Hernias

Question 1

What is a hernia?

Answer 1

the protrusion of a viscus into an abnormal space
a hernia is an organ or piece of tissue that passes through a hole and ends up somewhere it isn’t supposed to be. Herniation most commonly affects abdominopelvic organs but can also involve other parts of the body such as the intervertebral discs of the spine, the lung, or the brain.

Question 2

What is meant by a reducible hernia?

Answer 2

the contents of the hernia can be manipulated back into their original position through the defect from which they have emerged. These hernias are either left alone or repaired electively.

Question 3

What is meant by an incarcerated or irreducible hernia?

Answer 3

the contents of the hernia are stuck and cannot be pushed back into their original position. This can be due to sudden constriction of the hernia at the level of the fascial defect resulting in painful swelling of the tissues.

Acutely incarcerated hernias should be repaired urgently. Other hernias can gradually become adherent to the surrounding tissues over time without causing any constriction of the contents.

Chronically incarcerated hernias are usually repaired electively unless they are very painful or at high risk of obstruction or strangulation.

Question 4

What is meant by an obstructed hernia?

Answer 4

the contents of a hernia containing bowel are compressed to the extent that the bowel lumen is no longer patent, leading to obstruction. The cardinal features of intestinal obstruction are colicky abdominal pain, distension, vomiting and absolute constipation. These hernias generally require emergency surgery unless they can be reduced very quickly.

Question 5

What is meant by a strangulated hernia?

Answer 5

ompression of the contents of the hernia by the fascial defect prevents blood flow into the tissues, causing ischaemia which may lead to infarction and necrosis. This typically presents with disproportionately severe constant pain, systemic illness and sepsis. These hernias are the most serious and require emergency surgery as soon as possible to salvage or resect their contents.

Question 6

What is a hernia neck?

Answer 6

An abdominal hernia passes through an existing anatomical opening or an acquired fascial defect. Its contents are usually contained within a sac of parietal peritoneum. The opening it emerges from is called the hernia neck. This may be wide or narrow, and its edges may consist of fascial tissue, ligament or bone

Question 7

What are the two main causes of a hernia?

Answer 7

1. Increased intra-abdominal pressure
2. Weakened-tissues

Question 8

What causes increased intra-abdominal pressure?

Answer 8

1. Chronic cough: COPD, smoking, Bronchiectasis, cystic fibrosis
2. Abdominal distension: pregnancy, acites, peritoneal dialysis, obesity
3. Straining: Chronic constipation, prostatism, heavy lifting during work or exercise
4. Kyphoscholiosis (abnormal curvature of the spine)

Question 9

What are the causes of weakened tissues?

Answer 9

1. Congenital defects: patent processus vaginalis, patent umbilical ring
2. Collagen disorders: Ehlers-Danlos syndrome, vitamin C deficiency, family history of hernias
3. Trauma
4. Ageing
5. Chronic malnutrition
6. Long term corticosteroid use

Question 10

What is the most common type of hernia?

Answer 10

Inguinal hernia
Account for 70% of all hernias

Question 11

What is an inguinal hernia?

Answer 11

An inguinal hernia is an abnormal protrusion of abdominopelvic contents through the superficial inguinal ring into the groin.

Question 12

Where is the inguinal ligament?

Answer 12

The inguinal ligament runs between the anterior superior iliac spine (ASIS) and the pubic tubercle (PT). Just above this ligament runs a structure known as the inguinal canal.

Question 13

What is the function of the inguinal canal?

Answer 13

to provide a passageway between the peritoneal cavity and the external genitalia. In men, it transmits the spermatic cord to the testis, and in women, it contains the round ligament

Question 14

What does the inguinal canal carry in both sexes?

Answer 14

1. Ilioinguinal nerve
2. Genital branch of the genitofemoral nerve

Question 15

What is the deep inguinal ring?

Answer 15

Entry point from the abdominal cavity
The deep ring is located just above the mid-point of the inguinal ligament

Question 16

What is the superficial inguinal ring?

