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cc: gastro > Femoral + inguinal hernias > Flashcards

Femoral + inguinal hernias Flashcards

1
Q

What is the definition of a hernia?

A

A protrusion, bulge or projection of an organ or part of an organ through the body wall that normally contains it

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2
Q

Are inguinal or femoral hernias more common?

A

Inguinal

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3
Q

Which of femoral or inguinal hernias present with complications more frequently?

A

Femoral

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4
Q

What is the prevalence of groin hernias in the US?

A

5-10 percent of the population

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5
Q

What is the classical demographic/ethnic patient for hernias?

A

Old white male

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6
Q

What is the lifetime risk of developing a groin hernia for men vs women?

A

25% vs 5%

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7
Q

What is the peak age of presentation for groin hernias?

A

50-69 years for men

40-60 years for women

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8
Q

Of groin hernias, what percentage are inguinal vs femoral?

A

96% are inguinal, 4% femoral

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9
Q

Are direct or indirect hernias more common, and in women vs men?

A

Indirect are most common in both sexes

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10
Q

What are some risk factors for the development of hernias?

A

Previous hernia

Older age, caucasian, male

Chronic cough

Chronic constipation

Abdominal wall injury

FHx

Smoking

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11
Q

Is obesity a risk factor for developing hernias?

A

No

Large observational study from a Swedish hernia register involving 50,000 patients found lower incidence of hernia in obese patients

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12
Q

What causes a congenital hernia in the male?

A

The processus vaginalus not closing correctly, as well as the internal ring not closing correctly

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13
Q

When does a congenital hernia present?

A

Can be anywhere from early childhood to adulthood

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14
Q

What is the aetiology of an acquired hernia?

A

Weakening or disruption of the fibromuscular tissues of the body wall allowing intra-abdominal contents to protrude through the acquired defect

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15
Q

Is there any preference between left and right in indirect inguinal hernias?

A

Yes

Right is more common in both males and females

Thought to be due to the later descent of the right testicle, and in females by asymmetry of the female pelvis

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16
Q

What is the origin of the hernia sac in relation to the inferior epigastric artery in indirect inguinal hernias?

A

Lateral to the artery

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17
Q

What is the origin of the hernia sac in relation to the inferior epigastric artery in direct inguinal hernias?

A

Medial to the artery

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18
Q

What is the name of the triangle of anatomical structures that are important in the consideration of hernias?

A

Hesselbach’s triangle

19
Q

What forms Hesselbach’s triangle?

A

Inguinal ligament inferiorly

Inferior epigastric vessels laterally

Rectus abdominus muscle medially

20
Q

Why do direct inguinal hernias occur?

A

Weakness in the floor of the inguinal canal

Secondary to connective tissue abnormalities in many cases, or weakness in abdo muscles due to chronic overstretching or injury

21
Q

Where do femoral hernias arise from?

A

Inferior to the inguinal ligament

Protrude through the femoral ring which is medial to the femoral sheath and lateral to the lacunar ligament

22
Q

What can cause a congenital femoral hernia?

A

There is no such thing, they are all acquired

23
Q

Are femoral hernias also more common in men?

A

No

More common in women

24
Q

What percentage of femoral hernias present as emergency cases with complications?

A

40%

25
Q

Which population is most likely to present with a hernia complication to ED?

A

Women

Higher incidence of femoral hernias, and with inguinal the rings are smaller and everything is tighter in general

26
Q

What is the normal symptom that hernias will present with?

A

A heaviness or dull discomfort in the groin

May or may not be associated with a visible bulge

27
Q

How does the groin discomfort associated with hernias change with time?

A

Becomes worse when intra-abdominal pressure is increased, such as with straining, lifting heavy weights, coughing, prolonged standing, etc

Discomfort will be worse at the end of the day

Resolves when the patient stops straining or lies down

28
Q

Can hernias present with moderate to severe pain?

A

Yes

Indicates a complicated hernia however, and demands urgent investigation

29
Q

What is the most common finding on physical examination with hernias?

A

A bulge

30
Q

How can you detect a hernia on physical exam that is not grossly obvious?

A

Place the tip of the finger into the external inguinal ring and ask the patient to cough, the contents may come down to touch the fingertip

31
Q

How should you position the patient to best see a hernia?

A

Erect

32
Q

Can you assess for a cough impulse in a hernia with the patient standing?

A

Yes – this is the correct technique

Can be done supine as well though

33
Q

What can you do to identify a hernia on physical exam, when the hernia is not obvious (often won’t be)?

A

Nothing

Can’t palpate into the inguinal canal, can’t usually feel a cough impulse

34
Q

Which of the groin hernias are medial to the pubic tubercle, and which are lateral?

A

Femoral is lateral

Inguinal is medial

35
Q

What is the approx sensitivity and specificity of the physical exam and history together for diagnosing groin hernias?

A

Sensitivity 75%

Specificity 96%

36
Q

When do you perform imaging in diagnosing hernias?

A

When the type is not clear

Identify an occult hernia

To distinguish a hernia from another clinical entity

And to identify complicated hernias

37
Q

What is peritoneography/herniography?

A

Contrast is injected into the peritoneum and radiographic imaging is performed

Slightly more accurate but hardly ever done because ultrasound is very good and non-invasive and inexpensive

38
Q

Why is it particularly important to distinguish between inguinal and femoral hernias?

A

Because you can use watchful waiting for inguinal hernias, but femoral hernias pretty much always need to be operated on soon because they have a much higher chance of developing complications

39
Q

How do patients typically present when they have a complicated hernia?

A

Nausea/vomiting

Abdominal distension

Groin pain or mass

Bowel obstruction

40
Q

What is the definitive management for any type of hernia?

A

Surgical repair

41
Q

Why do we use watchful waiting in the case of inguinal hernias, rather than just treat them before they become symptomatic?

A

Because two studies showed that there was no penalty in morbidity or mortality for delaying repair until symptoms develop

42
Q

What are the contraindications to mesh hernia repair?

A

Mainly stems from standard contraindications to anaesthetics

Active infection prohibits the placement of foreign material into the body however

43
Q

What is an important complication of mesh hernia repair surgery?

A

Neuralgia

44
Q

What are some things you can do pre-operatively in mesh hernia repair to limit post-operative neuralgia?

A

Reduce post-operative pain with intensive pre and peri-op analgesia

Choice and placement of mesh – lighter mesh may have less inflammation

Prophylactic neurectomy – division of ilioinguinal nerve if it becomes entangled in the mesh

Careful approach to the surgery

cc: gastro (6 decks)

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