Hernias Flashcards
(29 cards)
Hernia Examination
- Ask the patient to stand – inspect for any obvious lumps or scars and comment on your findings. Small hernias, saphena varices and varicocoeles may only be visible on standing so make sure you do this!
- Examine the genitalia and both groins – if you can see a lump ascertain its features, ask the patient to cough and feel for an impulse, listen over it for bowel sounds and ask the patient to try to reduce it. Once reduced find the pubic tubercle and place your index finger on it – ask the patient to cough and determine whether lump appears above and medial (inguinal) or below and lateral (femoral).
- If there’s a scrotal swelling – determine if it has an upper border (you cannot get above a hernia) - if not it is likely to be an inguinalscrotal hernia. If so it is likely to be a cord or testicular lump – determine whether it is separate from the testes and does it transluminate.
Hernia - Definition
The protrusion of a viscous or part of a viscous through a defect in the wall of its containing cavity into an abnormal position.
Several terms are commonly used to describe hernias:
- Hernias are said to be irreducible if they cannot be pushed back into their normal position due to adhesions.
- An incarcerated hernia is where the contents of the hernia sac are kept inside by adhesions.
- Gastrointestinal hernias are obstructed if bowel contents cannot pass through them.
- A hernia is strangulated if the blood supply is restricted and the tissue becomes ischaemic.
Components of a Hernia
Neck, body and fundus ± contents e.g. bowel, omentum or bladder.
Inguinal Hernias and Canal
Inguinal hernias – the most common type of hernia which is often found in men.
The inguinal canal – the deep or internal ring is located at the mid-point of the inguinal ligament (1.5cm above the femoral pulse) and the superficial or external ring is located medial and superior to the pubic tubercle.
Inguinal Hernias - Direct and Indirect
- Indirect hernias pass though the internal inguinal ring and if large out through the external inguinal ring.
- Direct hernias pass directly through the posterior wall of the inguinal canal and into a weakness in the abdominal wall known as Hesselbach’s triangle – this area is medial to the inferior epigastric vessels and lateral to the rectus abdominus muscles.
Hernias - Predisposing Factors
- Congenital – patent processus vaginalis.
- Acquired – male (ratio may be as high as 9:1), 6th decade of life, chronic cough, constipation, urinary obstruction (due to prostatic disease), severe muscular effort, heavy lifting, ascites, obesity, previous incision and repair or past abdominal surgery e.g. damage to iliohypogastric nerve during appendectomy.
Distinguishing Between Hernias
- Femoral and inguinal hernias – use their relation to the pubic tubercle – femoral hernias are below and lateral and inguinal hernias are above and medial to it. If unsure place a finger on the pubic tubercle ask the patient to cough and see where it emerges.
- Direct and indirect inguinal hernias - reduce the hernia, occlude the internal ring and ask the patient to stand and cough – if the hernia does not appear it is indirect (but gold standard is using the relation to the inferior epigastric artery during surgery – indirect hernias are lateral and direct hernias are medial).
Features of Hernias
- Indirect – common (80% of hernias) and can strangulate.
- Direct – these are less common (20% of hernias), reduce easily and rarely strangulate.
- Femoral – common in females, are frequently irreducible and frequently strangulate.
Inguinal Hernia Mx - Conservative
Advise the patient to diet if overweight and to stop smoking. Treat risk factors – improve treatment of asthma or COPD and treat constipation or urinary obstruction.
Inguinal Hernia Mx - Surgical
Herniotomy – excision of the sac and herniorrhaphy (sutures) or hernioplasty (mesh) – repair of the posterior wall and deep inguinal ring.
Older operations involve suturing the posterior wall but repairs using polypropylene mesh to reinforce the posterior wall are now commonly used – tension free repair so reoccurrence rates are less.
Laparoscopic repair is also possible, gives similar reoccurrence rates and has many benefits – less post-operative pain and earlier return to work.
Inguinal Hernia - Surgery Complications
- Early – haematoma of the wound or the scrotum or infection.
- Late – hernia reoccurrence, ischamic orchitis or chronic groin pain or paraesthesia.
- With new mesh procedures or laparoscopic repairs patients can work after 2 weeks.
Femoral Hernias
Bowel enters the femoral canal and presents as a mass in the upper medial thigh or above the inguinal ligament (points downward whereas an inguinal hernia points towards the groin).
They occur more often in women especially in middle age and the elderly. These hernias are more likely to be irreducible and to strangulate due to the rigidity of the borders of the femoral canal.
The Femoral Canal
The boundaries of the femoral canal are anteriorly the inguinal ligament, medially the lacunar ligament, laterally the femoral vein and iliopsoas and posteriorly the pectineal ligament.
Femoral Hernias - Management
Repair is recommended due to the risk of strangulation – elective repair involves herniotomy – ligation and excision of sac and herniorrhaphy – repair of the defect usually by suturing the inguinal ligament to the pectineal ligament. If there is strangulation a bowel resection may also be required.
Lump in the Groin Differential Diagnosis
Inguinal lymph nodes (usually below the inguinal ligament), saphena varix (a dilated varicose vein at the sapheno-femoral junction), femoral artery aneurysm, a hydrocele of the cord, a lipoma of the cord or an incompletely descended testicle (empty scrotum).
These other lumps will not have features of a hernia – cough impulse, reducibility and bowel sounds.
Incisional Hernias
A hernia through a previously acquired defect which is usually iatrogenic or due to injury e.g. stabbing. When a wound fails it presents with an incisional hernia (where skin healing is complete) or wound dehiscence (which is partial or complete).
Incisional Hernia - Predisposing Factors
- Preoperative – old age, malnutrition, obesity, malignancy, radiotherapy, corticosteroids, cytotoxic drugs, jaundice or uraemia.
- Operative – midline incision, closure technique, suture material or surgical skill.
- Postoperative – increased abdominal pressure, infection or haematoma.
Wound Dihiscence - Management
Occurs at approximately the 10th postoperative day with pain, fever, discharge from the wound and in some cases evisceration of abdominal contents.
Reassure the patient, give analgesia and IV fluids and cover eviscerated bowel in large sterile swabs.
Incisional Hernia - Management
Conservative – decrease associated risk factors such as chronic cough or straining due to constipation or urinary obstruction and weight loss before surgical repair.
Para-umbilical Hernia
Occur just above or below umbilicus and bowel or omentum can herniate through the defect.
Risk factors – obesity and ascites and surgery advised as high risk of strangulation.
Epigastric Hernia
These pass through the linea alba above the level of the umbilicus.
Spigelian Hernia
Occur through the linea semilunaris at the lateral edge of the rectus sheath below and lateral to the umbilicus.
Lumbar Hernia
Occur through 1 of the 2 lumbar triangles.
Richter’s Hernia
Involve bowel wall only not the bowel lumen so it’s the only type of hernia that can strangulate but not obstruct.
