Hernias

Question 1

Hernia definition

Answer 1

Fascial defect resulting in protrusion of a viscus into an area it is not normally contained

Question 2

Are hernias more common in males or females?

Answer 2

Males

Question 3

Frequency of the following hernias: femoral hernia, indirect and direct inguinal hernia

Answer 3

Indirect inguinal hernia (50%)
Direct inguinal hernia (25%)
Femoral hernia (5%)

Question 4

Most common hernias in males and females. Which one are each sex predisposed to

Answer 4

1. Most common: Indirect inguinal hernia
2. Males predisposed to indirect inguinal hernia
3. Females predisposed to femoral hernia

Question 5

3 risk factors for hernias

Answer 5

1. Increased intra-abdominal pressure (obesity, pregnancy, chronic cough, heavy lifting, constipation)
2. Congenital abnormality (patent processus vaginalis)
3. Previous hx of hernia or hernia repair

Question 6

What is the vessel that that differentiates whether it is a direct vs. indirect hernia

Answer 6

Inferior epigastric artery

1. Indirect is lateral to artery
2. Direct is medial to artery

Question 7

Describe an indirect inguinal hernia

Answer 7

• Originates from deep inguinal ring
• Lateral to inferior epigastric artery
• Descends to scrotal sac/ labia majora

Question 8

Describe a direct inguinal hernia

Answer 8

• Herniation through Hesselbach’s triangle
• medial to inferior epigastric artery
• does NOT descend into scrotal sac

Question 9

What are the boundaries of Hesselbach’s triangle?

Answer 9

Medial: rectus abdominus
Lateral: Inferior epigastric artery
Inferior: Inguinal Ligament

Question 10

Describe a femoral hernia

Answer 10

• hernia through femoral canal (below inguinal ligament and medial to femoral vein)

Question 11

Which type of hernia is at highest risk of incarceration and strangulation?

Answer 11

Femoral hernia

Question 12

Define incarceration and strangulation

Answer 12

Incarceration: irreducible

Strangulated: vascular supply is compromised

Question 13

What are the signs and symptoms of strangulation

Answer 13

• Pain and tenderness
• bowel obstruction symptoms: N/V, distended abdomen, constipation and obstipation
• Bowel necrosis/sepsis: fevers and chills

** SURGICAL EMERGENCY

Question 14

Presentation of hernia

Answer 14

• swelling or fullness at hernia site. Enlarges with coughing, lifting, straining. Disappears in supine
• Often no pain on palpation unless strangulated or incarcerated

Question 15

How to make a diagnosis?

Answer 15

• Physical exam usually sufficient
• U/S or CT abdo can help
• CT useful for obturator hernia, internal abdominal hernia

Question 16

Management of non-incarcerated or non-strangulated hernia

Answer 16

• If small and minimally symptomatic, first occurrence: surgical repair not necessary. Counsel on strangulation sx
• Otherwise: surgical repair (herniorrhaphy) within 1 month of detection

Question 17

What are the complications of hernia repair

Answer 17

• Recurrence (15-20%) risk. Less common with mesh/tension-free surgical repair
• Scrotal hematoma
• Nerve entrapment (ilioinguinal or genital branch of genitofemoral)
• Stenosis/occlusion of femoral vein, causing acute leg swelling
• ischemic colitis
• Penile ecchymosis
• Scrotal ecchymosis
• Wound infection
• Chronic Pain

Question 18

Management of acutely incarcerated and strangulated hernia

Answer 18

Acutely incarcerated - attempt reduction, if irreducible, surgical repair for fear of strangulation

Strangulated hernia - emergent surgical repair