Hernias

Question 1

What is the definition of a hernia?

Answer 1

Protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position.

Question 2

What is a hiatus hernia?

Answer 2

Protrusion of an organ from the abdominal cavity into the thorax through the oseophageal hiatus. This is typically the stomach.

These are extremely common but usually asymptomatic. Estimated 1/3 of individuals over 50 have a hiatus hernia.

Question 3

What are the two classifications of hiatus hernias?

Answer 3

Sliding hiatus hernia (80%) - the gastro-oseophageal junction (GOJ), the abdominal part of the oseophagus and frequently the cardia of the stomach move or ‘slides’ upwards through the diaphragmatic hiatus into the thorax.

Rolling in Para-Oseophageal hernia (20%) - upward movement of the gastric fundus occurs to lie alongside a normal GOJ which creates a ‘bubble’ of stomach in thorax. True hernia with peritoneal sac. Proportion of stomach herniating may increase with time and eventually whole stomach could be thorax.

Can also get mixed type hernias.

Question 4

What are the risk factors for developing a hiatus hernia?

Answer 4

Increasing Age is biggest risk factor
Pregnancy
Obesity
Ascites

Question 5

What are the clinical features of hiatus hernias?

Answer 5

Vast majority completely asymptomatic

May experience GORD symptoms - often more severe and treatment-resistant

Question 6

What other signs and symptoms may occur in hiatus hernia?

Answer 6

Vomiting and weight loss (rare but serious)
Bleeding and/or anaemia (secondary to oseophagus ulceration)
Hiccups or palpitations (irritation to diaphragm or pericardial sac)
Swallowing difficulties (oseophageal strictures or rarely incarceration of the hernia)

Question 7

What my be seen of examination of hiatus hernia?

Answer 7

Typically normal examination

But may here bowel sounds within chest if hernia significant.

Question 8

What are the differential diagnosis for hiatus hernia?

Answer 8

Cardiac chest pain

Gastric or pancreatic cancer - particularly if signs of gastric outlet obstruction, early satiety or weight loss

GORD

Question 9

What is the gold standard investigation of a hiatus hernia?

Answer 9

OGD - shows upward displacement of GOJ

Question 10

What other investigations could be done for a hiatus hernia be found on?

Answer 10

Diagnosed incidentally on CT/MRI

Contrast shallow

Question 11

What is the conservative management of hiatus hernia?

Answer 11

PPI - taken in morning before food
Weight loss, altered diet, raise head of bed when sleeping
Smoking cessation and reduction in alcohol intake - both inhibit LOS function

Question 12

When is surgical management indicated in hiatus hernias?

Answer 12

Remaining symptomatic despite maximal medical therapy

Increased risk of strangulation/volvulus (rolling type or mixed hernia or contains other abdominal viscera) - usually require stomach decompression via a NG tube prior to surgery

Nutritional failure - due to gastric outlet obstruction

Question 13

What are the two aspects of hiatus hernia surgery?

Answer 13

Cruroplasty - hernia reduced from thorax to abdomen. Any large defects may require mesh to strength repair

Fundoplication - gastric fundus wrapped around lower oseophagus and stitched in place - aims to strengthen LOS and keep GOJ below diaphragm - may be full or partial wrap.

Question 14

What are the complications specific to hiatus hernia surgery?

Answer 14

• Recurrence of hernia
• Abdominal bloating - inability to bleach
• Dysphagia - too tight or too narrow. Common early on due to oedema. Settles with most pts but may enquire revision surgery.
• Fundal necrosis - blood supply via left gastric artery and short gastric vessels disrupted. Surgical emergency, typically requiring major gastric resection.

Question 15

What are the complication of hiatus hernias?

Answer 15

Incarceration and strangulation - especially rolling type

Gastric volvulus - require prompt surgical intervention

Question 16

How do the gastric volvulus as a result of hiatus hernias clinically present?

Answer 16

Borchardts traid:

• severe gastric pain
• retching without vomiting
• inability to pass and NG tube

Question 17

What are inguinal hernias?

Answer 17

When abdominal cavity contents enter into the inguinal canal.

Most common type of hernia.

Question 18

What are the two main subtypes of inguinal hernias?

Answer 18

Direct inguinal hernias (20%) - through Hesselbachs triangle - often occur in older pts, often from secondary abdominal wall laxity or significant increase in intra-abdominal pressure

Indirect inguinal hernias (80%) - deep inguinal ring - incomplete closure of processus vaginalis

Question 19

Where are the two types of inguinal hernias located relative to the inferior epigastric vessels?

Answer 19

Indirect - lateral

Direct - medial

Question 20

What are the risk factors for inguinal hernias?

Answer 20

Male
Increasing age
Raised intra-abdominal pressure - from chronic cough, heavy lifting, chronic constipation
Obesity

Question 21

What are the borders of the inguinal canal?

