Hernias

Question 1

What are the 3 types of groin hernia?

Answer 1

Direct inguinal
Indirect inguinal
Femoral

Question 2

What anatomy is involved with a direct inguinal hernia?

Answer 2

Protrudes through hesselbach’s triangle

Passes medial to the inferior epigastric artery

Question 3

What are the borders of the Hesselbach’s triangle?

Answer 3

Medial – lateral border of the rectus abdominis muscle.
Lateral – inferior epigastric vessels.
Inferior – inguinal ligament.

Question 4

What causes direct inguinal hernias?

Answer 4

Defect or weakness in the transversalis fascia area of the Hesselbach triangle

Question 5

Who generally gets direct inguinal hernias?

Answer 5

Male adults

Question 6

What anatomy is involved with a indirect inguinal hernia?

Answer 6

Protrudes through the inguinal ring

Passes lateral to the inferior epigastric artery

Above and medial to pubic tubercle

Question 7

What causes indirect inguinal hernias?

Answer 7

Failure of the processus vaginalis to close

embryonic developmental outpouching of the parietal peritoneum

Question 8

Who generally gets indirect inguinal hernias?

Answer 8

Infants

Males

Question 9

What anatomy is involved in femoral hernias?

Answer 9

Protrudes below the inguinal ligament, lateral to the pubic tubercle

Question 10

What is worrying about femoral hernias?

Answer 10

High risk of strangulation

Question 11

Who generally gets femoral hernias?

Answer 11

Adult females

Question 12

Define hernia

Answer 12

Protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it

Question 13

What are risk factors for abdominal wall hernias?

Answer 13

obesity
ascites
increasing age
surgical wounds

Question 14

What are the presenting features of abdominal wall hernias?

Answer 14

palpable lump
cough impulse
pain
obstruction: more common in femoral hernias
strangulation: may compromise the bowel blood supply leading to infarction

Question 15

What are the different types of abdominal wall hernia?

Answer 15

Inguinal
Femoral
Umbilical
Paraumbilical
Epigastric
Incisional

Question 16

What is an umbilical hernia?

Answer 16

Symmetrical bulge under the umbilicus

Question 17

What is a paraumblical hernia?

Answer 17

Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus

Question 18

What is a epigastric hernia?

Answer 18

Lump in the midline between umbilicus and the xiphisternum

Most common in men aged 20-30 years

Question 19

What are congenital inguinal hernias?

Answer 19

Indirect hernias resulting from a patent processus vaginalis

Occur in around 1% of term babies. More common in premature babies and boys

Question 20

What is incarceration of a hernia?

Answer 20

herniated tissue cannot be reduced

Question 21

How urgent is hernia strangulation?

Answer 21

Surgical emergency that requires urgent management

Question 22

How will strangulated hernias present?

Answer 22

tender and likely non-reducible, and may also present with a systemically unwell patient

Question 23

How can femoral hernias be repaired?

Answer 23

laparoscopically or via a laparotomy

laparotomy only option in emergency

Question 24

How are hernias diagnosed?

Answer 24

Clinically by observation/palpation

Imaging only when complex e.g. obese

Question 25

What are some differentials for a groin lump?

Answer 25

``` Indirect inguinal hernia Direct inguinal hernia Femoral hernia Inguinal lymphadenopathy Psoas abscess Femoral aneurysm ```

Question 26

What question do you want to ask about a groin lump?

Answer 26

How long has it been there? Is the lump always there? Does it reduce when lying down? Painful? will be if strangulated hernia, groin abscess Other lumps?

Question 27

What may cause hernias to increase in size?

Answer 27

Increase intra-abdo pressure e.g. Coughing, straining on loo

Question 28

How can you differentiate between hernias and lymph nodes?

Answer 28

Swollen lymph lodes are solid Hernias, aneurysms etc. are softer and can be fluctuant Aneurysms will be fluctuant

Question 29

What are the differences in direct and indirect hernias?

Answer 29

Direction of reducibility Direct - reduce superiorly Indirect - reduce inferiorly

Question 30

Why must the rest of the abdomen be examined with an hernia?

Answer 30

Check for masses, ascites, tumour, gross faecal loading | All can raise intra-abdo pressure which can predispose hernia

Question 31

What bedside test can help confirm whether a hernia is direct or indirect?

Answer 31

Reduce the hernia Place a finger over the deep ring Ask pt to cough If hernia emerges whilst you are occluding the deep ring it must be direct If only emerges once finger is removed it is indirect

Question 32

What can a strangulated hernia cause?

Answer 32

Small bowel obstruction | Colicky pain, N+V

Question 33

What are the management options for a direct inguinal hernia?

Answer 33

Nothing - advise to represent if it becomes symptomatic Truss - prevents bowel obstruction, only if reducible Surgery

Question 34

What are the causes inguinal lymphadenopathy?

Answer 34

Infective Systemic - HIV - TB Infective local - Lower limb/groin infection/STD Neoplastic Systemic - Lymphoma - Leukaemia Neoplastic local - Mets