Hernia Flashcards

1
Q

Define hernia

A

The protrusion of a viscus/organ through a defect of the wall containing cavity into an abnormal position

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2
Q

Describe how embryology can contribute to a hernia

A

Testicular development is determined by the y chromosome and it must produce testosterone to descend
1. The testis, guided by the mesenchymal gubernaculum, migrates down into the inguinal canal
2. The structures found in the scrotum (testis, vas, blood vessels) pass through the abdominal wall and pick up layers
3. These layers make up the coverings of the spermatic cord
4. A remnant of the peritoneal invagination (Processus vaginalis) may remain patent → fluid or abdominal contents can pass into it → hydrocoele or hernia

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3
Q

Explain how an umbilical hernia may arise

A

The umbilical ring allows passage of vessels through the abdominal wall muscles between mother and foetus
After birth and disintegration of the cord, the ring remains, with spontaneous closure typically by 5yo (growth of abdominal muscles and fusion of peritoneal and fascial layers)
Failure or delay in this process leads to the formation of an umbilical hernia

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4
Q

What is incarceration and strangulation of a hernia

A

Incarceration = abdominal viscera or omentum becomes stuck within the hernia (irreducible)

Strangulation = viscera becomes stuck in the hernia with compromise to their blood supply → ischaemia or necrosis

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5
Q

What are the types of hernia

A

Inguinal
Umbilical
Paraumbilical
Femoral
Epigastric
Congenital diaphragmatic
Exomphalos/omphalocoele
Gastroschisis

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6
Q

What is the cause of inguinal hernias, where is it most likely to be and what is the risk difference between age groups

A

Persistently patient processus vaginalis
Hernia emerges from the deep inguinal ring through the inguinal canal (usually INDIRECT)
More likely to be right sided (as left PV obliterates before the right)
The risk of incarceration is higher in infants than older children

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7
Q

Which hernia are babies more likely to get if born premature

A

Direct inguinal hernia as they weaker tissue that is more friable

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8
Q

What are the risk factors for an inguinal hernias

A

Preterm infants (esp. LBW)
Boys (as ovaries don’t leave the abdominal cavity)
Infants with chronic lung disease
Conditions causing abdominal fluid or increased abdominal pressure e.g. cystic fibrosis
CT disorder

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9
Q

What are the symptoms and signs of an inguinal hernia

A

Lump in the groin
- May extend into the scrotum or labia majora
- Usually asymptomatic, intermittent, visible on sraining
- Reducible unless incarcerated (tender, red, firm)
Non-transluminable (but may be in young patients)
Abdominal pain
Irritability
Nausea and vomiting
Swelling in the scrotum visible upon straining or crying

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10
Q

What is the management for an inguinal hernia

A

Surgery (herniotomy)
- First few months of life - urgent hernia repair (higher risk of strangulation)
- >1yo: elective surgery

Neonates: If reducible → elective herniorrhaphy repair
- <6w: correct within 2 days
- <6m: correct within 2 weeks
- <6yo: correct within 2 months

Most cases are performed as day cases, neonates and premature infants are kept in hospital overnight as there is a recognised increased risk of post operative apnoea.

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11
Q

What are the complications and prognosis of inguinal hernias

A

Incarceration
Herniotomy- recurrence, damage to vas deferens, testicular vessels, ascending ipsilateral testicle secondary to scarring
Excellent prognosis with surgical repair

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12
Q

What are the risk factors for an umbilical hernia

A

Prematurity
Afro-Caribbean
Down’s syndrome
Mucopolysaccharide storage devices
Low birth weight
Ehlers-Danlos syndrome
Hypothyroidism

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13
Q

What are the symptoms and signs of an umbilical hernia

A

Hernia:
- Painless
- Reducible
- More prominent on straining or crying

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14
Q

What is the management for an umbilical hernia

A

Observation: Typically resolves by 4-5 years of age (most by 12 months)

If it persists beyond 4-5yo → elective outpatient surgical repair

Large or symptomatic hernia (>1.5cm) → intermittent symptoms of incarceration or recurring pain → elective repair at 2-3yo

Incarceration → manually reduce with pressure + surgical repair within 24h (may require emergency op if it cannot be reduced)
+ safety net

