hernias Flashcards
(39 cards)
def hernia
The protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.
irreducible - contents can’t be pushed back into place
obstructed - bowel contents cannot pass - features of intestinal obstruction
strangulated - ischemia occurs, pt requires urgent surgery
incarceration - contents of the hernial sac are stuck inside by adhesions. Care must be taken with reduction as it is possible to push an incarcerated hernia back into the abdominal cavity, giving the initial appearance of successful reduction.
inguinal hernia
a loop of bowel or mesentery protrudes out from the abdomen via the deep inguinal ring, enters the inguinal canal first into the inguinal area and then into the scrotum.
indirect hernia
protrusion of the hernial sac through deep inguinal ring with coverings of spermatic cord, following path of inguinal canal
pass through internal ring and if large out of external ring
direct inguinal hernia
push their way directly forward through the transversalis fascia and posterior wall of the inguinal canal into a defect in the abdo wall (Hesselbach’s triangle, MEDIAL to the inferiro epigastric vessels and lateral to the rectus abdominus)
only pass through the superficial ring
femoral hernia
abnormal protusion of a peritoneal sac often with abdominal contents through the femoral canal
aetiology inguinal hernia
male > female
prematurity
age
obesity
bladder outflow obstruction
chronic cough
constipation
urinary obstruction
heavy lifting
ascites
past abdo surgery (eg damage ot the iliohypogastric nerve during appendectomy)
Indirect inguinal hernias are associated with a patent processus vaginalis, an invagination of the embryonic parietal peritoneum into the scrotum. This results in the formation of the inguinal canal which permits the testes to subsequently enter the scrotum from the abdomen. - usually closes but in some people stays open
muscle weakening can also explain why hernias are also more common at the sites of surgical incisions, ie. surgical scars. These are known as incisional hernias, and can easily be demonstrated on the abdomen, if present, by asking a patient to lift their torso off the examination couch without using their hands (almost as if they are doing a sit-up). The increased pressure within the abdomen will cause the viscera involved to pop outwards at the surgical scar.
aetiology direct hernia
acquired
weakening of transversalis fascia
- secondary to conditions resulting in increased intraabdominal pressure (e.g., chronic obstructive pulmonary disease with chronic coughing, constipation)
- long term glucocorticoid use
Hernial sac protrudes directly through the posterior wall of the inguinal canal (without involvement of the spermatic cord or round ligament of the uterus)
Only surrounded by the external spermatic fascia
through hesselbach triangle - inguinal ligament, inferior epigastric vessel, rectus abdominus
aetiolofgy indirect inguinal hernia
congenital
Most commonly results from incomplete obliteration of processus vaginalis during fetal development (but can also be acquired).
May not become apparent until adulthood despite being present since birth.
Surrounded by the external spermatic fascia, cremasteric muscle fibers, and internal spermatic fascia
aetiology femoral hernia
advancing age and female (wider angle between inguinal ligament and pectineal part of pubic bone, and wider femoral canal)
increased intra-abdominal pressure
- obestity
- constipation
- chronic cough
- straining during micturition (due to prostatic hypertrophy)
- straining due to prostatism
multiparity
previous abdo surgeries - especially thise involving the inguinal region
almost always acquired
protrusion of intraperitoneal contents along with the transverse abdominal fascia through the femoral ring into the femoral canal
aetiology miscellaneous hernia
weakness in the abdominal wall (eg due to obesity or previous surgery) and increased intraabdominal pressure eg coughing and straining allows formation of the hernial sac
RF hernia
obesity
abdominal distension eg ascites
post-op wound infection
path
inguinal pathology
- indirect, direct and a combination ‘pantaloon’ hernia
- indirect R more common than L - R testis descends later
femoral pathology
- narrow margins of canal predispose to incarceration of hernia contents - omentum, bowel, extraperitoneal fat or ovary
