Inguinal, Femoral and other Hernias Flashcards
What is a hernia?
Weak point in a cavity wall leading to abnormal protrustion of a bodys cavity, taking its linings with it.
A hernia is a protrusion of a viscus or other structure beyond the normal coverings of the cavity in which it is contained
List 4 typical features of an abdominal wall hernia
- Soft lump protruding from the abdominal wall
- May be reducible
- May protrude on coughing or standing
- Aching, pulling or dragging sensation
List 3 key complications of a hernia
- Incarceration (cant be reduced)
- Obstruction
- Strangulation
What is meant by Incarceration?
Cannot be reduced, bowel is trapped in the herniated position
Can lead to obstruction and strangulation
What is meant by Obstruction?
How would this present?
Blockage in the passage of faeces through the bowel
Presents with vomiting, generalised abdominal pain and absolute constipation
What is meant by Strangulation?
How would this present?
Hernia is non-reducible and it cuts off the blood supply causing ischaemia
Presents with significant pain and tenderness at the hernia site
Surgical emergency
What is the hernia sac?
Hernia sac has FUNDUS, BODY and NECK
List the coverings of a hernia sac
- skin
- subcutaneous fat
- aponeurosis
- muscle
- endo-cavity fascia
- endothelial lining – peritoneum in the abdomen
List the most common contents of a hernia
Small bowel and omentum is most common
List 4 main causes of hernia
Increased intra abdo pressure
Weakness/defect
Obesity
Congenital
List 4 things which cause an increase in abdominal pressure and may precipitate a hernia
Heavy lifting
Chronic cough
Straining to pass urine/faeces
Pregnancy
Why do hernias with a wider neck has lower risk of complications?
Because the size of opening means contents can easily pass out and can also be easily put back in
Lower risk of incarceration, obstruction and strangulation
What is Richters Hernia?
When the antimesenteric wall of intestine protrudes through a defect in the abdominal wall
Results in strangulation and necrosis without obstruction
How do you examine a hernia?
Examine in SUPINE & STANDING Positions
- Lying position to help to reduce the hernia
- Standing position/gravity helps hernia to reappear
- CONTROL of hernia is the ability to prevent the hernia reappearing by digital pressure at the neck
- Remember to examine the opposite side and other common sites
- Consider features of predisposing factors like COPD, Prostatism, colonic cancer
- TENDER HERNIA indicates strangulation
- Obstructed hernia- features of intestinal obstruction (details)
How does an inguinal hernia present?
Soft lump in the inguinal region (in the groin)
What are the 2 types of inguinal hernias?
Direct vs Indirect
What is a direct inguinal hernia?
Hernia due to weakness in the abdominal wall through Hesselbach’s triangle
What are the boundaries of Hesselbach’s triangle?
Medial – lateral border of the Rectus Abdominis
Lateral – Inferior epigastric vessels
Inferior – Inguinal ligament
What is a Indirect Inguinal hernia?
Where the bowel herniates through the inguinal canal which runs between the deep and superficial inguinal ring
What is the significance of the inguinal canal in males during foetal development?
Allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum
What is the significance of the inguinal canal in females during foetal development?
The round ligament, attached to the uterus, passes through the deep inguinal ring, inguinal canal and then attaches to the labia majora
What is the purpose of the processus vaginalis?
What normally happens to this structure?
The processus vaginalis (pouch of peritoneum) allows the testes to descend from the abdominal cavity, through the inguinal canal and into the scrotum
Normally after the decent, the deep inguinal ring closes and the processus vaginalis is obliterated
How may development failure lead to a an indirect hernia?
When there is failure of the inguinal ring to close and the processus vaginalis remains intact
This leaves a patent tract through which the bowel can herniate through
What specific finding on examination can help differentiate a direct vs indirect inguinal hernia?
When an indirect hernia is reduced and pressure is applied to the deep inguinal ring - It will remain reduced!
What is a femoral hernia?
Compare the location of a direct vs indirect inguinal hernia?
