Hernias

Question 1

What is a hernia?

Answer 1

A protrusion of a viscus/part of a viscus (organ) through a defect of the wall of its containing cavity into an abnormal posiiton

Question 2

What is meant if a hernia is irreducible?

Answer 2

Contents cannot be pushed back into place

Question 3

What is meant when a hernia is described as obstructed?

Answer 3

Bowel contents cannot pass - features of intestinal obstruction

Question 4

What is meant by a strangulated hernia?

Answer 4

A hernia that is cutting off the blood supply to the intestines and tissues in the abdomen.

Question 5

What is meant by incarceration of a hernia?

Answer 5

Contents of the hernial sac are stuck inside by adhesion

Question 6

What is a femoral hernia?

Answer 6

Bowel enters the femoral canal, presenting as a mass in the upper medial thigh or above the inguinal ligament where it points down the leg

Question 7

What sex do femoral hernias occur most commonly in?

Answer 7

Females - especially middle aged and elderly

Question 8

What is the anterior boundary of the femoral triangle?

Answer 8

Inguinal ligament

Question 9

What is the medial boundary of the femoral canal?

Answer 9

The lacunar ligament and pubic bone

Question 10

What is the lateral border of the femoral triangle?

Answer 10

Iliopsoas and femoral vein

Question 11

What are the contents of the femoral canal?

Answer 11

• Fat
• Cloquet’s node

Question 12

What is the differential diangosis for someone presenting with features of a femoral hernia?

Answer 12

• Inguinal hernia
• Saphena varix
• Enlarged Cloquet’s node
• Lipoma
• Femoral aneurysm
• Psoas Abscess

Question 13

How would you manage a femoral hernia?

Answer 13

Surgical repair

• Herniotomy
• Herniorrhaphy

Question 14

Where are paraumbilical hernias found?

Answer 14

Occur just above of below the umbilicus

Question 15

What are risk factors for paraumbilical hernias?

Answer 15

• Obesity
• Ascites

Question 16

How would you manage a paraumbilical hernia?

Answer 16

Leave it, or repair of rectus sheath (Mayo repair)

Question 17

What are epigastric hernias?

Answer 17

Hernias which pass through the linea alba above the umbilicus

Question 18

What is an incisional hernia?

Answer 18

Following breakdown of muscle closure after surgery

Question 19

What is a Spigelian hernia?

Answer 19

Occurs through the linea semilunaris at the lateral edge of the rectus sheath, below and lateral to the umbilicus

Question 20

What is an obturator hernia?

Answer 20

Occurs through the obturator canal

Question 21

Where is pain typically felt with obturator hernias?

Answer 21

Along the medial side of the thigh

Question 22

What is an indirect inguinal hernia?

Answer 22

Passess through the internal inguinal ring, and, if large, out through the external inguinal ring

Question 23

What is a direct inguinal hernia?

Answer 23

Hernias which push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal

Question 24

What is the surface anatomy of the deep inguinal ring?

Answer 24

The mid-point of the inguinal ligament - 1^_1/2 cm above the femoral pulse (which crosses the mid inguinal point)

Question 25

What is the surface anatomy of the superficial inguinal ring?

Answer 25

Just superior and medial to the pubic tubercle

Question 26

What is hesselbach's triangle?

Answer 26

The space bounded by the lateral border of the rectus abdominis medially, the inguinal ligament inferiorly, and the inferior epigastric vessels laterally. The inguinal triangle contains a depression referred to as the medial inguinal fossa, through which direct inguinal hernias protrude through the abdominal wall

Question 27

What factors predispose to the development of inguinal hernias?

Answer 27

* **Male** * **Chornic cough** * **Contipation** * **Urinary obstruction** * **Heavy lifting** * **Ascites** * **Post-abdo surgery**

Question 28

How would you assess an inguinal hernia on examination?

Answer 28

Lying and standing * **Look for previous scars** * **Feel other side** * **Examine external genitalia** * **Assess reducibility** * **Ask patient to cough** - feel for impulse if not visible

Question 29

How would you clinically try to determine if a hernia was direct or indirect?

Answer 29

Reduce the hernia to deep inguinal ring and occlude the ring. Ask the patient to cough/stand - if the hernia is restrained, it is indirect; if it is not, it is direct

Question 30

In terms of the epigastric artery, where do direct hernias arise form?

Answer 30

Medial to inferior epigastric artery

Question 31

In terms of the inferior epigastric artery, where do indirect hernias arise from?

Answer 31

Lateral to inferior epigastric artery

Question 32

How could you initially manage an irreducible hernia?

Answer 32

Manually reduce - to prevent strangulation and necrosis

Question 33

What would you advise someone coming in for a hernia repair to do pre-op?

Answer 33

* **Lose weight** * **Stop smoking**

Question 34

How would you repair an inguinal hernia?

Answer 34

**Mesh repair** - polypropylene mesh reinforces wall

Question 35

When would mesh repair be contraindicated in managing an inguinal hernia?

Answer 35

* **Strangulated hernias** * **Contamination with pus/bowel contents**

Question 36

What other methods can be used to repair hernias besides mesh repair?

Answer 36

Laparoscopic repair - TAPP, TEP

Question 37

How long would you advise someone do rest following hernia surgery?

Answer 37

* **Open approach** - 4 weeks - 8 weeks * **Laparoscopic** - 2 weeks

Question 38

What are the contents of the inguinal canala in a male?

Answer 38

* **External spermatic fascia** * **Cremasteric muscle** * **Internal spermatic fascia** * **Spermatic cord** * Vas deferens * Lymphatics * Remnant of processus vaginalis * Arteries to the vas * Pampiniform plexus * Sympathetic nerves * Ilioinguinal nerve * Genital branch of the genitofemoral nerve

Question 39

What are the contents of the inguinal canal in females?

Answer 39

* **Round ligament of the uterus** * **Ilioinguinal nerve** * **Genital branch of genitofemoral nerve** * **Blood vessels and lymphatics**

Question 40

What is the cremaster muscle an extension of?

Answer 40

Internal oblique and transversus abdominus muscle

Question 41

What is the external spermatic fascia an extension of?

Answer 41

External oblique muscle

Question 42

What is the internal spermatic fascia an extension of?

Answer 42

Transversus abdominus muscle

Question 43

What makes the floor of the inguinal canal?

Answer 43

Inguinal and lacunar ligament

Question 44

What makes the roof of the inguinal canal?

Answer 44

Fibres of transversalis and internal oblique

Question 45

What makes the posterior wall of the inguinal canal?

Answer 45

Transversalis fascia and conjoint tendon

Question 46

What makes the anterior wall of the inguinal canal?

Answer 46

External oblique aponeurosis and internal oblique for lateral 1/3rd