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15
Q

What should be advised on safety netting for a hernia

A

Strangulation
Vomiting, pain
Unable to push the hernia in
Complete constipation, unable to pass flatus

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16
Q

Describe paraumbilical hernias

A

Due to defects in the linea alba that are in close proximity to the umbilicus
The edges of a paraumbilical hernia are more clearly defined than those of an umbilical hernia
They are LESS LIKELY to resolve spontaneously than an umbilical hernia

17
Q

Describe femoral hernias in children

A

Difficult to differentiate from indirect inguinal hernias
Located below inguinal canal (through femoral canal)
Differentiation often made during operation
S/S same as for indirect inguinal hernia

18
Q

Describe epigastric hernias

A

Occur in the midline, anywhere from xiphoid process to the umbilicus
Most contain preperitoneal fat
10% have multiple defects - multiple lumps in midline

19
Q

What are the signs and symptoms of an epigastric hernia

A

Abdominal mass (Commonly enlarges)
Abdominal pain/tenderness
Pain and irritation of the skin (due to hernias rubbing against clothes)

20
Q

What is the management for an epigastric hernia

A

Refer to hospital for further assessment
Surgical repair

21
Q

Describe congenital diaphragmatic hernias

A

1 in 2,000
Herniation of the abdominal viscera into the chest cavity due to incomplete formation of the diaphragm → pulmonary hypoplasia + hypertension → resp. distress
Usually represents a failure of the pleuroperitoneal canal to close completely
most common type of CDH is a left-sided posterolateral Bochdalek hernia which accounts for around 85% of cases.

22
Q

What are the signs and symptoms of a congenital diaphragmatic hernia

A

Resp. distress (Dyspnoea, Tachypnoea)
Failure to respond to resuscitation
Barrel-shaped chest
Scaphoid-appearing/ concave abdomen (because of loss of abdominal contents into the chest)
Cardio-Resp exam:
- Reduced breath sounds
- Absence of breath sounds on the ipsilateral side
- Displaced heart sounds and apex beat if left sided herniation

23
Q

What is the management for congenital diaphragmatic hernia

A
  1. intubate and ventilate (prevent swallowing of air → expansion of bowel within the chest
  2. Decompress bowel using NG tube and suction
  3. Place an umbilical artery line for frequent monitoring
  4. Refer for surgery to close the diaphragmatic defect and reduce the viscera into the abdominal cavity

Note: avoid bag-and-mask ventilation as it may cause expansion of the bowel within the chest

24
Q

What are the complications of congenital diaphragmatic hernia

A

Persistent pulmonary hypertension of the newborn
Chronic respiratory disease, pulmonary hypoplasia (compression by herniated viscera)
Recurrent hernia problems
Spinal/ chest wall abnormalities
GI difficulties- volvulus, acute bowel obstruction which may lead to perforation of herniated loop
Neurological sequelae

25
Q

What is the prognosis for congenital diaphragmatic hernia

A

50% of newborns survive despite modern medical intervention
depends on (1) liver position, (2) lung-to-head ratio
Improved survival rates with better preoperative management to avoid lung injury
If the lungs are hypoplastic, mortality is high

26
Q

Describe exomphalos/omphalocoele and its risk factors

A

Bowel protruding out of the body with a peritoneal covering (umbilicus attached)

RF: Chromosomal abnormalities in 15% of cases (Trisomy 13 (Patau’s), 18 (Edward’s), 21 (Down’s); Turner’s)

27
Q

What is gastroschisis

A

paraumbilical abdominal wall defect → abdominal contents outside body, without peritoneal covering

28
Q

What are the signs of hernia incarceration

A

Unsettled pain
Vomiting
Tenderness
Unable to pass stool (constipation)
Poor feeding
Non-reducible firm inguinal scrotal mass
Erythema
Oedema
Abdominal distension

29
Q

What are the signs of strangulation

A

Expansile cough impulse
Pain
Fever
Increase in the size of a hernia or erythema of the overlying skin
Peritonitic features such as guarding and localised tenderness
Bowel obstruction e.g. distension, nausea, vomiting
Bowel ischemia e.g. bloody stools

30
Q

What is the management for hernia incarceration/strangulation

A

Urgent admission and assessment to the surgery team
→ emergency manual reduction of hernia contents under sedation (IV morphine) with repair after 48 hours to allow oedema to settle