Answer 16

an exit point into the groin
The superficial ring lies just above and lateral to the pubic tubercle.

Question 17

What is a direct inguinal hernia?

Answer 17

A direct inguinal hernia is caused by a weakness in the posterior wall of the inguinal canal in an area known as Hesselbach’s triangle.

Abdominal contents (usually just fatty tissue, sometimes bowel) are forced “directly” through this defect into the inguinal canal. The hernia enters the canal medial to the deep ring and exits via the superficial ring

Question 18

What is an indirect inguinal hernia?

Answer 18

the abdominal contents enter the deep ring, pass along the length of the inguinal canal and exit via the superficial ring

Question 19

What are the similarities of direct and indirect inguinal hernias?

Answer 19

1. Both types of inguinal hernia exit the superficial ring and can sometimes enter the scrotum (inguinoscrotal hernia)

Question 20

What are is the difference between indirect and direct inguinal hernias?

Answer 20

The principle of this is that if you place your finger over the deep inguinal ring (just above the mid-point of the inguinal ligament), then you can control an indirect inguinal hernia which has been reduced. If when you press the deep ring, the hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point and is, therefore, a direct hernia.

Question 21

What are the risk factors for inguinal hernias?

Answer 21

1. Males
2. Peak age 70
3. Low BMI (obesity = protective)

Question 22

What are the clinical features of inguinal hernias?

Answer 22

Mostly asymptomatic
- Can present with groin pain/discomfort (especially after coughing or bending over)
-Pain/ altered sensation over the scrotum or inner thigh due to compression of ilioinguinal nerve
-Change in bowel habits or urinary symptoms

Question 23

What type of hernias commonly present to emergency departments?

Answer 23

1. Incarcerated
2. Obstructed
3. Strangulated

Question 24

How can inguinal hernias be diagnosed?

Answer 24

Clinical examination: palpable swelling above and medial to the pubic tubercule
In diagnostic uncertainty, an ultrasound scan of the groin can help differentiate between other possible causes

Question 25

What are some differential diagnoses for inguinal hernias?

Answer 25

1. Enlarged lymph nodes
2. Fatty lumps
3. Vascular pathology

Question 26

What is the gold standard of treatment for inguinal hernias?

Answer 26

Mesh repair

Question 27

What is open repair for inguinal hernias?

Answer 27

Open repair involves directly exploring the inguinal canal via a groin incision, identifying and protecting important structures (including the spermatic cord and ilioinguinal nerve), reducing the contents of the hernia back into the abdominal cavity, and placing a mesh to strengthen the deep inguinal ring and the posterior wall. It is a simple operation with excellent results and can be done under either general or local anaesthetic.

Question 28

What type of hernia is open repair preferred for?

Answer 28

Large inguinoscrotal hernias

Question 29

What is the laparoscopic repair approach?

Answer 29

The operation involves visualising the anatomy from within the abdominal cavity, opening the peritoneum, pulling the contents of the hernia back inside, and placing a mesh in the preperitoneal space to cover the defect

Question 30

What type of hernias is the laparoscopic repairs preferred for?

Answer 30

Recurrent or bilateral inguinal hernias

Question 31

What is a femoral hernia?

Answer 31

A femoral hernia is an abnormal protrusion of abdominopelvic contents through the femoral canal into the medial upper thigh.

Question 32

How common are femoral hernias?

Answer 32

Femoral hernias are a less common type of groin hernia, accounting for 3-5% of all hernias. They frequently present with bowel obstruction, but the diagnosis is often missed in clinical practice.

Question 33

What important structures pass beneath the inguinal ligament?

Answer 33

the femoral artery, the femoral vein and the femoral nerve.

Question 34

What order does the femoral artery, the femoral vein and the femoral nerve lie in?

Answer 34

The order in which these structures lie is easy to remember using the ‘NAVY VAN’ mnemonic. With the ‘Y’ signifying the creases of the groin, this illustrates how the structures lie from lateral to medial (nerve, artery, vein).

