6.2: Hernias, Bowel Obstruction and Constipation Flashcards
(33 cards)
What is a hiatus hernia? Describe the two types
Hernia through the diaphragm;
1. Sliding: type of inguinal hernia where a retroperitoneal structure “slides” down the posterior abdominal wall and herniates directly or indirectly into the inguinal canal, dragging overlying peritoneum with it
- Rolling: part of the fundus may pass into the chest alongside the esophagus
What is the most common region where hernias occur and which two types of hernias occur commonly within this region? How might you differentiate between them?
Groin hernia
- 85% inguinal hernia
- 15% femoral hernia
Inguinal hernias occur above the inguinal ligament, whereas femoral hernias protrude onto the upper thigh below the inguinal ligament.
What are the seven types of ventral hernias?
- Para-umbilical
- Epigastric
- Spighelian
- Incisional
- Para-stromal
- Umbilical
- Port site
What is the most common form of a hernia? In which gender are they more common and why?
Indirect inguinal hernia: more common in males, as the testicular apparatus is much more fragile than the round ligament of the uterus
List seven major causes if hernias
WWDTPCS
- Weakness due to structures leaving/entering the abdomen; spermatic cord, femoral vessels, esophagus, obturator nerve
* can be due to ageing; degenerative weakness - Design weakness: in posterior wall of inguinal canal or lumbar triangle
- Developmental failures; umbilicus (adult version para umbilical hernia), processes vaginalis
- Trauma
- Pregnancy: hormones make ligaments slack for birth and increases the intra-abdominal pressure (ascites will also do this)
- Collagen disease (FH)
- Smoking
What is significant about the mid-point in the inguinal ligament
Where femoral artery is found
*halfway between ASIS and pubic symphysis
What is the myo-pectineal orifice (MPO) and what type of hernia is it responsible for?
Weal area down in the groin and is what direct hernias come through
How common are femoral hernias and which gender are they more common in? What are they more likely to become incarcerated than an inguinal hernia and what is one other potential complication that can occur?
Uncommon due to the inflexibility of the lacunar ligament, more common in females. More likely to be incarcerated as the femoral canal has a ‘tighter entrance’ and intestine is likely to get stuck.
Femoral hernias are also likely to strangulate (prevent circulation) due to the lacunar ligament and can cause bowel obstruction
How would you examine a patient with a suspected groin hernia?
Examine standing them up, ask patient to cough but if nothing can be observed must invaginate the scrotum with a finger and stick it up along the inguinal canal, hoping to feel the hernia coming out through the deep inguinal ring while the patient coughs.
What are three generic and six specific causes of lumps?
Generic:
- Lymph node
- Lipoma
- Sebaceous cyst
Specific: inguinal or femoral hernia, sapheno varix (small venous aneurysm), hydrocele of the cord (hydrocele of the canal nuke in females), ectopic testis (can be found anywhere in the line of descent), psoas abscess (abscess of TB of the spine which drains down the iliopsoas muscle and appears in the groin)
What are the five ways hernias can develop?
- Occult: can’t see
- Reducible:
- Irreducible: (incarcerated) can’t push it back in
- Strangulated: cuts off blood supply (venous cut off first as it’s lower pressure and can have venous gangrene, but arterial continues to pour in)
5: Infarcted
Which hernia can give you strangulation without obstruction?
Richter’s Hernia: anti-mesenteric wall of intestine protrudes through a defect in the abdominal wall - causes strangulation and infarction of one of the bowel walls
What is a sliding hernia? Name three organs where this may occur
Possibility for a sigmoid, caecum or appendix sliding hernia
What is a Pantaloon hernia?
Combined direct and indirect hernia (straddles the inferior epigastric vessels)
Why are umbilical hernias a common congenital disorder and how would you treat one?
In normal embryological development the midgut herniated out of the umbilical ring and should return a few weeks later, BUT if it doesn’t this provides a defect in the abdominal wall that abdominal contents can herniate out of.
They often close themselves spontaneously but operate of there is danger of strangulation or if they haven’t closed by age 4-4.5
What is a para-umbilical hernia and in which population group is it most common?
Weakening of tissues around the umbilicus or in the linea alba around the umbilicus. Common in obese patients and multiparous women
Where do spigelian hernias occur?
In the junction between linea semilunaris and the arcuate line
What are five patient factors, 2 wound factors and 2 surgical factors that predispose someone to an incisional hernia? How common are they and what is a potential complication?
5% occur after all abdominal operations, 50% occur within 5 years of an operation
Patient factors: obesity, chemotherapy/cancer, immunosuppressive, malnutrition, chronic cough
Wound factors; poor tissues and wound infection (if collagen fibres don’t heal properly post surgery can get an infection)
Surgical factors: suturing material (how strong) and technique
Can get bowel obstruction due to adhesions in the bowel (but not strangulation)
What is divarication of recti and which population group is the most predisposed to it?
A bulge over the linea alba due to weakened muscles BUT it’s not a hernia (repaired for purely cosmetic reasons), common in obese patients and pregnancy
What is a para-stomal hernia and which type of surgical operation is likely to cause one? What are two potential complications?
Commonly caused by a colostomy, introducing a stoma weakens the surrounding abdominal wall and a part of bowel can come into the stoma.
Can cause obstruction and strangulation, and also leakage out the sides of the bag due to the increased pressure
What are the two types of rare external hernias and how are they caused?
- Lumbar hernia: A defect in the posterolateral abdominal wall. Doesn’t tend to strangulate and can be left alone
- Obturator hernia; obturator nerve goes through obturator foramen which can weaken the area leading to a hernia. Can cause leg pain
Why should we operate on hernias?
*4 reasons
Which type of hernia is always referred to for immediate surgery?
- Painful or aching symptoms
- Cosmetic
- Bowel obstruction
- Risk of strangulation (1%) but if it occurs mortality is >15%
Femoral hernia always operated on
How is an inguinal hernia treated? What are 3 general principles of hernia repair?
- Operate: open, laparoscopic (GA); can give a TAPP (trans abdominal preperineal or TEPP (total extraperitoneal)
- Non-operative; Truss (metal band that pushes the hernia in), no treatment
General principles
- Don’t put tension (i/e no strenuous post-surgical physical work)
- Use specialized mesh; generates scar tissue
- Laparoscopic reinforcement
When would you give local vs general anaesthetics in surgical hernia repair?
May give local anaesthetic to reduce risk of comorbidities, if patient is not very fit and hernia not very big giving a general anaesthetic may be too dangerous
