Herniation Flashcards
Herniation definition
Any structure passing through another but ending up in the wrong place
Two factors required for development of a hernia
Structural weakness, increased pressure
Normal anatomical weakness for hernias to develop
Diaphragm - diaphragmatic hernia
Umbilicus - umbilical hernia
Inguinal canal - inguinal hernia
Femoral canal - femoral hernia
Abnormal anatomical weakness for hernias to develop
Congenital diaphragmatic hernia, surgical scars - incising hernia
Causes of increased pressure that can lead to hernia
Chronic cough, pregnancy, strenuous activity, straining bowel movements or urination
Where is the linea alba?
Xiphoid process to pubic symphysis
Where does the umbilicus lie in relation to the linea alba?
Partway along it
Where is the inguinal region?
Around the area of the hip crease
What is the linea semilunaris
Semilunar line separating the anterior abdominal wall from the lateral abdominal wall. It is the line lateral to where your abs would be
What does the inguinal ligament mark?
An anterior boundary between the abdomen and thigh
Where does the inguinal ligament run?
Anterior superior iliac spine inferomedially to the pubic tubercle
Where is the sublingual space? What does it do?
Below the inguinal ligament and allows communication from the abdominal structures with the thigh
Where is the inguinal canal? What does it do?
Just above the inguinal ligament and allows communication from the abdominal structures with the perineum
What is the inguinal canal?
Oblique passage between the abdomen and perineum
Which direction does the inguinal canal run?
Inferomedially
Where is the entrance to the inguinal canal?
Deep inguinal ring in contact with abdominal structures
Where is the exit from the inguinal canal?
Superficial inguinal ring in contact with body wall structures or perineum
Contents of the inguinal canal
Spermatic cord or round ligament of the uterus, blood and lymphatic vessels, ilioinguinal nerve
Where do testes develop?
Posterior abdominal wall
When do the testes descend?
7th week
Gubernaculum
Fibrous cord which during development shortens and contracts
What does the gubernaculum attach?
Inferior pole of the testes to the skin of the body wall
What does the gubernaculum become in adults?
Spermatic cord in males and round ligament of uterus in females
What is the vaginal process?
Area of peritoneum that gets deeper at about the 12th week
Tunica vaginalis
Pocket of peritoneal fluid created by two layers of the vaginal process
What happens when the two borders of the vaginal process do not form?
It can create a pathway for herniation to occur
What makes up the boundaries of the inguinal canal of the:
- Anterior wall
- Posterior wall
- Roof
- Floor
Anterior - external oblique aponeurosis, internal oblique muscle (laterally)
Posterior - transversus fascia (laterally), conjoint tendon (medially)
Roof - transversalis fascia (laterally), arches of internal oblique and transversus abdominus aponeurosis, external oblique aponeurosis
Floor - gutter of infolded inguinal ligament
Hesselbach’s triangle (inguinal triangle)
Inferior epigastric artery, inguinal ligament, lateral border of rectus abdominus
Site of direct inguinal herniation
Hesselbach’s triangle
Direct inguinal hernia:
- Path taken
Directly through the abdominal wall structures to gain access to inguinal canal, medial through the inferior epigastric artery, through Hesselbach’s triangle to superficial ring parallel to the spermatic cord
Indirect inguinal hernia:
- Path taken
Uses inguinal canal and deep inguinal ring. Uses a pathway already created by the body to get access to the inguinal canal. Passes lateral to inferior epigastric artery, through the superficial ring and within the spermatic cord or layers of abdominal wall
Where is the sub-inguinal space?
Posterior and inferior to the inguinal ligament
What does the sub-inguinal space contain?
Hip flexors, femoral artery and vein, lymphatics, nerves
Where can femoral herniation arise?
Femoral canal
Classification of hernias (3)
Reducible, incarcerated or irreducible hernia, strangulated hernia
Reducible hernia
Hernia can be easily pushed back into the abdomen
Incarcerated/irreducible hernia
When a hernia cannot be manipulated back to the abdomen
Strangulated hernia
Vascular supply to the contents contained within the hernia is compromised, resulting in ischaemic and gangrenous tissue
Treatment for hernias
Conservative management or surgical management
Epigastric hernia:
- Definition
- Presentation
- Fascial defect in the linea alba between the xiphoid process and umbilicus
- Midline lump, 75% asymptomatic but can present with pain
Paraumbilical hernia:
- Aetiological factors
- Presentation
- Management
- Stretching of abdominal wall by obesity, multiple pregnancies or ascites
- Frequently asymptomatic or present with pain
- Nearly always surgical - do not resolve spontaneously and high incidence of incarceration and strangulation
3 coverings of the spermatic cord
Internal spermatic fascia, cremasteric fascia, external spermatic fascia
6 contents of the spermatic cord
Vas deferens, arteries (testicular artery, artery to Vas deferens, cremasteric artery), pampiniform plexus, lymphatics, nerves, remains of the processus vaginalis
Are direct inguinal hernias or indirect inguinal hernias more common?
Indirect
Diagnosis of inguinal hernia
Groin swelling which usually disappears lying down, usually located above and medial to the pubic tubercle, palpable cough impulse on examination, dynamic ultrasound can be helpful
Management of inguinal hernia
Non-surgical or surgical
Management of femoral hernia
Surgical
Predisposing factors to incisional hernia
Wound complications, inherited collagen abnormalities, advanced age, smoking, morbid obesity, malignancy, surgical technique