- vascular supply compromised - tissues become ischemic/gangrenous
epi hernia
inguinal - more in men than women, commonest type of hernia in both, 55-85yrs. 10 elective repairs per 10000 population in UK/yr
indirect > direct
femoral - occur more often in female, especially in middle age (40-70) and the elderly
indirect inguinal hernia occurs in approx. 2% infants, 4% of male births
sx inguinal hernia
visible, palpable groin protusion or bulge
inguinal pain - doesnt always correlate to the size of the hernia
Increase of symptoms during physical activity (walking or standing, coughing, sneezing, abdominal pressure)
disappears when pt lies down
irreducibility
epi miscellaneous hernia
incisional, epigastric and paraumbilical hernias are relatively common
umbilical hernias commonly seen in newborns - especially afro-caribbeans
sx femoral hernia
non complicated femoral
- a globular, subcutaneous swelling in groin - inferior to inguinal ligament, lateral to pubic tubercle and medial to femoral vein
- swelling enlarges with coughing
- possible non-specific dragging pain
- lower abdo discomfort
small so often present with strangulation/obstruction = surgical emergency
- pain
- abdo distension
- nausea
- vom
- absolute constipation
sx miscellaneous hernia
may be asymptomatic
pts may notice lump themselves
may present because of discomfort, irreducibility, increase in size, pain or for cosmotic reasons
strangulated hernias - painful, red and swollen
obstruction - constipation, colicky abdo pain, nausea, vomiting.
Richter hernias have symptoms of obstruction but still pass flatus as the bowel lumen is still patent.
sign femoral
bowel enters the femoral canal - presents as mass in upper medial thigh or above the inguinal ligament pointing down leg
likely to be irreducible and strangulate because of the rigidity of the borders of the femoral canal
swelling in groin below and lateral to pubic tubercle - if large may spread up and over the inguinal ligament
absence of cough reflex over inguinal ring
if incarcerated/strangulated = tender
signs of bowel obstruction - distention, high pitched bowel sounds
sign inguinal
points to the groin
Indirect inguinal hernia may be associated with a communicating hydrocele
groin lump - may extend to scrotum or labia
emerge above and medial to pubic tubercle
standing hernia associated with cough impulse
indirect may be controlled by pressure over deep ring
auscultation might show bowel sounds in hernia
may be irreducible if incarcerated
very tender if strangulated
signs of complications - bowel obstruction, systemic upset, pyrexia and tachycardia
deep (internal) ring
midpoint of the inguinal ligament approx 1.5cm above the femoral pulse which crosses the mid inguinal point
superficial (external) ring
split in the external oblique aponeurosis just superior and medial to pubic tubercle - the bony prominence forming medial attachment of the inguinal ligament
sign, miscellaneous hernia
have a cough reflex (owing to transmitted pressure from the abdomen)
can be reduced (pushed back) into the abdomen.
abnormal swelling that increases in size with coughing or abdominal straining
often non-tender and soft
may become tender and irreducible if incarcerated or strangulated
assess for bowel sounds, or signs of obstruction in acute presentation
inguinal hernia ix
look for previous scars
feel other side - more common on R
examine external genitalia
ask if the lump is visible, if so ask the patient to reduce it - if they cant make sure not a scrotal lump
if no lump visible feel for cough impulse
repeat exam with ot standing
FBC, U&Es, CRP, clotting, G&S if operation likely
ABG indicate bowel ischemia in hernia - met acidosis and high lactate
US - visualisation of the hernial orifice and hernial contenst may be possible, exclude other groin lumps
erect CXR and AXR
CT/MRI - to distinguish from ddx in difficult cases
however typically diagnosed on history and exam
distinguishing direct from indirect
reduce the hernia and occlude the deep ring with 2 fingers (midpoint of inguinal ligament - between ASIS and pubic tubercle)
ask pt to cough or stand
if hernia is restrained it is indirect, if not it is direct
gold standard for determining is at surgery - direct are medial to inferior epigastric vessels, indirect are lateral
