Inguino Scrotal Swellings / Hernias Flashcards
Hernia definition
Protrusion of viscus from cavity from which it is enclosed through abnormal or weak opening in wall cavity
Commonest cause of small bowel intestinal obstruction in Ghana and other developing countries
Hernia
What is an external hernia
Sac protrudes through abdominal wall
What is an internal hernia
Sac does not protrude outside trunk even when well formed
Percentage of inguinal hernia in all hernia
80-92%
Percentage of femoral hernia
2-5 %
Where is femoral hernia more common
Europe / North America
What is umbilical hernia
Protrusion of viscus thorugh blended linea alba in the umbilicus
Where is umbilical hernia more common in the world
Developing countries
What is a para umbilical hernia
Protrusion above, below or by the side of umbilicus
What is an epigastric hernia
Protrusion through linea alba between xiphisternum and the umbilicus
What is an incisional hernia
Protrusion through abdominal surgical scar
What is a spigelian hernia
Protrusion in spigelian zone between the muscular fibres and aponeurosis of transversus abdominis lateral to rectus sheath
What is lumbar hernia
Protrusion through inferior or superior lumbar triangle
What is obturator hernia
Protrusion in the obturator canal
What is a sciatic hernia
Protrusion through the greater or lesser sciatic foramen
Predisposing factor of hernia
Defect or weakness of the wall of te abdominal cavity
Precipitating factor of hernia
Repeated increased intra abdominal pressure leading to protrusion of viscus
5 causes of defects or weakness of abdominal wall
Embryological or anatomical
Ageing, infection with weak scars , multiple pregnancies , obesity
Site of penetration of blood vessel weakened
Weakened muscle due to nerve damage
Straining / injury leading to muscular tear
Causes of increased intra abdominal pressure
Chronic cough
chronic urinary obstruction
chronic constipation
heavy Manual work
weightlifting
frequent pregnancies
Parts of hernia sac
Mouth
Neck
Body
Fundus
What content could you find in hernial sac
Omentum
Small intestine
Parts of colon
Appendix
Uterine Adnexa
Part of bladder
What is a reducible hernia
If content return completely into abdomen when patient lies down or pressure applied to it
Complications of hernia
Irreducibility
Strangulation
Fistula
Rupture
Main cause of hernial irreducibility
Formation of adhesion between sac and contents
Accumulation of impacted faeces in herniated colon
Percentage of inguinal hernia and femoral hernia that strangulate
5%- inguinal
30% - femoral
2 types of groin hernia
Inguinal hernia
Femoral hernia
What is the inguinal canal
Oblique passage downwards and forwards above groin
Content of inguinal canal
Testicular vessels
Spermatic cord
Ilioinguinal nerve
Genital branch of the genito-femoral nerve - male
Round ligament - female
Length of inguinal canal in adults
4cmm
Most lateral ring of inguinal canal
Internal inguinal ring
Most medial ring in inguinal canal
External inguinal ring
Shape of internal inguinal ring
U shaped
What is the internal inguinal ring made of
Evagination in transversalis fascia
Anatomical location of internal inguinal ring
1.25cm above mid inguinal point
Perpendicular to mid inguinal point
1.25 cm above midpoint to inguinal ligament
Medial to inguinal ligament t
Length of opening of internal inguinal ring
12-20mm high
6-10 mm wide
Boundaries of internal inguinal ring
Superior - lower arching fibers of internal oblique
Inferior / medial - inferior epigastric vessels
Type of inguinal hernia going though internal inguinal ring
Indirect inguinal hernia
Percentage of recurrence in indirect inguinal hernia repair
60-75%
Location of external inguinal ring
Above and lateral to pubic tubercle
Opening in external oblique aponeurosis
Shape of external inguinal ring
Triangular
Apex upwards and laterally
Base above pubic tubercle
Size of external inguinal ring
2.5x1.25 cm
Boundaries of inguinal canal
Anterior - external oblique aponeurosis
Laterally - muscular fibers of internal oblique
Posterior - transversalis fascia
