Hernias

Question 1

What is a hernia

Answer 1

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

Question 2

Give at least 3 risk factors for hernias

Answer 2

• obesity
• ascites
• increasing age
• surgical wounds

Question 3

What are the typical features of an abdominal wall hernia

Answer 3

• palpable lump
• cough impulse - protusion
• pain or ache

Question 4

What are the three key complications of hernias

Answer 4

• incarceration
• obstruction
• strangulation

Question 5

Regarding hernias, what is incarceration

Answer 5

where the herniated tissue cannot be reduced (typically painless)

Question 6

Regarding hernias, describe obstruction (including presentation)

Answer 6

• hernia causes a blockage in the passage of faeces through the bowel
• presentation: vomiting, generalised abdo pain, absolute constipation. surgical emergency

Question 7

Regarding hernias, describe strangulation (include presentation)

Answer 7

hernia will be likely non-reducible and the blood supply to a part of an organ or tissue trapped in a hernia is cut off
* presentation: painful, irreducible lump. fever, guarding, bloody stools

Question 8

While awaiting surgery for a strangulated hernia, should the hernia be manually reduced? Explain your answer.

Answer 8

• it is not recommended that you manually reduce strangulated hernias
• this can exacerbate peritonitis

Question 9

What is an indirect inguinal hernia

Answer 9

where the bowel herniates through the inguinal canal
* passes lateral to the inferior epigastric artery

Question 10

What causes indirect inguinal hernias

Answer 10

Failure of the processus vaginalis to close

Question 11

What is a direct inguinal hernia

Answer 11

hernia protrudes directly through the abdo wall, through hesselbach’s triangle
* Passes medial to the inferior epigastric artery

Question 12

What causes a direct inguinal hernia

Answer 12

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

Question 13

What are features of inguinal hernias

Answer 13

• groin lump - superior and medial to the pubic tubercle
• lump disappears on pressure or when the patient lies down
• discomfort and ache: often worse with activity
• Protrudes below the inguinal ligament, lateral to the pubic tubercle

Question 14

What are the management options for inguinal hernias

Answer 14

• treat medically fit patients even if they are asymptomatic
• unilateral inguinal hernias are generally repaired with an open approach with a mesh
• bilateral and recurrent inguinal hernias are generally repaired laparoscopically using a mesh

Question 15

What are the immediate complications of inguinal hernia repair

Answer 15

• bleeding/ haematoma
• injury to ilioinguinal nerve - may lead to numbness or tingling over the superomedial thigh, base of penis, or anterior scrotum/labia

Question 16

What gender is more commonly affected by inguinal hernias

Answer 16

Much more common in males

Question 17

What are femoral hernias

Answer 17

when a section of the bowel or any other part of the abdominal viscera pass into the femoral canal

Question 18

What are the features of femoral hernias

Answer 18

• A lump within the groin, that is usually mildly painful
• inferolateral to the pubic tubercle
• Typically non-reducible
• more common in women
• high risk of strangulation

Question 19

How are femoral hernias managed

Answer 19

• Surgical repair is a necessity, given the risk of strangulation, and can be carried out either laparoscopically or via a laparotomy

Question 20

What is a hiatus hernia

Answer 20

herniation of part of the stomach above the diaphragm

Question 21

Describe the two types of hiatus hernias

Answer 21

• sliding (95%): the gastroesophageal junction moves above the diaphragm
• rolling: a separate part of the stomach(e.g. fundus) herniates through the oesophageal hiatus

Question 22

Give 2 risk factors for hiatus hernias

Answer 22

• obesity
• increased intraabdominal pressure (e.g. ascites, multiparity)

Question 23

How may hiatus hernias present

Answer 23

• heartburn
• acid reflux
• regurgitation
  *

Question 24

How are hiatus hernias diagnosed

Answer 24

• barium swallow is the most sensitive test
• endoscopy may be first-line

Question 25

How are hiatus hernias managed

Answer 25

* conservative management - weight loss * medical: proton pump inhibitor therapy * most people don't require surgical repair

Question 26

What is an epigastric hernia

Answer 26

Lump in the midline between umbilicus and the xiphisternum