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Flashcards in Hernia Deck (43):
1

Types of hernia

1. Internal
2. External
Inguinal
Femoral
Incisional
Obturator

2

Litres hernia

Meckels diverticulum within the defect

3

Predisposing

1. Weakness in abdominal wall
2. Increased intrabdominal pressure

4

Weaknesses in abdominal wall mechanisms

1. Congenital
Patent umbilical ring
Patent oricessus vaginalis
Canal of nuck
Diaphragmatic defect
2. Where normal structure pass through
Esophageal hiatus
Diaphragm
Obturator
Sciatic foramen
3. Acquired
Surgical scar
Incision
Muscle wasting
Fatty infiltration

5

Causes of + intra-abdominal pressure

Coughing
Vomiting
Pregnancy
Ascites
Organomegaly
Obesity
COAD
Heavy lifting

6

Complications

1. Irreducibility
2. Obstruction
3. Strangulation

7

Irreducibility

Should be operated on ASAP->obstruction and pain
1. Adhesions between the contents and the sac
2. Fibrosis leading to narrowing of neck, or sudden ++IAP contents moves through and content move back

8

Obstruction

Occlusion of the lumen contained within the sac
Signs of intestinal obstruction->vomiting, constipation, distension, tender

9

Strangulation

Lymph and venous congestion->++Pressure, reduced arterial supply= ischemic, necrosis, perforation->peritonitis

Needs surgery

10

How is the integrity of the inguinal canal maintained

Shutter mechanism
Oblique orientation
Posterior wall

11

Indirect hernia: cause, types

Failure of processus vaginalis to completely obliterate
1. Bubonocele= within canal
2. Funicular= to superficial ring
3. Complete= within scrotum/labia majora

12

Inguinal hernias in children are always what type

Indirect
Due to patent ductus vaginalis

13

In children, what side is more common

Right
Descent is slightly later

14

What is a direct hernia

Through posterior wall of inguinal canal

15

Do direct hernias occur in children

No

16

Principles of treatment

1. Correct the defect
2. Correct causes of +intra-abdominal pressure
-lose weight, lose ascites, lose baby
-Better COPD/asthma management

17

Attempts to reduce hernia

1. Elevate end of the bed
2. After 20-30 mins firm manual pressure
3. Provide analgesia prior to attempt

18

Management of uncomplicated hernia

1. No treatment->+morbidities, not tolerate surgery, Truss
2. Watchful waiting->small, asymptomatic. Reassess in 6 months. No harm in waiting
3. Operative
4. Diet, stop smoking

19

Management in comlpicated

Always surgery
1. ABC, cannula
2. IVF,
3. Investigations
FBC, Group and hold, LFTs, UEC, glucose
ECXR->perforation
AXR->Obstruction
3. Keep NBM
4. Surgical consult
5. Analgesia
6. NGT
7. Prophylaxis antibiotics: cephazolin 2g
8. Consent and book
9. Admit

20

Purpose of surgical management

1. Reduce the hernial contents
2. Excise the sac->herniotomy, most cases
3. Repair and close the defect->restore normal anatomy (herniorrhaphy), or insert additional material (hernioplasty)

21

Herniorraphy

1. Strengthening of posterior wall and repair of EO aponeurosis in front of canal
a. Nylon darn repair
2. Bassini
3. Shouldice

22

Hernioplasty

1. Insertion of prosthetic mesh
2. Two arms encircle deep ring, sutured to posterior wall

23

Ilioinguinal nerve

Traverses the inguinal canal near the external inguinal ring. Provides unilateral sensory innervation to the pubic region and the upper portion of the scrotum or the labia majora. This is the nerve most commonly injured during open herniorrhaphy

24

Iliohypogastric nerve

Passes superior to the internal inguinal ring and provides sensory innervation to the skin superior to the pubis

25

Genitofemoral nerve

The genital branch of the genitofemoral nerve travels within the spermatic cord to provide sensation to the scrotum and the medial thigh. The femoral branch of this nerve supplies sensation to the skin of the anterior thigh.

