Hernias -abdominal and hiatus

Question 1

RF for abdominal wall hernia

Answer 1

• High BMI
• Multiparous
• Poor nutritional state
• Male
• Older age

Question 2

Emergency repairs and mesh choice

Answer 2

• Level of contamination factors into decision of which mesh will be used

Question 3

Types of abdominal wall hernias

Answer 3

Question 4

What is an epigastric hernia?

Answer 4

• Occurs in upper abdominal region
• Through fibres of linea alba
• Often asymptomatic but present as reducible lump

Question 5

Epigastric hernia surgery

Answer 5

• If symptomatic - surgery
• Via open or laparoscopic
• Mesh used to repair depending on size (if more than 1cm needs mesh)

Question 6

What is Divararification of the recti?

Answer 6

• Stretching of linea alba
• Widening gap between rectus abdominus muscles
• As there is not a defect in abdo wall - this is not a hernia
• RF inc older age and multiparity
• Just need physio, surgery is purely cosmetic if done

Question 7

What is a spigelian hernia? What is it associated with?

Answer 7

• Rare form of abdo hernia
• Level of arcuate line at semilunaris
• Lump at lower lateral edge of rectus abdominus
• Associated with higher rates of undescended teste (cryptochidism) - failure of gubernaculum
• Open or laparoscopic repair

Question 8

Obturator hernia - what is it? And who is at risk

Answer 8

• Hernia of pelvic floor through obturator foramen into obturator canal
• More common in women (wider pelvis) and frail older pts (lack of fat in canal)
• Lump in upper medial thigh

Question 9

Sign of obturator hernia

Answer 9

• Positive Howship-Romberg sign
• Hip and knee pain exacerbated by thigh extension, medial rotation and abduction
• Due to compression of obturator nerve

Question 10

Management obturator hernia

Answer 10

• Risk of strangulation high
• Repair urgently

Question 11

What is a Richters hernia?

Answer 11

• Often surgical emergency
• Partial herniation of bowel where only the antimesenteric (part of bowel opposite side to mesentery) border becomes involved
• Only part of bowel lumen is within hernial sac
• Risk of ischaemia is high due to compormise to blood supply

Question 12

What is a lumbar hernia?

Answer 12

• Rare posterior hernia
• Occur spontaneously or iatrogenic following surgery - often open renal surgery
• Present as posterior lump, associated with back pain

Question 13

Rare abdominal wall hernias

Answer 13

• Littre - hernia containing meckels diverticulum
• Amyand - contains vermiform appendix
• De Garengeot - femoral hernia containing appendix

Question 14

What is hiatus hernia?

Answer 14

• Protrusion of organ from abdominal cavity into thorax through oesophageal hiatus (where oesophagus passes through diaphragm)
• Typically stomach
• VERY COMMON - often asymptomatic

Question 15

Anatomical classification of hiatus hernia

Answer 15

• I - sliding hernia
• II - rolling hernia
• III - mixed type
• IV - other structures

Question 16

Sliding hernia

Answer 16

Involving:
* GOJ - gastrooesophageal junction
* Abdominal part of oesophagus
* Cardia of stomach
* These 3 move/slides upwards through diaphragm hiatus into thorax
* MOST COMMON

Question 17

Rolling hernia

Answer 17

• Upward movement of the gastric fundus
• Lies alongslife GOJ = bubble of stomach in thorax
• True hernia with peritoneal sac

Question 18

Mixed type hiatus hernia

Answer 18

• Gastric fundus and GOJ herniate above hiatus
• Fundus lies above GOJ

Question 19

Other structures

Answer 19

• Structures other than stomach herniate through oesophageal hiatus

Question 20

Type of hiatus hernia and associations

Answer 20

• Sliding –> GORD
• II-IV = paraoesophageal hernias, higher risk of gastric ischaemia/volvulus

Question 21

Gastric volvulus

Answer 21

• Stomach twists on itself by 180 degrees
• = obstruction of gastric passage and tissue necrosis
• Needs urgent surgery

Question 22

Triad for gastric volvulus

Answer 22

Borchardts:
* Sudden severe epigastric pain
* Retching without vomitting
* Inability to pass NG tube

Need urgent CT and emergency surgery

Question 23

RF for hiatus hernia

Answer 23

• Age related loss of diaphragmatic tone
• Increase intra-abdo pressure - coughing lots
• Increased size of diaphragmatic hiatus
• Pregnancy, obesity and ascites –> increased pressure
• Previous oesophageal and stomach surgery

Question 24

Presentation of hiatus hernia

Answer 24

• Majority asymptomatic
• GORD
• Epigastric pain - worse lying flat
• Less common - hiccups, palps (irritated diaphragm/pericardial sac) vomitting, dysphagia, anaemia (due to ulceration and bleeding)

Question 25

Investigations for hiatus hernia

Answer 25

• Upper GI endoscopy - OGD
• Shows upwards displacement of GOJ
• Oesophagitis, gastritis or Barretts too

Question 26

Management hiatus hernia

Answer 26

• Asymptomatic, incidental finding - nothing
• Conservative - PPI, weight loss, altered diet (low fat, avoid meals before bedtime, smaller portions)
• Surgical if ongoing, increased risk of complications, nutritional failure

Question 27

Further investigations for surgical management for hiatus hernia

Answer 27

• Oesophageal manometry - pressure in oesophagus during swallowing, assess for achalasia
• Ambulatory 24hr oesophageal pH monitoring - level of reflux quantified, assess reflux episodes and symptoms relationship
• Contrast swallow/meal - rule out strictures/motility disorders and diagnose hernia

Question 28

Surgery for hiatus hernia

Answer 28

• Cruroplasty - hernia reduced back into abdomen, hiatus resized using sutures or mesh
• Fundoplication - gastric fundus wrapped around lower oesophagus and stitched (can be full 360 wrap or partial)

Question 29

Complications of hiatus hernia surgery

Answer 29

• Recurrence of hernia
• Abdominal bloating/increased flatulence due to inability to belch from tightness of wrap
• Dysphagia - wrap too tight or crural repair too narrow (often transient post op due to oedema)
• Fundal necrosis - blood supply via left gastric artery and short gastric vessels disrupted