Name of triangle close to external inguinal ring
Hesselbach’s triangle
Boundaries of hesselbach’s triangle
Lateral - inferior epigastric arteru
Medial - lateral border of rectum sheath
Inferior - inguinal ligament
Posterior. - transversalis fascia
Type of inguinal hernia going though hesselbach triangle
Direct inguinal hernia
Boundaries of femoral triangle
Superior - inguinal ligament
Medial - adductor longus
Lateral - sartorius
Lateral floor - iliopsoas
Medial floor - pectineus
Anterior - skin , superficial fascia , deep fascia lata
Content of femoral triangle
Femoral canal
femoral vein
femoral artery
femoral nerve
lymph nodes
Length of the femoral canal
1.25-3cm
Which testes descend later than the other , right or left
Right
Percentage of incense with incomplete descent of testes
4%
Processes vaginalis becomes which structure in the scrotum soon after birth
Tunica vaginalis
Consequences of failure of obliteration of the processus vaginalis
Indirect inguinal hernia
Encysted hydrocele of the cord
infantile hydrocele -noncommunicating
congenital hydrocele communicating
Percentage of male with inguinal hernia
16%
Percentage of male and female with inguinal hernia
95% of hernia in males
40-50% of hernia in females
Percentage of indirect hernia between 20 to 49 years old
60%
 Direct inguinal hernia is twice as common on the right or the left side
On the right side
Percentage of indirect inguinal hernia that are bilateral
10 %
 True or false , direct inguinal hernia are as common on the right as on the left in both sexes
True
Main cause of indirect hernia
Congenital - due to patient processus vaginalis
Main cause of direct inguinal hernia
Ageing or trauma or congenital deficiencies lead to weakening of transversalis fascia
Is there often strangulation of direct inguinal hernia
No -> large neck
Main symptoms of inguinal hernia
Swelling in the groin
pain in the groin
Signs of inguinal hernia
Swelling in the groin
Swelling in the groin when coughing
Direct or indirect coughing test
Direction of hernia
Complete ( enters scrotum or labium majus ), incomplete
How do you differentiate a direct from an indirect inguinal hernia in examination
Reduce swelling
Place finger over site of internal inguinal ring
Ask patient to cough -> if appears then most likely direct inguinal hernia
Oblique direction of hernia -> indirect
Directly forwards into canal. -> direct
Type of inguinal hernial who can be complete
Indirect
Differential diagnosis of inguinal hernia in male
Femoral hernia
vagina hydrocele
encysted hydrocele of the cord
malgaigne’s bulges
ectopic or undescended testes
cyst of the epididymis
inguinal lymphadenopathy
Saphena varix
sebaceous cysts
lipoma
Differential diagnosis of inguinal hernia in the female
Femoral hernia
cyst of the Canal of Nuck
lipoma
Treatment of inguinal hernia
Surgery
Read about inguinal hernia repair
Sex more at risk of femoral hernia
Female
Women at risk of femoral hernia
Multifarious
Elderly
Causes of femoral hernia
Stretching , weakness and breach of transversalis fascia near femoral ring due to increased intra abdominal pressure
Shape of course of femoral hernia from its descent from abdominal cavity
J shaped
Main symptoms of femoral hernia
Swelling in the groin
Discomfort or pain in the groin
Signs of femoral hernia
Swelling below inguinal ligament t
Visible and palpable cough impulse
No lump disappearances possible when lying down
Reducible or irreducible
Differential diagnosis of femoral hernia
Inguinal hernia
saphena varix
psoas abscess
lipoma
enlarged inguinal lymph nodes
femoral aneurysm
sebaceous cyst
Treatment of femoral hernia
Surgery
Types of umbilical hernia
Congenital (exomphalos) - defect through umbilicus with jelly like substance
Infantile - through blended aponeurosis of linea alba in umbilicus
Para umbilical - above or by the side of umbilicus
Types of exomphalos
Major - sac diameter > 5cm
Minor - sac diameter < 5 cm
What is gastroschisis
Full thickness tear of anterior abdominal wall on the right of the umbilicus
Second most common hernia type in Ghana for female
Para umbilical hernia
