Abdominal wall hernias Flashcards

1
Q

Define hernias of the abdominal wall

A

An abnormal protrusion of abdominal contents though the fascia of the abdominal wall

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2
Q

List the contents of a hernia

A

Always contains a portion of the peritoneal sac May contain viscera, usually small bowel and omentum

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3
Q

Describe the aetiology of congenital abdominal hernias

A

Associated with developmental disorders e.g. persistent processus vaginalis, failure of complete obliteration of the umbilical opening

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4
Q

Describe the aetiology of acquired abdominal hernias

A

Weakness of the abdominal wall due to ageing or previous surgery. Risk increased in conditions that increase intra-abdominal pressure.

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5
Q

What terms are used to describe an abdominal hernia?

A

Reducible: contents can be fully restored to the abdominal cavity, spontaneously or with manipulation. Incarcerated: part or all of the contents cannot be reduced due to narrow neck and/or adhesions. Strangulated: twisting or entrapment compromises blood supply to the hernia ➔ obstruction and infarction

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6
Q

What may be seen on examination of a hernia?

A

Occur at weak spot May reduce on lying down, or with direct pressure May have expansile cough impulse

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7
Q

Name 5 common types of abdominal wall hernias

A

Inguinal hernia (commonest) Femoral hernia Incisional hernia Epigastric hernia Umbilical hernia

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8
Q

What is the commonest type of abdominal hernia?

A

Inguinal hernia

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9
Q

What is the M:F ratio for inguinal hernias?

A

8:1

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10
Q

How can inguinal hernias be classified?

A

Direct: medial to inferior epigastric artery Indirect: lateral to inferior epigastric artery

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11
Q

Differentiate between an indirect and direct inguinal hernia

A

Indirect: occurs at any age (usually young), congenital, lateral to inf epigastric a, often descend to scrotum, narrow neck ➔ more likely to strangulate Direct: uncommon in children and young adults, acquired, medial to inf epigastric a, rarely descend to scrotum, wide neck ➔ rarely strangulate

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12
Q

Name 2 risk factors for indirect inguinal hernias

A

Prematurity Male

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13
Q

Name 3 risk factors for direct inguinal hernia

A

Male Obesity Constipation Chronic cough Heavy lifting

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14
Q

Describe the presentation of inguinal hernias

A

Lump in the groin May have sudden pain Expansile cough impulse Ache or dragging sensation, especially at the end of the day

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15
Q

Outline the management of inguinal hernias

A

Reassurance if small and asymptomatic Symptomatic hernias or Hx of incarceration or bowel obstruction ➔ offered hernia repair -Consider hernia truss: supports tissue and relieves pain Hernia repair: reduction or excision of sac, closure of defect with minimal tension.

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16
Q

What structure do indirect inguinal hernias travel through?

A

Inguinal canal: transmits the spermatic cord/round ligament, and the ilioinguinal nerve.

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17
Q

What is the content of the spermatic cord?

A

Vessels: testicular a, cremasteric a, artery of vas deferens Nerves: genital branch of genitofemoral, autonomic supple to testicles, ilioinguinal n Structures: vas deferens, pampiniform venous plexus, testicular lymphatics Coverings: external spermatic fascia, cremasteric fascia, internal spermatic fascia

18
Q

What anatomical location is most commonly associated with direct inguinal hernias?

A

Hesselbach’s triangle: -Inguinal ligament (inferiorly) -Inferior epigastric artery (laterally) -Lateral border of rectus abdominis (medially)

19
Q

Outline the anatomy of the femoral canal

A

Anterior: inguinal ligament Posterior: pectineal ligament Medial: lacunar ligament Lateral: femoral vein

20
Q

Which sex is most likely to have a femoral hernia?

A

Women

21
Q

Describe the presentation of femoral hernias

A

Lump in the groin, lateral and inferior to the pubic tubercle, medial to femoral pulse Lower abdominal pain if incarcerated *30% present as emergencies due to high risk of strangulation

22
Q

Name 3 differentials for femoral hernias

A

Low presentation of inguinal hernia Femoral canal lipoma Saphena varix (dilatation of proximal long saphenous v) Hydrocele Spermatic cord hydrocele Lymphadenopathy Psoas abscess Varicocele

23
Q

What is the most concerning complication of femoral hernia?

A

Strangulation of the femoral hernia. High risk due to the narrow opening and rigid boundaries of the femoral canal.

24
Q

Describe the presentation of a strangulated hernia

A

Red and tender Tense and irreducible Colicky abdominal pain Distension Vomiting

25
Q

Outline the treatment of femoral hernias

A

Due to high risk of strangulation, all femoral hernias should be repaired as an elective process. -Low approach (Lockwood’s) -Trans-inguinal approach (Lotheissen’s) -Thigh approach (McEvedy’s) Truss (conservative) has no place in management

26
Q

What can be done to reduce the rate of recurrence of femoral hernias?

A

Narrowing of the femoral canal after hernia repair

27
Q

State 3 differences between true umbilical hernias and paraumbilical hernias

A

True: occur through the umbilical cicatrix, almost always congenital, commoner in Afro-Caribbean races. Para: occur through the paraumbilical tissue, acquired, common in obese and parous women.

28
Q

Describe the pathophysiology of epigastric hernias

A

Defects in the line alba between the xiphisternum and umbilicus, at sites of penetration of nerves and vessels.

29
Q

Describe the presentation of umbilical hernias

A

Small, centrally places within the umbilicus Often contains pre-peritoneal fat Rarely contains bowel or omentum May be painful, but rarely strangulates

30
Q

Describe the presentation of paraumbilical hernias

A

Variable size, up to moderate Many potential locations Distorts shape of umbilicus May contain bowel or omentum Often painful and occasionally strangulates

31
Q

Describe the presentation of epigastric hernias

A

Variable size, up to large Always along midline Most frequently only contains pre-peritoneal fat Moderate risk of strangulation

32
Q

Outline the management of umbilical hernias

A

<1cm ➔ almost always spontaneously close by 5yr >1.5cm or in child >4yr ➔ repair Symptomatic hernias or high risk complications ➔ repair

33
Q

Name 3 factors that predispose to incisional herniation?

A

Wound infection Steroid use, anaemia, or malnutrition pre-op Midline laparotomy Poor surgical technique in abdominal closure

34
Q

When do incisional hernias most commonly present?

A

Up to 5yr post-op

35
Q

What significant complication can occur following large incisional herniation?

A

Viscera are often permanently herniated If this occurs for a long period of time, the abdominal wall muscles retract ➔ small abdominal cavity that may not contain all the retracted viscera.

36
Q

Outline the management of incisional hernias

A

<4cm (S) ➔ simple sutured repair >4cm (M or L) ➔ mesh repair -Above umbilicus: between post rectus sheath and rectus abdominis muscle -Below umbilicus: pre-peritoneal space *Arcuate line

37
Q

What are the signs of a strangulated hernia?

A

Irreducible Tender Overlying erythema or cellulitis

38
Q

Why is it important to identify a strangulated hernia?

A

The region becomes ischaemic and subsequently gangrenous. Gangrene can lead to perforation of the bowel with ensuing peritonitis.

39
Q

What is the management of a strangulated hernia?

A

Emergency surgery within 6hr of strangulation

40
Q

What feature increases the risk of a hernia strangulating?

A

Narrow opening in the containing wall