Hernias

Question 1

What is a hernia

Answer 1

condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it

Question 2

What is a reducible hernia?

Answer 2

a hernia that can be manually “reduced” or pushed back through the defect

Question 3

what is an incarcinated hernia?

Answer 3

hernia which cannot be manually reduced (may NOT be painful) = surgery

Question 4

What is a strangulated hernia

Answer 4

an incarcerated hernia with some degree of torsion leading to ischemic bowel
very painful
emergency surgery

Question 5

how many sides foes the ingunial canal have?

Answer 5

Roof
Floor
Anterior wall
Posterior wall

Question 6

Posterior wall is made of?

Answer 6

Transversalis fascia and conjoined tendon of the internal oblique and transversus abdominis muscles

Question 7

What is the anterior muscle made of?

Answer 7

Primarily External Oblique muscle

Question 8

What is the floor of the inguinal canal?

Answer 8

Inguinal Ligament and Lacunar ligament

Question 9

What is the roof of the inguinal canal

Answer 9

External oblique & Transversus abdominis muscles

Question 10

Contents of Inguinal Canal

Answer 10

Males – Ilioinguinal nerve & Spermatic Cord

Females – Ilioinguinal nerve and Round Ligament of the uterus

Question 11

What does hesslebach’s triangle consist of?

Answer 11

Medial border – Rectus abdominis (sheath of muscle)
Lateral border – Inferior epigastric vessels
Inferior border – Inguinal ligament

Question 12

What is the entrance and exit for hesslebachs triangle

Answer 12

Deep inguinal ring – entrance to the inguinal canal

Superficial inguinal ring – exit of the inguinal canal

Question 13

What are 7 types of hernias?

Answer 13

inguinal
Femoral
Umbilical
Spigelian
Hiatal Hernia
Incisional / Ventral
Sports Hernia

Question 14

Epidemiology for hernias

Answer 14

Occur in 5% of all men at some point in their lifetime
Men > Women
75 – 80% of all hernias are groin (inguinal or femoral) hernias
2 – 20% are incisional / ventral
3 – 10% are umbilical

Question 15

What are the risk factors for Hernias

Answer 15

Increased intra-abdominal pressure
Coughing
Heavy lifting
Constipation or straining at stool
Pregnancy / ascites  
Obesity
Advancing age 
Smoking
Steroid use

Question 16

What is a direct hernia

Answer 16

Usually acquired, herniation through defect in the posterior inguinal wall (through Hesselbach’s triangle) – occurs most commonly in older males

Question 17

What is an indirect hernia

Answer 17

Usually congenital, through deep inguinal ring, lies within the spermatic cord, and the hernia sac is covered by the cremaster muscle – occurs most commonly in younger males and may be in scrotum

Question 18

Clinical Presentation of hernias

Answer 18

unilateral groin pain especially w/exertion

Report of intermittent bulge in groin

Question 19

What is the gold standard for hernias?

Answer 19

surgical repair – herniorraphy

Question 20

what are 4 different techniques for hernias

Answer 20

Open
Laparoscopic
Mesh vs No mesh
Local anesthesia w/sedation / vs GA

Question 21

What are some complications of hernias?

Answer 21

incarceration
strangulated hernia
pediatric hernias

Question 22

Epidemiology of femoral hernias?

Answer 22

84% of femoral hernias occur in women
25% of femoral hernias become incarcerated or strangulated
Hernia protrudes through the femoral canal – so sac is seen or palpated in the upper thigh

Question 23

Clinical Presentation of femoral hernias

Answer 23

May complain of intermittent groin mass/bulge or pain
Presenting feature may be small bowel obstruction due to incarceration / strangulation
Elderly pts may be asymptomatic EVEN in the face of incarceration
Bulge just BELOW the inguinal ligament
Tenderness if incarcerated

Question 24

Treatment for femoral hernias?

Answer 24

Surgery

Question 25

Umbilical hernia epidemiology?

Answer 25

Congenital defects African Americans > Caucasians Most newborn umbilical hernias close spontaneously by age 2 Patients w/ascites have a higher incidence of umbilical hernias Have a generally low rate of incarceration

Question 26

Clinical Presentation for umbilical hernias

Answer 26

Painless bulge around umbilicus May present with gastric symptoms (pain) In children under 2 – wait for spontaneous closure unless LARGE In adults often associated w/obesity Visible and palpable umbilical defect Often easily reducible by just pushing on defect

Question 27

Spigelian Hernias facts

Answer 27

Protrude through the Spigelian fascia – this structure is near the terminus of the transversus abdominis muscle along the lateral edge of rectus abdominis

Question 28

Clinical presentation for spigelian hernias

Answer 28

Often pts present with obscure abdominal pain and no apparent cause no bulge seen or palpated because it is obscured by abdominal wall

Question 29

Diagnostic imaging for spigelian hernias

Answer 29

Ultrasound CT scan Diagnostic laparoscopy

Question 30

Treatment for spigelian hernias

Answer 30

Surgical referral | Probable surgical intervention

Question 31

Hiatal Hernia

Answer 31

Reflux barrier composed of two components working together prevent reflux Lower esophageal sphincter Crural diaphragm Stomach can herniate up through diaphragm into thoracic compartment

Question 32

What is the clinical presenation for hiatal hernia

Answer 32

May have some epigastric tenderness but physical findings may be lacking Present w/symptoms similar to GERD – dyspepsia, reflux Some types of HH can present w/postprandial pain, bloating, early satiety, SOB w/meals, dysphagia

Question 33

How to make a diagnosis of hiatal hernia

Answer 33

Chest X-ray (CXR) – look for air fluid levels in mediastinum on lateral x-ray Barium swallow – can confirm Dx also looks for strictures, ulcers, (this is the gold standard for Dx) Esophagogastroduodenoscopy (EGD) – can help if pt has Barrett’s esophagus Esophageal manometry

Question 34

How to treat hiatal hernia

Answer 34

asymptomatic – no further Tx is indicated If pt is symptomatic – trial of medical management – similar to Rxing GERD Surgical management is a major surgical procedure

Question 35

5 causes of Incisional or Ventral Hernia

Answer 35

``` Infection Malnutrition Obesity Flawed wound closure Conditions that increase abdominal pressure on a wound ```

Question 36

Clinical Presentation of Incisional or Ventral Hernia

Answer 36

Presence of bulge at incision site Reproducing intermittent bulge with Valsalva maneuver and that disappears with exhalation Edge of fascial defect is usually palpable on exam Prior Hx of surgical procedure Presence of previously noted pre-disposing factors Complaints of intermittent or persistent bulge at incision site

Question 37

Treatment for incisional or ventral hernia

Answer 37

Definitive treatment is surgical repair

Question 38

Sports hernia

Answer 38

Can often go unrecognized Also called Athletic Pubalgia Seen most frequently in high performance athletes Painful musculotendinous injury to the medial inguinal floor

Question 39

Clinical presentation for sports hernia

Answer 39

Tenderness over the pubic ramus Usually high performance athlete with history of groin or lower abdominal pain aggravated by physical activity and relieved by rest

Question 40

Treatment for sports hernia

Answer 40

Conservative Tx – activity modification, PT | If not helping consider surgical intervention