Question 35

What are the femoral artery and vein enclosed in?

Answer 35

Femoral sheath

Question 36

What is the function of the femoral canal?

Answer 36

The function of this space is to allow expansion of the femoral vein to increase venous return from the lower limb

Question 37

Where is the femoral canal located?

Answer 37

Lying medial to the femoral vein is a space known as the femoral canal.
narrow space bordered medially by the sharp edge of the lacunar ligament. Femoral hernias are therefore at very high risk of obstruction or strangulation.

Question 38

What does the femoral canal contain?

Answer 38

Fatty tissue
Lymph node of cloquet

Question 39

What are the risk factors for femoral hernias?

Answer 39

1. Females
2. increasing age (over 50)
3. Low BMI

Laparoscopic inguinal hernia repairs are protective against femoral hernias as the mesh should cover the femoral canal

Question 40

How do femoral hernias clinically present?

Answer 40

1. Lump in the groin below and lateral to the pubic tubercle
   Confirmed by ultrasound
   2.A significant proportion of femoral hernias present as an emergency with symptoms of bowel obstruction or strangulation, but the diagnosis is often missed due to inadequate clinical examination or inadequate imaging.
   These patients often become very unwell, and the bowel may perforate due to the diagnostic delay

Question 41

What is the management of femoral hernias?

Answer 41

Due to the high risk of complications, femoral hernias should always be repaired. There are many different ways to do this, but current guidelines advocate laparoscopic mesh repair as the best method.

Question 42

What is an obturator hernia?

Answer 42

An obturator hernia is an abnormal protrusion of abdominopelvic contents through the obturator foramen of the bony pelvis into the medial upper thigh.

Question 43

What is the prevalence of obturator hernias?

Answer 43

Obturator hernias are very rare, constituting less than 1% of all hernias. Due to their anatomical location, they are difficult to diagnose clinically. This often results in a missed or delayed diagnosis which leads to considerably increased morbidity and mortality for patients.

Question 44

What is the obturator foramen?

Answer 44

The obturator foramen is an anterior opening formed by the rami of the pubis and ischium on either side of the pelvis. It is roughly 3.5cm x 5cm in size and is the largest foramen in the human skeleton. Men tend to have a smooth, oval-shaped obturator foramen, whilst women’s are smaller and more triangular.

Question 45

What is the obturator foramen almost completely occluded by?

Answer 45

Obturator membrane

Question 46

What lies either side of the obturator membrane?

Answer 46

The obturator internus and obturator externus muscles lie on either side of this membrane, creating a muscular sandwich which further strengthens the seal covering the hole

Question 47

What passes through the obturator foramen obliquely and to the medial compartment of the thigh?

Answer 47

The obturator artery, vein and nerve form a neurovascular bundle which enters a small gap in the upper edge of the obturator membrane just beneath the superior pubic ramus.

Question 48

What is the nickname for obturator hernias?

Answer 48

‘little old lady hernia’

Question 49

What are the risk factors for obturator hernias?

Answer 49

1. Elderly multiparous women
2. Slim/ recently lost weight
   (The sharp pointy angles of the female obturator foramen also mean that structures that herniate through it are much more likely to get stuck there.)

Question 50

What percent of obturator hernias present to the emergency department?

Answer 50

More than 90% of obturator hernias present as an emergency with an acute abdomen and clinical features of bowel obstruction and/or strangulation. This usually occurs suddenly, but some patients may report self-limiting episodes of subacute obstruction at home previously.

Question 51

What are the symptoms of obturator hernias?

Answer 51

1. Colicky abdominal pain
2. Bloating
   3.nausea/vomiting

Question 52

What is found upon clinical examination of a patient with an obturator hernia?

