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Flashcards in Hernia and Abdominal Wall Problems Deck (49)
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1

#1 hernia in both male AND females?

indirect inguinal

2

Hernia general info

Protrusion of a viscus through an abnormal opening in the wall of a cavity in which it is contained

10% of population develops some sort in life. 3-4% current male population

50% indirect inguinal
25% direct (mostly people over 50)
15% femoral

Abdominal wall hernia is #1 condition requiring major surgery

3

External hernia

Sac protrudes completely through the abdominal wall. Ex = inguinal (indirect and direct), femoral, umbilical, epigastric

4

Internal hernia

sac is within the visceral cavity.

Ex = diaphragmatic (congenital or acquired), small intestine herniating in the paraduodenal pouch

5

Intraparietal hernia

sac is contained within abdominal wall

Ex = spigelian hernia

6

Reducible vs irreducible

Irreducible = incarcerated

Cannot be returned to abdomen

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Strangulated

vascularity of viscus is compromised

surgical emergency

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Layers of abdominal wall

skin
subq fat
camper's
Scarpa's
External oblique
Internal oblique
transversalis abdominis
transversalis fascia
peritoneal fat
peritoneum

9

Inguinal canal

Length = 4cm

Anterior = ext oblique aponeurosis

Posterior = transverse abdominal muscle aponeurosis and transversalis fascia

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Spermatic cord

Begins at deep ring and contains:

Vas Deferens and its artery

1 testicular artery

2-3 veins

lymphatics

Autonomic nerves

Fat

11

Genital nerve

Travels along with cremaster vessels to form neurovascular bundle

From L1 and L2

Motor and sensory

Innervates cremaster, skin of side of scrotum and labia

May sub for ilioinguinal nerve if it doesn't work

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Iliohypogastric, ilioinguinal nerves, genital branch of genitofemoral nerve

Iliohypogastric and ilioinguinal intertwine

originate from T12 and L1

Sensory to groin skin, base of penis, medial upper thigh

Genital branch of genitofemoral nerve is located on top of spermatic cord in 60% of people but can be found behind or within the cremaster muscle. Often cannot be found or is too small to be seen

13

Femoral canal structures

Lateral to medial = NAVEL

Nerve
Artery
Vein
Empty space
LN

14

Hesselback's triangle

lower abdominal wall

site of direct inguinal hernias

Inferior = inguinal ligament

Medial = rectus abdominis

Lateral = Inferior epigastric vessels (lateral umbilical fold)

15

Triangle of Grynfeltt

"superior lumbar triangle"

Bounded by 12th rib superiorly

Internal oblique anteriorly

Floor = fibers of quadratus lumborum muscle

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Triangle of Petit

"inferior lumbar triangle"

Posterior = Lat
Anterior = ext oblique

Inferior = iliac crest

Floor = fibers from int oblique and transversus ab

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Inguinal hernia - general

Hernias arising above the abdominocrural crease

Most common site for abdominal hernias

Male:Female = 25:1

Males: Indirect > direct (2:1)

Female: Direct is rare

Incidence, strangulation, and hospitalization all increase with age

Cause 15-20% of intestinal obstructions

18

Risk factors for inguinal hernia

1) Abdominal wall hernias occur in areas where aponeurosis and fascia are devoid of protecting support of striated muscle

2) They can be congenital or acquired by surgery or muscle atrophy

3) Female predisposition to femoral hernias: increased diameter of the true pelvis as compared to men, proportionally widens the femoral canal

4) Muscle deficiency of the internal oblique muscles in the groin exposes the deep ring and floor of inguinal canal, which are further weakened by intra-abdominal pressure

5) Connective tissue destruction (transverse aponeurosis and fascia): caused by physical stress 2/2 intra-abdominal pressure; smoking; aging; connective tissue disease; systemic illness; fracture of elastic fibers; alterations in structure, quantity and metabolism of collagen

