Week 7/8 - H - Hernias - Epigastric/(Para)Umbilical/Inguinal/Femoral/Incisional/Spigelium/Lumbar/Parastomal/Port-site, Pediatric

Question 1

Let’s discuss the different types of abdominal hernias What is a hernia? What are the different things that can predispose to a hernia?

Answer 1

A hernia is the abnormal protrusion of a cavity’s contents through a weakness in the wall of the cavity Predisposing factors * Anatomical - eg sites where structures exit through an opening the cavity * Inherited collagen disorders * Sites where surgical incisions are made

Question 2

Different types of hernia * Epigastric * Umbilical/Paraumbilical * Inguinal Hernia * Femoral Hernia * Spigelian Hernia * Lumbar Hernia * Incisional Hernia * Parastomal Hernia * Port-Site Hernia What are the different classifications of hernia?

Answer 2

Classifications of hernia Reducible - hernias that can easily be pushed back into the abdomen Incarcerated or irreducible - hernia cannot be manipulated back to the abdomen - can lead to strangulation Strangulated - vascular supply to the contents contained within the hernia is compromised - resulting in ischaemic and gangrenous tissue

Question 3

EPIGASTRIC HERNIA Management of hernias can be * Conservative / non-surgical management * Surgical management It usually depends on the type of hernia and whether there is strangulation or not What is an epigastric hernia? How does it present?

Answer 3

An epigastric hernia is when there is protrusion of a viscus (internal organ of the body, specifically one within the chest or abdomen) through a defect in the linea alba between the xiphoid process and the umbilicus Often asymptomatic lump, can present with pain

Question 4

If an epigastric hernia is incarcerated or strangulated, symptoms will depend on the organs involved What is the management?

Answer 4

Management is either conservative or surgical

Question 5

PARAUMBILICAL HERNIA Where do paraumbilical hernias occur? What are aetiological factors that increase the risk of this type of hernia?

Answer 5

Paraumbilical hernias occur just above or below the umbilicus Aetiological factors include stretching of the abdominal wall by obesity, multiple pregnancies and ascites

Question 6

How do paraumbilical hernias present? Do they often resolve spontaneously? How are they managed?

Answer 6

Paraumbilical hernias frequently present with pain and do not resolve spontaneously - high incidence of incarceration and strangulation Management is nearly always surgical

Question 7

ADULT UMBILICAL HERNIAS Why do adult umbilical hernias usually occur?

Answer 7

Adult umbilical hernias usually result from persistent elevation of intra-abdominal pressure - eg obesity, pregnancy, ascites

Question 8

How do adult umbilical hernias present and how are they treated?

Answer 8

The clinical presentation, management and complications of adult umbilical hernia are very similar to those of para-umbilical hernia Patient frequently presents with pain and do not resolve spontaneously - high incidence of incarceration and strangulation Management is nearly always surgical

Question 9

INGUINAL HERNIAS How long is the inguinal canal? Where does it start and where does it end?

Answer 9

The adult inguinal canal is approximately 4cm long It starts at the deep inguinal ring and ends at the superficial inguinal ring

Question 10

What does the inguinal canal transmit in * Males * Females

Answer 10

Males * Spermatic cord * Ilioinguinal nerve Females * Round ligament of the uterus * Ilioinguinal nerve

Question 11

What are the contents of the spermatic cord?

Answer 11

Spermatic cord * Vas deferens * Testicular artery, artery to vas deferens, cremasteric artery * Pampiniform plexus of veins * Genital branch of genitfemoral nerve, autonomic sympathetic twigs * Lymph vessels * Remains of the processus vaginalis

Question 12

The spermatic cord begins as the processus vaginalis - a periotneal diverticulum that passes through the abdominal wall and acquires tubular sheaths from as it goes which makes up the coverings of the spermatic cord What are the three coverings of the spermatic cord? What gives rise to each covering?

Answer 12

Internal spermatic fascia - arises as the processus vaginalis passes through the transversalis fascia Cremasteric fascia/muscle - arises as the processus vaginalis passes through the internal oblique muscle External spermatic fascia- arises as the processus vaginalis passes through the external oblique aponeurosis

Question 13

The inguinal canal has different borders * Roof (superior) * Anterior * Floor (inferior) * Posterior What forms the different borders of the inguinal canal? Clue - MALT (2Ms, As, 2Ls, 2Ts)

Answer 13

Roof - superior- fibres from internal oblique & transversus abdominus Muscles Anterior - fibres from external and internal oblique Aponeurosis Floor (inferior) -fibres from inguinal Ligament and Lacunar Ligament Posterior - fibres from Transversais fascia and conjoint Tendon

Question 14

The opening of the inguinal canal is the deep inguinal ring Where can this be located? What is the opening a defect in? What lies medially to the deep inguinal ring?

Answer 14

The deep inguinal ring can be located halfway betwen the ASIS (Anterior superior iliac spine) and pubic symphysis - about 1.3 cm above the inguinal ligament Medially to the deep inguinal ring lies the inferior epigastric vessels

Question 15

Inguinal hernias are the most common abdominal wall hernia Where do they lie in relation to the pubic tubercle? Where do femoral hernias lie in relation to the pubic tubercle?

Answer 15

Inguinal hernias lie super-medially (above and medial) to the pubic tubercle Femoral hernias lie infero-lateral (below and lateral) to the pubic tubercle

Question 16

Inguinal hernias lie super-medially (above and medial) to the pubic tubercle Femoral hernias lie infero-lateral (below and lateral) to the pubic tubercle How can you elecit this from a patient with a reducible hernia?

