T Flashcards
Hernia
Hernias are abnormal protrusions of a viscus (or part of it) through a weak normal or abnormal opening in a cavity that involves it, e.g., the abdomen.
Factors leading to hernia include:
Increased pressure, e.g., from lifting heavy weights, constipation, pregnancy, etc.
• Weakness in the walls of the cavity, e.g., due to aging, congenital diseases like Marfan syndrome and Ehlor-Danlos syndrome (both connective tissue diseases), trauma, surgery, etc.
Types of hernia: in general
Types of hernia :(location)
Congenital and Acquired
Umbilical, paraumbilical, Spigelian, epigastric, lumbar, inguinal (most common), incisional, femoral.
extending between the deep inguinal ring and superficial inguinal rings
Inguinal canal
deep inguinal ring (a hole in the transversalis fascia) and superficial inguinal rings (a hole in the aponeurosis of the external oblique)
is an oval opening in the fascia transversalis.
It is the beginning of the inguinal canal and is at a point midway between the ASIS and the pubic symphysis; it is just above the inguinal ligament and immediately lateral to the inferior epigastric vessels.
Deep inguinal ring
inguinal ring is a triangular (with the apex pointing above and the base being below)
defect in the EOA immediately above and medial to the pubic tubercle, and is composed of medial and lateral crus joined together by intercrural fibers.
Superficial inguinal ring
lie just medial to the deep inguinal ring
Inferior epigastric vessels
The inferior epigastric vessels lie just medial to the deep inguinal ring, passing from the iliac vessels to rectus abdominis
they’re used as a landmark to classify inguinal hernia types
The inguinal canal contains
the spermatic cord in males and the round ligament in females (and it also contains the ilioinguinal nerve, L1)
During development, independently from descent of the testis, the peritoneum of the abdominal cavity forms an evagination,, on each side of the midline into the ventral abdominal wall.
called the processus vaginalis,
Inguinal hernias can be categorized into two types These two basic types are fundamentally different
anatomy, causation and complications.
deep inguinal ring
This type is more common.
congenital inguinal hernia
the processes vaginalis should obliterate under hormonal control
Inguinal hernia in neonates and young children
muscles around the deep inguinal ring can prevent a hernia from developing until later in life, when, under the constant positive abdominal pressure, the deep inguinal ring and muscles are stretched and a hernia becomes apparent
oblique in its path
Indirect inguinal hernia
weakness in the posterior wall of the canal, termed Hesselbach’s triangle
Direct inguinal hernia
medial to the inferior epigastric vessels
acquired
stretching and weakening of the abdominal wall just medial to the inferior epigastric (IE) vessels.
is more likely in elderly patients
broadly based and therefore unlikely to strangulate.
Direct inguinal hernia
the names “indirect” and “direct” come from how the hernia is
Reduced
examination can differentiate the two types of swelling
Can you get above the swelling?
Possibly get above the swelling
Hydrocele
which is used to distinguish direct and indirect hernia.
Occlusion test
an inch above the inguinal ligament
above and medial to the pubic tubercle
below and lateral to the pubic tubercle.
Deep inguinal ring
Superficial inguinal ring
Femoral ring
Do occlusion test!!!!!
1) The patient is asked to lie down (supine) and reduce the hernia
2) After reduction, the thumb is placed over deep ring to occlude it and the patient is asked to cough.
Deep inguinal ring blocked and swelling appeared – Direct inguinal hernia
• Deep inguinal ring locked and swelling did not appear – indirect inguinal hernia
is done to differentiate between direct, indirect, or femoral hernia
Zeimans test (three finger test)
Do zeimans test
The hernia should be reduced first. The examiner stands on the side of the hernia and puts their index, middle and ring finger over the deep ring, superficial ring, and femoral region respectively. The patient is asked to cough and impulse is felt:
• At index finger à indirect
• At middle finger à direct
• At ring finger à femoral
Examine inguinal lymphnode as well as the lesion might be scrotal swelling
Examination of inguinal hernia technique
How hernia is managed
Surgically
Open surgery or laparscopy
Herniotomy
Herniorrhaphy:
Hernioplasty:
Herniotomy: removal of the hernial sac only
Herniorrhaphy: herniotomy plus repair of the posterior wall of the inguinal canal
Hernioplasty: herniotomy plus reinforcement of the posterior wall of the inguinal canal with a
synthetic mesh
The most common adverse events following hernia repair with mesh
pain, infection, hernia recurrence, adhesion, and bowel obstruction.
Symptoms of inguinal hernia
A painless reducible bulging.
Indirect inguinal hernia may be congenital and appear in infancy or childhood (patent processus vaginalis)
Groin discomfort or pain. The discomfort may be worse on bending or lifting. Relieved with lying down
Heaviness in groin and scrotum
Irreducible bulging without obstruction(adhesion) Obstruction of the contents of the sac:
sudden pain, nausea, and vomiting
Symptoms of an inguinal hernia-continue
(strangulation) if the blood supply compromised lead to ischemia of the contents with severe pain, tenderness, fever and tachycardia plus signs and symptoms of intestinal obstruction.
Inflammation of hernia contents like appendicitis and salpingitis Direct hernia sac rarely descend to scrotum
Direct inguinal hernia is always acquired
Strangulation symptoms
if the blood supply compromised lead to ischemia of the contents with severe pain, tenderness, fever and tachycardia plus signs and symptoms of intestinal obstruction.
Howww is Diagnosis of herniaa
Clinical history and examination is sufficient for almost all cases In rare cases when diagnosis can not be done clinically
- Ultrasound by an expert if still not obvious - MRI with Valsalva
- Herniography (a contrast study)
Note: Herniography and MRI are rarely done, even if the clinical features are not obvious and US isn’t helpful. Investigations are rarely used, aside from ones used to prepare for surgery
With this technique, you use one port that has all three openings.)
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