6) Other: Abdominal distention, ascites with chronic increase in intra-abdominal pressure, peritoneal dialysis

19

Symptoms of inguinal hernia

Asymptomatic sometimes

Symptomatic - nonspecific discomforts vary by patient

Pain: Worse at the end of the day and relieved at night when patient lies down (bc hernia reduces)

Groin hernias do NOT usually cause testicular pain. Likewise, testicular pain doesn't usually indicate the onset of a hernia

20

Dx of inguinal hernia

PE

In standing position, have patient strain or cough. Hernia sac will enlarge and transmit a palpable impulse

Hydroceles can resemble an irreducible groin hernia. To distinguish, transilluminate (hernia will not light up)

21

Ddx of inguinal hernia

Abdominal wall mass

Desmoids

Neoplasm

Adenopathy

Rectus sheath hematoma

22

Radiology role in inguinal hernias

diagnosis is clinical

imaging only used in special cases like when obesity limits clinical exam (US/CT)

23

Management of inguinal hernia

Principles of Tx:
1) Tension-free repair of hernia defect

2) Repair using fascia, aponeurosis or mesh

3) Suture material used should hold until fibrous tissue is formed over it

4) Resuscitation in case of strangulated hernia with gangrene with shock or with intestinal obstruction

Nonsurgical:
1) No role for medical management in patient who can tolerate surgery

2) Can be considered in moribound patients

3) Hernia truss is a device to keep a reducible hernia contained by external pressure

Surgical:
1) Treatment of choice

2) Herniotomy is when hernia sac is ID'd, freed, its neck ligated and the sac is reduced. May be enough in young, muscular person and in kids

3) Herniorrhaphy and hernioplasty are herniotomy along with repair of posterior wall of inguinal canal and internal ring

24

Complications of surgical repair

Ischemic orchitis with testicular atrophy

Residual neuralgia

Both: more common with anterior groin hernioplasty bc of the nerves and spermatic cord dissection and mobilization

25

Prognosis following surgery

Expert surgeons 1-3% in 10y follow up

Caused by excessive tension on repair, deficient tissue, inadequate hernioplasty or overlooked hernias

Decreased with relaxing incisions

More common with direct hernias

26

Direct inguinal hernia

A direct hernia enters inguinal canal through its weakened posterior wall. The hernia does NOT pass through internal ring

- Lies posterior to spermatic cord
- Practically never enters scrotum
- wide neck (strangulation rare)
- almost all in men
- common in older age groups
- common in smokers due to weakened connective tissue
- predisposing factors = hard labor, cough, straining, and so on
- can lead to damage to ilioinguinal nerve

Symptoms:
- bulge in groin
- Dull dragging pain in inguinal region referred to testis
- Pain increases with hard work and straining

27

Indirect inguinal hernia

Herniation through internal ring traveling to external ring. If complete, it can enter the scrotum while exiting external ring

If congenital, associated with patent processus vaginalis

B/l in 33% of cases

Most common hernia in men AND women

Occurs at all ages

More common in men

In first decade of life, the right-sided hernia is more common than left bc of late descent of R testis

28

Femoral hernia def

Form of indirect hernia arising out of the femoral canal beneath the inguinal ligament (medial to femoral vessels)

Female: Male = 2:1

Males affected are in younger group

Rare in children

Uncommon - 2.5% of all groin hernias

Left side 1:2 right side 2/2 sigmoid colon tamponading the left femoral canal

Common in elderly patients

High incidence of incarceration due to narrow neck

22% strangulate after 3 months
45% after 21 months

29

Anatomy of femoral hernia

Femoral canal is 1.25cm long and arises from femoral ring to the saphenous opening

Femoral sac originated from femoral canal through defect on the medial side (common) or anterior (rare) side of femoral sheath

30

Symptoms of femoral hernia

Dull dragging pain in groin with swelling

If obstructed, can cause vomiting and constipation

If strangulated, can lead to severe pain and shock

Swelling arises from below the inguinal ligament