Answer 16

Ask the patient to reduce their hernia If they can, then ask them to cough afterwards * If the lump appears above and medial to the pubic tubercle, this is an inguinal hernia * If the lump appears below and lateral, this is a femoral hernia

Question 17

Hesselbach’s triangle also allows you to distinguish between the two types of inguinal hernia, direct and indirect What are the boundaries of hesselbach’s triangle? Which type occurs within the triangle and which type occur outwith?

Answer 17

Hesselbach’s triangle boundaries Laterally - inferior epigastric vessels Medially - lateral border of rectus abdominus muscle Inferiorly - inguinal ligament Direct inguinal hernias occurs within Indirect inguinal hernias occur outwith

Question 18

The two types of inguinal hernia are direct and indirect What is the difference in the way in which each occurs? Where do they lie in relation to the inferior epigastric vessels?

Answer 18

Indirect inguinal hernias enters the inguinal canal via a congenital weakness in the deep inguinal ring and is therefore lateral to the inferior epigastric vessels A direct inguinal hernia pushes through a weak area in the posterior wall of the inguinal canal and is medial to the inferior epigastric vessels

Question 19

Which type of inguinal hernia is more common? What are the different risk factors for inguinal hernias?

Answer 19

2/3rds of inguinal hernias are indirect (lateral to inferior epigastric vessels) Risk factors include * Males * Chronic cough * Constipation * Urinary obstruction * Heavy lifting * Ascites * Past abdo surgery

Question 20

How is an inguinal hernia diagnosed on examination? What scan be used if in doubt?

Answer 20

* The groin swelling usually disappears when lying down * It is located above and medial to the pubic tubercle * The cough impulse is a clinical sign that is elicited when examining a hernia. If the swelling expands upon coughing, it is said to have a ‘cough’ impulse The presence of an expansile cough impulse is almost diagnostic of a hernia. If in doubt, USS can be helpful

Question 21

Which type of inguinal hernia is more likely to strangulate?

Answer 21

Indirect inguinal hernias are more common, and more likely to strangulate than the less common, direct inguinal hernias

Question 22

What is the treatment of an inguinal hernia?

Answer 22

Non-surgical If going for surgery - WEIGHT LOSS and STOP SMOKING * Open surgery or laproscopic surgery is then carried out

Question 23

FEMORAL HERNIAS How do femoral hernias occur? How can you tell it is a femoral hernia on examination?

Answer 23

Femoral hernias occurs as the bowel enters the femoral canal, presenting as a mass in the upper medial thigh or above the inguinal ligament - where it would point down the leg unlike an inguinal hernia which points toward the groin They present below and lateral to the pubic tubercle

Question 24

Which sex are femoral hernias more common in? What is recommended as treatment and why?

Answer 24

Femoral hernias are more common in thin, elderly females Surgery is recommended as treatment as strangulation can commonly occur

Question 25

INCISIONAL HERNIAS What is the cause of incisional hernias?

Answer 25

Incisional hernias are iatrogenic They develop through a defect in a scar of a previous abdominal operation - commonest complication of a laparotomy

Question 26

What are predisposing factors to incisional hernias?

Answer 26

Predisposing factors for incisional hernias * Wound Complications (Preoperative, perioperative and postoperative factors) * Inherited Collagen abnormalities * Advanced Age * Smoking * Morbid Obesity * Malignancy * Surgical Technique

Question 27

What management of incisional hernias will reduce hernia recurrence but can increase risk of infection after surgery?

Answer 27

Mesh repair reduces the risk of hernia recurrence but can increase the risk of infections over suture repair

Question 28

SPIGELIAN HERNIA Where do spigelian hernias occur?

Answer 28

Spigelian hernias occur through the linea semilunaris at the lateral edge of the rectus sheath, below and lateral to the umbilicus

Question 29

LUMBAR HERNIA What do lumbar hernias occur through?

Answer 29

Lumba hernias occur through the superior or inferior lumbar triangles in the posterior abdominal wall

Question 30

PARASTOMAL HERNIAS What is a para-stomal hernia?

Answer 30

Parastomal hernia is the most frequent complication associated with the creation of an ileostomy or colostomy. It is defined as an incisional hernia that occurs at or adjacent to the stoma. It is almost an inevitable complication of an ostomy creation if left in place long enough

Question 31

PORT SITE HERNIA What are port site hernias?

Answer 31

Port site hernia (PSH) is a rare type of incisional hernia occurring at port sites after laparoscopic surgery.

Question 32

Paediatric hernias Include * Umbilical hernias * Inguinal hernias * Gastoschisis * Omphamocele (exomphalos) What does an umbilical hernia result from? What is the treatment?

Answer 32

A paediatric umbilical hernia results from a persistent defect in the transversalis fascia resulting in a symmetric umbilical bulge Surgery is rarely needed as most cases resolve by the age of 3

Question 33

What type of inguinal hernia is found in paediatric inguinal hernias? What causes a paediatric inguinal hernia? What are the risk factors?

Answer 33

Paediatric inguinal hernias are indirect inguinal hernias They occur due to a patent processus vaginalis More common in premature babies and boys

Question 34

What is the management of paediatric inguinal hernias?

Answer 34

Should be surgically repaired soon after diagnosis as at risk of incarceration and then strangulation

Question 35

What is the difference between gastroschisis and exomphalos (aka omphalocele)?

Answer 35

Gastoschisis is the protrusion of abdominal contents through a defect in the anterior abdominal wall to the right of the umbilicus Exomphalos (omphalocele) is the protrusion of abdominal contents through a central defect in the abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum

Question 36

What is the treatment of both gastroschisis and omphalocele?

Answer 36

Prompt surgery is required for gastroschisis as there is nothing protecting the intestines Prompt surgery also required for omphalocele (has a protective membrane over the intestines so technically not as urgent)