MP&S - Hernias Flashcards
what is the definition of a hernia?
a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it (often involving the intestine at a weak point in the abdominal wall)
what is a reducible hernia?
a hernia that can be manually “reduced” or pushed back through the defect
what is a incarcerated hernia?
a hernia which cannot be manually reduced (may NOT be painful)–surgery
what is a strangulated hernia?
an incarcerated hernia with some degree of torsion leading to ischemic bowel (very painful) emergency surgery
what makes up the roof of the inguinal canal?
External oblique & Transversus abdominis muscles
what makes up the floor of the inguinal canal?
Inguinal Ligament and Lacunar ligament
what makes up the anterior wall of the inguinal canal?
Primarily External Oblique muscle
what makes up the posterior wall of the inguinal canal?
Transversalis fascia and conjoined tendon of the internal oblique and transversus abdominis muscles
what are in the contents of the inguinal canal in the male?
Ilioinguinal nerve & Spermatic Cord
what are in the contents of the inguinal canal in the female?
Ilioinguinal nerve and Round Ligament of the uterus
what makes up the medial, lateral, inferior border of Hesselbach’s triangle?
medial- rectus abdominis
lateral- Inferior epigastric vessels
inferior-inguinal ligament
who gets hernias more men or women?
men
75-80% of all hernias happen where?
in the groin usually inguinal or femoral
what percent of hernias are incisional/ventral?
2-20%
what percent of hernias are umbilical?
3-10%
Patients who have an inguinal hernia will what other type of hernia?
3% of patients with a inguinal hernia will have a contralateral hernia at time of presentation
patients who DO NOT have a contralateral hernia when they present will likely have what?
12% of patients who DO NOt have a contralateral hernia at time of presentation will go on to develop contralateral hernias
what % of inguinal hernias will become incarcerated
10%
what % of incarcerated hernias will become strangulated?
10%
what type of hernia is more prevalent in men?
inguinal
what type of hernia is more prevalent in women?
femoral
incisional/ventral hernias are more prevalent in?
obese males
what are risk factors for hernias?
Increased intra-abdominal pressure: coughing, heavy lifting, constipation, pregnancy Obesity Advanced age Smoking Steroid use
what are the 2 types of inguinal hernias
Direct
Indirect
Direct hernia?
Usually acquired, herniation through defect in the posterior inguinal wall (through Hesselbach’s triangle) – occurs most commonly in older males
Indirect hernia?
Usually congenital, through deep inguinal ring, lies within the spermatic cord, and the hernia sac is covered by the cremaster muscle – occurs most commonly in younger males and may be in scrotum
What will a hernia feel like on index finger?
an indirect hernia will be felt on finger tip
a direct hernia will be felt on pulp of finger
what is the gold standard treatment for hernia?
herniorraphy
what must you do with a patient who has a incarcerated hernia?
a non-reducible hernia should be referred to a surgeon
how should a patient be positioned when reducing a hernia?
have patient lying supine
what type of hernia is a surgical emergency?
stangulated hernia because it compromises the bowel and can lead to an infarcted bowel
what should be done with pediatric hernias?
complication rate is 20X higher in emergent pediatric hernia repair so need referral to pediatric surgeon
Femoral hernia facts
84% of femoral hernias occur in women
25% of femoral hernias become incarcerated or strangulated
hernia protrudes through the femoral canal and is palpated on upper thigh
what will the history be like in patients with femoral hernia’s
may complain of intermittent groin mass/bulge or pain
presenting feature may be small bowel obstruction due to incarceration/strangulation
Elderly patients may be asymptomatic even in the face of incarceration
Consider occult femoral hernia in females presenting with a small bowel obstruction
what will a femoral hernia PE be like
bulge just BELOW the inguinal ligament
Tenderness if incarcerated
Tx for femoral hernia
referral to surgeon
Umbilical hernia facts
congenital defect
African American>Caucasians
Most newborn umbilical hernias close spontaneously by age 2
Patient with ascites have a higher incidence of umbilical hernia
low rate of incarceration
umbilical hernia presentation
painless bulge around umbilicus
present with gastric symptoms
associated with obesity in adults
In kids under 2 wait for spontaneous closure unless LARGE
what is a Spigelian hernia?
protrudes through the spigelian fascia near the terminus of the tranversus abdominis muscle along the lateral edge of rectus abdominis
why is a spigelian hernia hard to dx
because hernia lies between abdominal muscles so there is no bulge
Its a rare hernia but easily missed and therefore potentially dangerous
spigelian hernia presentation?
ofter patient present with obscure abdominal pain and no apparent cause
spigelian hernia tx
surgery
Hiatial hernia fast facts
reflux barrier composed of two components working together to prevent reflux:
Lower esophageal sphincter
crural diaphragm
stomach can herniate up through diaphragm into thoracic compartment will hear bowel sounds in chest cavity
once stretched by herniated stomach muscles the crural diaphragm cannot provide adequate pressure to prevent gastric contents moving into herniated region
what will the history of a patient with hiatial hernia be like?
presents with symptoms similar to GERD, post prandial pain, bloating, early satiety, SOB with meals
what diagnostics would you want to order for hiatial hernia
CXR- look for air fluid levels in mediastinum
Barium swallow
EGD
Esophageal manometry
surgery is not done unless all other medical options have been exhausted
TX for hiatial hernia that is found accidently and asymptomatic
no tx needed
if pt is symptomatic
trail of medical management similar to GERD
Surgical management is major surgical procedure
Incisional or ventral hernia fast facts
occurs at site of previous surgery results from dehiscence of abdominal cavity Causes: Infection malnutrition obesity flawed wound closure Conditions that increase abdominal pressure
what will history be like for patient with incisional or ventral hernia
prior Hx of surgery
presence of previously pre-disposing factors
complaints of intermittent or persistent bulge at incision site
tx for incisional hernia
definitive tx is surgical repair
high incidence of recurrence if contributing factors are not controlled
sport hernia fast facts
called athletic pubalgia
seen in high performance athletes
painful musculotendinous injury to medial inguinal floor caused by and exacerbated by vigorous sport or physical exertion
can occur in sports where there is much rapid lateral movement
hockey, soccer or sports with short off seasons
NOT A TRUE HERNIA
what is history like of pt with sports hernia
usually high performance athlete with history of groin or lower abdominal pain aggravated by physical activity and relieved by rest
no complaints of bulge or mass
what will PE be like for a sports hernia
tenderness over pubic ramus
no evidence of true hernia or lower abdominal pathology
Tx for sports hernia
conservative tx: activity modification, PT
if no helping consider surgical intervention
