Lecture 4- Abdominal hernias Flashcards
A hernia is a
protrusion of part of the abdominal contents beyond the normal confines of the abdominal walls
hernia
Consists of three components:
- Contents of the sac
- The sac itself (peritoneum)
- Coverings of the sac (layers of the abdominal wall)
Signs and symptoms
- Fullness/swelling
- Increase in size when intraabdominal sweeling increases e.g. coughing, weight lifting
- Painful/ constant ache
If a hernia gets stuck (incarcerated)
- Cannot be reduced (pushed back in)
- Painful
- May feel sick/ vomiting
- Tissue damage- ischaemia and necrosis
- Leaking bowl- sepsis
Common hernias
- Inguinal hernias
- Femoral
- Umbilical
- Incisional hernias
what is the inguinal canal
- Inguinal canal is an oblique passage in the lower part of the abdominal wall
male inguinal canal hernia
Male – abdomen –> scrotum
7x more likely in men
female inguinal canal hernia
embryology of the inguinal canal
(diagram is a sagittal view of the development of the testes)
- Descent of the testes helps us understand the development of the inguinal canal and inguinal hernias
- Processes vaginalis is the pointy part of the peritoneal cavity (antero infero)
- Tunica vaginalis is a remnant of the processes vaginalis
- Gubernaculum becomes the scrotal ligament (yellow)
embryology of the inguinal canal: problems
Problems come when the processes vaginalis does not obliterate properly
(you can have different amounts of peritoneal in the testis depending on where and if
When the processes vaginalis does not obliterate……
- The cavity can fill with fluid create a hydrocele
- Can also provide a pathway for hernias into the scrotum
MUSCLES of the anterolateral abdominal wall
external oblique
internal oblique
transverse abdominus
3D image of the inguinal canal
floor of the inguinal canal
inguinal ligament (thickened roll of the external oblique)
lacunar ligament
is a triangular extension of the inguinal ligament that goes down and inserts on the pectineal line- a ridge on the superior ramus of the pubic bone
posterior wall of the inguinal canal
transversalis fascia- where deep ring comes from
roof of the inguinal canal
muscular arches of the internal oblique and transversus abdominus
anterior wall of the inguinal canal
aponeurosis of the external oblique (superficial ring)
% of hernias that are inguinal
75%
two types of inguinal hernias
indirect- 50%
direct- 25%
% of umbilical hernia
10%
% of incisional hernia
10%
% of femoral hernia
3-5%
indirect inguinal henrias are more common in
males (x7)and mainly affect right side
Indirect inguinal hernia
‘a hernia where the herniating structure exits the containing cavity of the abdominal wall by entering the deep ring of the inguinal canal, progressing varying lengths down the canal according to where the processes vaginalis was obliterated. Lies lateral to the inferior epigastric vessels’
Part of the abdominal contents goes through the inguinal canal
- Enters via the deep ring
- Depends on where the processes vaginalis obliterated as to how far it goes down the inguinal canal e.g. if it didn’t obliterate at all it could go into the scrotum
direct inguinal hernia
‘Does not enter the inguinal canal, it bulges through the weak point in the anterior abdominal wall- Hesselbach triangle. This hernia will also potentially bulge at the location of the superficial inguinal ring ( a weakness).’
- Lies medial to the inferior epigastric vessels
*we class the hernia by the location it exits*
femoral hernias are more common in
females (due to anatomical differences in pelvic anatomy)
- Females still have more inguinal hernias than femoral
- Uncommon because the femoral ring is quite small
- More dangerous due to higher likelihood of incarceration – becomes stuck- irreducible ( blood goes (high pressure of artery) in but cant come out)
- Strangulated hernia
outline why femoral hernias are bad
- Femoral hernia can go down the femoral canal
- Can pop out the saphenous opening
- Location of femoral hernia is inferior to inguinal ligament
umbilical hernias facts
hernia through the umbilical rings
- Common condition (most resolve spontaneously
- M= f incidence
umbilical hernias risk factors
- prematuee
- african descent
- low birth rate
physiology of umbilical hernia
- A hernia through the umbilical rings
- Defect in linea alba
- Umbilical cord passes through
- Should normally close (age 3-4)
umbilical hernia is rarely associated with
incarceration or strangulation
- surgery is very effective
Para-umbilical hernia (umbilical hernia that effects adults)
- Hernia through defect in linea alba – near umbilicus
- F>M
- Obesity risk factor
- Risk of strangulation
Incisional hernias
Hernias that come through a previous incision
incisional hernia Risk factors
- Previous surgery
- Emergency surgery x 2 risk
- Obesity
- Midline incision
- Wound infection
- Advancing age
- Hernia
prognosis for incisional hernia
- Majority remain asymptomatic
- 6-15%= incarcerates
- 2% strangulation
common incisions for abdominal surgery
- midline incision
- paramedian incision
- gridiron
- pfannestiel
- kocher
Midline incision –
through lineal alba- can be extended – post op pain
2. Paramedian incision-
poor cosmetic results- can damage nerves/ structures
Gridiron –
appendicectomy
Pfannestiel –
obstetric and urology
Kocher incision-
open cholecystectomy (removal of gall bladder- mostly done by key hole)