Answer 52

The deep position of the hernia means there is hardly ever a lump to feel on clinical examination. In addition to abdominal symptoms, up to 50% of patients present with pain and altered sensation along the inner thigh due to compression of the obturator nerve by the hernia, which is relieved by flexing the hip and worsened by internally rotating it. This is known as the Howship-Romberg sign and is pathognomonic for an obturator hernia. The Hannington-Kiff sign describes an absent adductor reflex on the affected side, but this can be hard to confidently elicit and is probably not worth relying upon as a diagnostic tool.

Question 53

What is the gold standard test for an undifferentiated acute abdomen?

Answer 53

CT scan of the abdomen and pelvis with portal venous contrast

Question 54

What is the management for obturator hernias?

Answer 54

. Open surgery via a lower midline laparotomy remains the standard, especially if bowel resection is required, but a laparoscopic approach offers better visualisation and access to deep structures within the pelvis with improved patient outcomes.

Question 55

What is the fastest and safest way to close the hernia defect in an acutely unwell patient with an obturator hernia?

Answer 55

Simple suture repair is the fastest and safest way to close the hernia defect in an acutely unwell patient but has a much higher risk of recurrence than a mesh repair.

Question 56

What is an umbilical hernia?

Answer 56

An umbilical hernia is an abnormal protrusion of intra-abdominal contents through a fascial defect in or around the umbilical ring.

Question 57

How common are umbilical hernias?

Answer 57

Umbilical hernias are the most common ventral hernia. They account for at least 15% of all hernias and are estimated to affect 25% of the general population.

Question 58

What is the umbilicus?

Answer 58

The umbilicus is a dimpled structure on the midline of the anterior abdominal wall at the level of the L3/L4 intervertebral disc.

Question 59

What occurs in a true umbilical hernia?

Answer 59

A true (or direct) umbilical hernia is a congenital problem which occurs when the umbilical ring fails to close, resulting in herniation of intra-abdominal contents into the middle of the cicatrix. This is extremely common, especially in children, and is why so many people have an “outie” belly button

Question 60

What occurs in a paraumbilical/ indirect umbilical hernia?

Answer 60

A paraumbilical (or indirect umbilical) hernia is associated with an acquired fascial defect in the linea alba located within 3cm of the umbilical ring and results in a hernia which lies separate from the cicatrix. Umbilical hernias vary considerably, ranging from a few millimetres to a football.

Question 61

What are the risk factors for umbilical hernias?

Answer 61

1. Females
2. Pregnancy
3. Downs syndrome
4. Beckwith-Wiedermann syndrome
5. Obesity
6. Acites
7. Cirrhosis

Question 62

What are the symptoms of umbilical hernias?

Answer 62

Umbilical hernias are usually asymptomatic. Symptomatic patients usually report a longstanding lump in their belly button which may be causing them varying amounts of bother. Due to their central position in the abdomen, symptomatic umbilical hernias may contain extraperitoneal fat, omentum, small bowel or transverse colon. Hernias containing bowel are at risk of obstruction or strangulation as most have fairly small fascial defects, and the umbilical ring is made from thick fibrous tissue. As many as 20% of umbilical hernias will present with acute complications.

Question 63

What is found upon examination of an umbilical hernia?

Answer 63

1. Palpable swelling in or around umbilicus
2. Umbilicus may be everted or distorted
3. Overlying skin can become stretched and thin (risk of infection)
   - Ultrasound or CT scan in diagnostic uncertainty

Question 64

How are asymptomatic umbilical hernias managed?

Answer 64

Asymptomatic umbilical hernias have a low risk of complications and can safely be managed conservatively. These patients should be safety-netted about worrying symptoms to look out for and when to seek further medical advice.

Question 65

How are symptomatic umbilical hernias managed?

Answer 65

undergo open repair with a mesh to reduce the risk of recurrence.

Question 66

How does the size depend on which surgery is performed in umbilical hernias?

Answer 66

Very small hernias less than 1cm in size or women who plan to become pregnant in the future can be treated with simple suture repair instead. Large umbilical hernias more than 4cm in size or patients at high risk of wound infection are better managed with a laparoscopic approach.