26

Consenting for hernia

1. You have an inguinal hernia->bowel and the sac pushed through muscle layer of abdominal wall. Surgery to avoid strangulation.
2. Laparoscopic (3 incisions)->push bowel back through to abdominal wall, a mesh sutured over the top. Non absorbable permanent sutures. Quick and effective, does require GA.
3. IV line and catheter
4. Stay in hospital 1-2 days.
5. Fast from midnight, arrive on day.
6. After operation->not to strain/heavy lifting, avoid driving 1 weeks, avoid sex for several weeks, work leave 1-6 weeks, judge exercise by pain and confidence
7. General risks:
Nausea, vomiting, diarrhea, allergy (GA)
Infection
Bleeding
Atelectasis ->Pain and mobilise
Wound infection, dishiscience
MI, stroke, DVT/PE
Death
8. Specific
Change to laparotomy
Damage to bladder, GIT
Gas causing complications
Urinary retention, ileus
Swelling of testicle and scrotum, hematoma
Epididymis damage->may reduce fertility
Ilioinguinal nerve damage->long term burning and aching
Testiuclar atrophy->damage to testicular artery
Adhesions
Scar
Recurrence
Incisional hernia
9. Agree and consent, transfusion?

27

Management following hernia repair

1. Simple analgesia
2. Mobilising
3. DVT prophylaxis
4. Avoid heavy lifting, driving, straining 6-8 weeks. Off work 2-4 weeks

28

Femoral hernia: presentation, etiology, epidemiology

1. Bulge at femoral canal
2. Transversalis fascia disrupted
3. Most common site for richters, localised weak at femoral ring, +IA pressure
4. Epidemiology:
Women, older, parous

29

Management of femoral hernia

1. Advise surgery
2. Open and empty sac->sutures between inguinal and pectineal ligaments

30

Umbilical hernia in children: epidemiology, prognosis, management

1. Found in 5-10% children
2. 1/3 close within a month, rarely persist >3-4 months
3. Rarely irreducible, rarely strangulates
4. Generally do nothing as most will resolve
5. Look to treat when ++size or presents at school age

31

Incisional hernias: what, predisposing, management

1. Protrusion at site of scar, 5% in 5 years
2. Poor surgical, local wound complications, impaired wound healing, +IA pressure
3. Needs repair->difficult to repair when large, risk of irreducibility and complications

32

Presenttaion of epigastric hernia

Young fit males presenting with epigastric discomfort
Defect in linea alba
May be confused with peptic ulcer
USS can be used to visualise

Mayo or keel repair

33

Location of deep inguinal ring

Mid point of inguinal ligament, 1 1/2 cm above femoral pulse

34

Location of superficial inguinal ligament

Superior and medial to pubic tubercle

35

Differential for groin pain

1. Hernia
2. Muscle strain
3. Adenopathy
4. Testicular torsion

36

Obturator hernia: define, epiD, examination findings

1. Herniation through the obturator canal alongside the obturator vessels and nerves. 2. This hernia occurs mostly in women, particularly multiparous women with a history of recent weight loss.
3. A mass may be palpable in the medial thigh, particularly with the hip flexed, externally rotated, and abducted
(Howship-Romberg sign).

37

What makes up the anterior wall of hasselbachs triangle

In this triangle, the peritoneum and transversalis fascia are the only components of the anterior abdominal wall.

38

Physiology of wound healing

1. Inflammatory: immediate->few days->sterilise, +growth factors, fibroblasts and keratinocytes
2. Proliferation: fibrin-fibrinogen, collagen, wound matrix and +strength
3. Remodelling: capillary regression= less vascularised, +in wound tensile strength

39

Clinical factors affecting wound healing

1. Infection: delayed fibroblast proliferation/matrix/deposition
2. Nutrition->vitamin C and A (fibroB, collagen cross linking, epithelial)
3. Oxygenation
4. Corticosteroids
5. DM

40

Time of highest risk of evisceration and wound dishiscence

At 7 days

41

Technical factors relating to abdominal closure failure

1. INadequate tissue incorporation
2. Inappropriate sutures
3. Excessive tension
4. Inadequate patient relaxation
5. Inappropriate suture placement

42

When to suspect fascial defects

Drainage of serous or serosanguinous fluid from otherwise normal wound

43

Most common form of incisional hernia repair

Mesh