Indirect is lateral to inferior epigastric artery
Direct is medial to inferior epigastric artery
What is a Femoral Hernia?
Herniation of the abdominal contents through the femoral canal
Occurs below the inguinal ligament, at the top of the thigh
What are femoral hernias at a high risk of and why?
Incarceration, Obstruction and Strangulation
Because the opening between the peritoneal cavity and the femoral canal is the femoral ring which is a very narrow opening
What are the boundaries of the femoral CANAL?
(FLIP)
- Femoral vein laterally
- Lacunar ligament medially
- Inguinal ligament anteriorly
- Pectineal ligament posteriorly
What are the boundaries of the femoral TRIANGLE?
(SAIL)
- Sartorius – lateral border
- Adductor longus – medial border
- Inguinal Ligament – superior border
What are the contents of the femoral TRIANGLE?
(NAVY-C)
- Femoral Nerve
- Femoral Artery
- Femoral Vein
- Y-fronts
- Femoral Canal (containing lymphatic vessels and nodes)
What are incisional hernias?
Occur at the site of an incision from previous surgery
What is an umbilical hernia?
Occur around the umbilicus due to a defect in the muscle around the umbilicus
Common in neonates and can resolve spontaneously. Can also occur in older adults
What is a Spigelian Hernia?
Occurs between the lateral border of the rectus abdominis and the linea semilunaris (site of the spigelian fascia)
Narrow base so increased risk of incarceration, obstruction and strangulation?
What is Diastasis Recti?
Widening of the linea alba forming a larger gap between the rectus muscles, not technically a hernia
Gap becomes most prominent when the patient lies on their back and lifts their head. There is a protruding bulge along the middle of the abdomen.
This can be congenital (in newborns) or due to weakness in the connective tissue, for example following pregnancy or in obese patients.
No treatment is required in most cases, but surgical repair is possible.
How does Diastasis Recti present?
Protruding bulge along the middle of the abdomen
Gap becomes most prominent when the patient lies on their back and lifts their head
List 2 causes of Diastasis Recti
- Congenital (in newborns)
- Weakness in the CT ie. following pregnancy or in obese patients
What is an Obturator Hernia?
How may it present?
Where the abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvis
Often asymptomatic but may present with pain in the groin or medial thigh (irritation of obturator nerve)
List 2 risk factors for an obturator hernia
- Women, particularly in older age
- Multiple pregnancies
- Vaginal deliveries
What is Howship–Romberg sign?
Sign of obturator hernia
Refers to pain extending from the inner thigh to the knee when the hip is internally rotated and is due to compression of the obturator nerve
What are Hiatus Hernia?
Herniation of the stomach up through the diaphragm
What are the 4 types of hiatus hernias?
- Type 1: Sliding
- Type 2: Rolling
- Type 3: Combination of sliding and rolling
- Type 4: Large opening with additional abdominal organs entering the thorax
Compare a Sliding vs Rolling Hiatus Hernia?
Sliding: stomach slides up through the diaphragm, with the GOJ passing up into the thorax
Rolling: where a separate portion of the stomach (ie. the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus
List 3 key risk factors for a hiatal hernia
- Increasing age
- Obesity
- Pregnancy
How do Hiatus Hernias present?
Dyspeptic symptoms:
- Heartburn
- Acid reflux
- Reflux of food
- Burping
- Bloating
- Halitosis (bad breath)
List 4 investigations which may show a hiatus hernia
- Chest x-rays
- CT scans
- Endoscopy
- Barium swallow testing
- Can be intermittent, meaning they may not be seen on investigations
Treatment of a hiatus hernia?
Conservative: medical treatment of GORD
Surgical (laparoscopic fundoplication) if there is a high risk of complications or symptoms are resistant to medical treatment
What are the 3 principals of Hernia repair?
- Conservative management: good for wide neck or patients unfit for surgery
- Tension-free repair (surgery): placing mesh over defect
- Tension repair (surgery): suturing defect back together