Answer 21

Floor - inguinal ligament
Anterior - aponeurosis of the external oblique
Roof - internal oblique and transversus abdominis
Posterior - transversalis fascia

Question 22

How will a reducible inguinal hernia present?

Answer 22

Lump in groin which will disappear with minimal pressure or when the pt lies down. Moderate discomfort which can worsen with activity or standing.

Question 23

How will a incarcerated/strangulated inguinal hernia present?

Answer 23

Painful, tender and erythematous
Irreducible
Pain out of proportion to clinical signs
Features of bowel obstruction may be present

Question 24

What specific feature should be noted on examination of an inguinal hernia?

Answer 24

• Cough impulse - may be absent if irreducible
• Location - inguinal (superomedial to the pubic tubercle) or femoral (inferolateral to pubic tubercle)
• Reducible
• if it enters the scrotum can you get above it?

Question 25

What is the only definitive way of differentiating between indirect and direct inguinal hernias?

Answer 25

At the time of surgery

Question 26

What are the differential diagnosis of inguinal hernias?

Answer 26

``` Femoral hernia Saphena varix Inguinal lymphadenopathy Lipoma Groin abscess Internal iliac aneurysm ``` If in scrotum then: hydrocele, varicocele or testicular mass

Question 27

What are the investigations for inguinal hernias?

Answer 27

Usually clinical diagnosis If diagnostic uncertainty or or exclude other diagnosis: Ultrasound scan CT imaging if features of obstruction or strangulation.

Question 28

What is the indication for surgery in inguinal hernias?

Answer 28

Symptomatic should be offered surgical interventions | Signs of obstruction or strangulation

Question 29

Which patients are managed conservatively for inguinal hernias?

Answer 29

Asymptomatic - but should be warned about future surgical management and safety netted on signs of strangulation.

Question 30

What are the two types of inguinal hernia repairs?

Answer 30

Open repair (Lichtenstein technique most commonly used) Laparoscopic repair (either total extra peritoneal (TEP) or trans abominable pre-peritoneal(TAPP)).

Question 31

When are open mesh repairs performed in inguinal hernias?

Answer 31

Primary inguinal hernias

Question 32

When is laparoscopic approach used in inguinal hernias repair?

Answer 32

Bilateral or reccurent inguinal hernias Certain pts with primary unilateral hernia - those at high risk of chronic pain or in females due the risk of presence of femoral hernia.

Question 33

What are the main complications of inguinal hernias?

Answer 33

Incarceration Strangulation Obstruction

Question 34

What are the post-op complications in inguinal hernia repairs?

Answer 34

Pain, bruising, haematoma, infection or urinary retention Recurrence Chronic pain Damage to vas deferens or testicular vessels - ischaemic orchitis

Question 35

What are femoral hernias?

Answer 35

Abdominal viscera or omentum passes through the femoral ring and into the potential space of the femoral canal. Relatively uncommon and high rate of strangulation. More common in females.

Question 36

What are the risk factors for femoral hernias?

Answer 36

Female Pregnancy - higher incidence in multiparous women Raised intra-abdominal pressure Increasing age

Question 37

What are the clinical feature of femoral hernias?

Answer 37

Small lump in groin - asymptomatic aside from lump - unlikely to be reducible May just present with vomiting - should have groins examined 30% present as emergency either obstruction or strangulation

Question 38

On examination of hernias how would you differentiate femoral and inguinal hernias?

Answer 38

Femoral - found inferno-lateral to pubic tubercle (and medial to femoral pulse) Inguinal - supero-medial to pubic tubercle Femoral hernias can roll up in front of inguinal ligament and are often misdiagnosed as inguinal.

Question 39

What are the differential diagnosis for femoral hernias?

Answer 39

``` Inguinal hernia Lipoma Lymph node Saphena varix Femoral artery aneurysm Athletic pubalgia ```

Question 40

What are the investigations for femoral hernias?

Answer 40

All need surgery - so pre-op investigations Clinically diagnosis but often additional imaging required: - ultrasound - CT abdomen-pelvis scan

Question 41

What is the management of femoral hernias?

Answer 41

All should be managed surgically within 2 weeks due to high risk of strangulation.

Question 42

What does a surgery for femoral hernias involve?

Answer 42

Reducing the hernia | Narrowing the femoral ring - with sutures or mesh plug

Question 43

What are the two approaches that can be taken in femoral hernia surgery?

Answer 43

Low approach - below inguinal ligament - does not interfere with inguinal structures but does limit space for removal of any compromised bowel. High approach - above the inguinal ligament - preferred in emergency - easier access

Question 44

What are the complications of femoral hernias?

Answer 44

Strangulation | Obstruction

Question 45

What is an incisional hernia?

Answer 45

Reducible, non-tender swelling at or near the site of a surgical incision.