fibres of transversus and internal oblique.
How to examine inguinal hernia?
Expose pt from umbilicus to knees
Begin with patient standing
Inspection - Look for any masses in groin. Ask patient to cough. Comment on appearance of mass -Site, size. - Features of inflammation
- Look for any scars
Previous hernia operations.
Palpation - Check if patient in any patin - Palpate from the side of the patient - Palpate mass for cough impulse - Define anatomy: relation to pubic tubercle? Above and medial: inguinal hernia.
Does mass extend into scrotim?
- Inguinoscrotal hernia are more likely to be indirect.
Ausculate for bowel sounds
- Hernia may lack bowel sounds if it just contains fat.
Repeat inspection + palpate with patient supine.
- Does the mass disappear when lying down.
Test for direct vs indirect hernia
- Ask patient to reduce hernia
- Place 2 fingers over deep ring and ask patient to cough.
- Mid point of inguinal ligament or 1/5cm above femoral pulse.
Hernia controlled = indirect
Not controlled = direct.
Wash hand + complete exam.
Surgical management of inguinal hernias?
Non-surgical
- Rx RF: cough, constipation
- Loss weight
- Can use a truss for patients are are unfit for surgery.
Surgical management
- Tension-free mesh (Lichtenstein repair) better than suture repair.
- Open approach can be done under LA or GA.
- Lap approach allows bilateral repair and improved cosmetics.
- primary unilateral repairs should be open.
Children only require sac excision.
Patients should return to non-manual work after 2-3 weeks and following laparoscopic reapir 1-2 weeks.
Complications of inguinal hernia?
- Early Haematoma/seroma formation: 10% - Intra-abdominal injury (lap) - Infection: 1% - Urinary retention
Late
- recurrence (<2%)
- Ischaemic orchitis
- Chronic groin pain.
What is a femoral hernia?
Protrusion of viscu through the femoral canal
Epidemiology
- F>M
- Middle aged and elderly
What is the aetiology in femoral?
Acquired: increased intra-abdominal pressure
- Femoral canal larger in females due to shape of pelvis.
Clinical features of femoral hernia?
Painless groin lump
- Neck inferior and lateral to the pubic tubercle
- Cough impulse
- Often irreducible
Commonly present with obstruction or strangulation
- Tender, red, hot
- Abdo pain, distension, vomiting, constipation
Management of femoral hernia?
50% risk of strangulation within 1 month.
Urgent surgery.
Surgery
- Elective: lockwood approach = Low incision over hernia with herniotomy and herniorrhaphy (suture ing. ligt. to pectineal ligt)
- Emergency: McEvedy Approach
- High approach in inguinal region to allow inspection and resection of non-viable bowel
- Then herniotomy and herniorrhaphy.
Incisional hernia definition?
Hernias arising through a previously acquired defect
Epidemiology
- 6% of surgical incisions
Risk factors for incisional hernias?
Pre-operative
- Increased age
- Obesity or malnutrition
- Comorbidities: DM, renal failure, malignancy
- Drugs: Steroids, chemo, radio
Intraoperative
- Surgical technique/skill (major factor)
- Too small suture bites
- Inappropriate suture material
- Incision type
- Placing drains through wounds
Post-operative
- Increased IAP: chronic cough, straining, post-op ileus
- infection
- Haematoma
Management of incisional hernias?
Surgery is not appropriate for all patients
Must balance risk of operation and recurrence with risk of obstruction/strangulation and pt chice.
- Usually broad-neck.
Conservative
- manage RF e.g constipation, cough
- Weight loss
- Elasticated corset
Surgical
- Pre-op
Optimise cardiorespiratory function
- Encourage weight loss
Nylon mesh repair: open or lap.
What is an umbilical hernia?
Congenital - Manage conservatively.
3% of LBs
Defect in umbilical scar
Risk factors
- Afro-caribbean
- trisomy 21
- Congenital hypothyroidism
Management
- Usually resolves by 2-3 yrs
- Mesh repair is no closure
- Can recur in adults: pregnancy or gross ascites
What is a paraumbilical hernia?
Features
- Acquired: middle aged obese man
- Defect through linea alba just above or below umbilicus
- Small defect –> strangulation (often omentum)
Risk factors
- Chronic cough
- straining
Management
- Mayo (Double-breast linea alba with sutures) mesh repair
Epigastric hernia?
- Young M > F
- Pea-sized swelling caused by defect in linea alba above the umbilicus
- Usually contains omentum: can strangulate.
Mesh repair
Spigelian hernia?
Hernia through linea semilunaris
Hernia lies between layer of abdo wall
Palpable mass more likely to be colon ca
Obturator hernia?
Old age F>M
Sac protrudes through obturator foramen
Pain on inner aspect of thigh or knee
Frequently present obstructed/strangulated
Lumbar hernia?
- Middle aged M>F
Typically follow loin incisions
Hernia through sup/inf lumbar triangles
Sciatic hernia?
- Hernia through lesser sciatic foramen
- Usually presents with a SBO + gluteal mass
Gluteal hernia?
Hernia through greater sciatic foramen
Usually presents as SBO + gluteal mass
Saphena varix?
Varicose vein in the thigh
Renal transplant?
Patients with end stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant.
Exclusion criteria include; active malignancy, old age (due to limited organ availability). Patients are medically optimised.
The kidney once removed is usually prepared on the bench in theatre by the transplant surgeon immediately prior to implantation
Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped.
Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped.
ATN occurs immediately and resolves.
Raised amylase?
Infection Intra-abdominal pathology Drugs Renal failure Congenital hyperamlyasaemia.
Nerve lesion during surgery?
Posterior triangle lymph node biopsy and accessory nerve lesion.
Lloyd Davies stirrups nerve injury
common peroneal nerve.
Thyroidectomy nerve injury
laryngeal nerve
Anterior resection of rectum
hypogastric autonomic nerves.
Axillary node clearance
long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve.
Inguinal hernia surgery nerve injury
ilioinguinal nerve.
Varicose vein surgery nerve injury
sural and saphenous nerves.
Posterior approach to the hip nerve injury
Sciatic nerve
Carotid endarterectomy
hypoglossal nerve. Hypoglossal nerve supplies ipsilateral motor component to tongue therefore deviates to the damaged side.
Best long term option to feed patient with stroke with unsafe swallow?
PEG tube.
