Hernias

Question 1

What is the most common type of Hiatus hernia?

Answer 1

Sliding - Gastro-oesophageal junction slides up into the chest. Often associated with GORD

Question 2

What is the less common type of Hiatus hernia?

Answer 2

Rolling - Gastro-oesophageal junction remains in the abdomen, but a bulge of stomach rolls into the chest with the oesophagus. LOS intact so GORD uncommon

Question 3

Which type of Hiatus hernia is more at risk of strangulation?

Answer 3

Rolling

Question 4

What investigations can be done for a patient with suspected Hiatus hernia?

Answer 4

CXR - Gas bubble and fluid level in chest
Barium swallow
OGD - Assess for oesophagitis
Manometry (Pressure sensing tube placed in oesophagus) to rule out Achalasia or Dysmotility

Question 5

What is the treatment of a Hiatus hernia?

Answer 5

Lifestyle adjustments - Lose weight
Treat any reflux - PPIs
Surgery if doesn’t respond to treatment or rolling as strangulation can occur

Question 6

What is the aetiology of Inguinal hernias?

Answer 6

More common in males (due to descent of the testes)

Tends to be in older patients for acquired and younger patients for congenital

Question 7

What are the two main causes of Inguinal hernias?

Answer 7

Congenital - Patent processus vaginalis (Should go after birth). Can fill with fluid (Hydrocele) or bowel (Indirect hernia)
Acquired - Mainly due to increased abdominal pressure eg chronic cough, constipation, severe muscular effort, obesity, ascites, appendectomy. Weakening of the muscle wall

Question 8

What is the pathology of a congenital Inguinal hernia?

Answer 8

Indirect
Patent processus vaginalis
Emerge through deep inguinal ring
Has the same 3 covering as the spermatic cord (Internal spermatic fascia, Cremasteric muscle, External spermatic fascia)
Descends into the scrotum
*Can strangulate*

Question 9

What is the pathology of an acquired Inguinal hernia?

Answer 9

Direct
Emerge through weakened area called Hesselbach’s triangle - medial to the inferior epigastric vessels
Rarely descent into scrotum
Rarely strangulate!

Question 10

What are the boundaries of Hesselbach’s triangle?

Answer 10

Superio-lateral - Inferior epigastric vessels
Medial - Linea semilunaris (lateral margin of the rectus sheath)
Inferior - Inguinal ligament

Question 11

What investigations can be done in a patient with suspected Inguinal hernia?

Answer 11

USS

Question 12

What are some of the clinical features of an Inguinal hernia in children?

Answer 12

Lump in groin which may descend into the scrotum
Exacerbated by crying or coughing
Commonly obstruct

Question 13

What are some of the clinical features of an Inguinal hernia in adults?

Answer 13

Lump in groin
Exacerbated by straining or coughing
May be a clear event that caused it in Hx
Dragging type pain that radiates to the groin
may present with strangulation or obstruction

Question 14

What questions are important to ask in a patient with a suspected hernia?

Answer 14

Is it reducible?
Is it painful?
Has there been any episodes of obstruction or strangulation?
Are there any predisposing factors? eg Straining, lifting, coughing
Occupation, lifestyle

Question 15

What are some of the non surgical treatments for an Inguinal hernia?

Answer 15

Manage any risk factors eg cough, constipation
Lifestyle adjustments eg weight loss
Truss (similar to support brace, support the area effected and keep it in the correct position)

Question 16

What are some of the surgical treatments for an Inguinal hernia?

Answer 16

Tension free mesh and suture repair
Open repair
Laparoscopic repair - better for recurrent hernias
Children may have herniotomy - sac excision

Question 17

What are some of the early complications of an Inguinal hernia repair?

Answer 17

Haematoma/Seroma
Intra-abdominal injury (Laparoscopic)
Infection
Urinary retention

Question 18

What are some of the late complications of an Inguinal hernia repair?

Answer 18

Recurrence
Chronic groin pain
Groin paraesthesia
Ischaemic orchitis (inflammation of testicles)

Question 19

What are the borders of the Inguinal canal?

Answer 19

Anterior wall - Aponeurosis of external oblique
Posterior wall - Transversalis fascia
Roof - Transversalis fasica, Internal oblique, Transversus abdominis
Floor - Inguinal ligament, lacunar ligament medially

Question 20

What are the borders of the Femoral canal

Answer 20

Anterior - Inguinal ligament
Posterior - Pectineal ligament, Pectineus muscle, Superior rami of the pubi
Medial - Lacunar ligament
Lateral - Femoral vein

Question 21

What are the borders of the Femoral triangle

Answer 21

Superior - Inguinal ligament
Lateral - Medial border of the Sartorius muscle
Medial - Medial border of the Adductor longus muscle (Also forms floor of the triangle)

Question 22

What is found at the mid inguinal point

Answer 22

Half way between ASIS and pubis symphysis

Femoral artery is found here

Question 23

What is found at the mid point of the inguinal ligament

Answer 23

Half way along the inguinal ligament which runs from ASIS to pubic tubercle
Deep inguinal ring is found here

Question 24

What are some of the risk factors for a Femoral hernia?

Answer 24

Female - due to wider shape of pelvis and changes during childbirth
Increasing age
Increased intra abdominal pressure

Question 25

What are some of the clinical features of a Femoral hernia?

Answer 25

Painless lump in the groin that has a cough impulse and often cannot be reduced *Commonly presents with strangulation/obstruction*

Question 26

What are the symptoms of strangulation or obstruction of a hernia?

Answer 26

``` Tender Erythematous Hot Abdominal pain Distension Vomiting Constipation ```

Question 27

What is the management of a Femoral hernia?

Answer 27

Urgent surgical repair as highly likely to strangulate

Question 28

Define Incisional hernia

Answer 28

Hernia arises through a previously acquired defect

Question 29

What are some of the pre operative risk factors for an Incisional hernia?

Answer 29

``` Increasing age Obesity Malnutrition Co morbidities eg DM, malignacy Drugs eg steroids, chemotherapy ```

Question 30

What are some of the intra operative risk factors for an Incisional hernia?

Answer 30

Srugical technique/skill - too small sutures or wrong material used Incision type/position eg midline Drain placement through wounds

Question 31

What are some of the post operative risk factors for an Incisional hernia?

Answer 31

Increased intra abdominal pressure eg cough, straining, post op ileus Infection Haematoma

Question 32

What is the management for an Incisional hernia?

Answer 32

``` Mange risk factors eg cough Weight loss Truss/Corset Surgery if appropriate (Nylon mesh repair) *Low chance of strangulation* ```

Question 33

What is the managment of Umbilical hernias?

Answer 33

Usually congenital | Tends to resolve when 2-3 y/o can recur in pregnancy or ascites

Question 34

What are some of the features of a Periumbilical hernia?

Answer 34

Middle aged obese men Defect through linea alba Chronic cough/straining are risk factors Mesh repair needed

Question 35

What causes an Epigastric hernia?

Answer 35

Defect in linea alba, small pea sized hernia Usually contains omentum Mesh repair

Question 36

What is a Spigelian hernia?

Answer 36

Hernia through linea semilunaris, lies between the layers of the abdominal wall High risk of strangulation Mesh repair

Question 37

What can cause a persistent midline bulge when patients lie down/raise head?

Answer 37

Divarication of the abdominal wall (Diastasis recti) Happens in obese or pregnant patients *Not a true hernia, weakening of the abdominal wall muscles*