Other abdominal wall hernias Flashcards
(42 cards)
Inguinal, femoral, para/umbilical, epigastric, and incisional hernias are covered elsewhere. List six other abdominal wall hernias
Spigelian, Obturator, Lumbar, Interparietal, Sciatic, Perineal
What is a speigelian hernia? What subtype of abdominal wall hernia is this?
Acquired ventral hernia though Speighel’s fascia (fused aponeurosis of IO & TA) Located between semilunar line & lateral edge of rectus)
It is therefore a Interperiatal hernia between two layers of abdominal wall
What is the incidence of speigelian hernias? In which group do they most commonly occur?
Uncommon; account for ≈2% of all hernias, women >50yo
What percentage of speigelian hernias are congenital (c.f. acquired?)
100% acquired (e.g. related to obesity, COPD, ? laparoscopy (ports/gas))
Describe the clinical presentation and examination findings of a speigelian hernia. What makes diagnosis difficult?
Abdo pain
GI Sx
A cough impulse may be palpable of the iliac fossa when standing (in a thin pt); this disappears when lying down
20% have strangulation at presentation
Dx may be difficult as the hernial defect may lie beneath an intact external oblique layer & therefore not be palpable
Where are speigelian hernias found?
- at what line
- at what level
- deep to what
- where else may it lie
- At what layer is a speigelian hernia almost never found?
Occur at semilunar line (of Speighel) = Linea semilunaris = the line where the sheaths of the lateral abdo muscles fuse to form the lateral rectus sheath
Almost always found above the level of the inferior epigastric vessels
≈ 90% are @ level of the arcuate line (semi-circular SDT)
The hernia often dissects within the layers of the abdo wall → lateral to rectus sheath
Usually lies deep to EO
Occasionally it lies within the rectus sheath, lateral to rectus muscle
Almost never penetrate to lie subcutaneously
What are the modes for investigation and repair of speigelian hernias?
CT or USS.
Repair:
Open: incise over tenderness / mass & split ex oblique to expose the sac → reduce hernia, excise sac & stitch the defect
Can be difficult to get decent tissue to fix onto medial
Laparoscopic: useful in Dx & Rx
What is the risk of incarceration in Speigelian hernias?
≈ 20% risk of incarceration; therefore should be repaired, strangulation in incarcerated hernias is common
What is a Bleicher’s Hernia
A Lumbar hernia
What is the definition of a lumbar hernia? What are two subtypes of lumbar hernia?
a hernia through an area of weakness through the superior or inferior lumbar triangles between the 12th rib & iliac crest
Petit’s hernia: inferior lumbar triangle – usually congenital… Petit= small = inferior = small kids
Grynfeltt’s hernia: superior lumbar triangle – usually acquired (trauma)
What are the medial, inferior, and lateral borders of an inferior lumbar triangle hernia?
Medial: Lat Dorsi
Inferior: Iliac Crest
Lateral: External Oblique
What are the medial, inferior, and lateral borders of a superior lumbar triangle hernia?
Medial: Quadratus Lumborum
Superior: 12th Rib
Lateral: Internal Oblique
How common are lumbar hernias? What two demographics are they seen in?
very rare
seen in young, athletic women & middle-aged men
What is the cause of lumbar hernias? How commonly are lumbar hernias congenital?
How do lumbar hernias present?
What mode of imaging may be most helpful?
usually the result of trauma, rarely congenital
Clinically
present as “a lump in the flank”
Tender mass, → back ache +/- heavy pulling feeling
Lumber bulge → appears on standing; disappears on lying down
Ix: CT may be helpful
How commonly is surgical repair of lumbar hernias required?
What two approaches may be used?
Why is mesh often used in the repair of lumbar hernias?
Repair if symptomatic or signs of strangulations
Flank approach with pt in lateral position
Or anterior retroperitoneal approach
Often use mesh as hard to reconstruct primarily because of immobile bony margins
NB// Difficult to repair because: (1) Of the anatomical boundaries, (2) Of there size, (3) Of the patient type, (4) They are bounded by muscle [not fascia]
Give four reasons that lumbar hernias are difficult to repair
Lumbar hernias are difficult to repair because: (1) Of the anatomical boundaries, (2) Of there size, (3) Of the patient type, (4) They are bounded by muscle [not fascia]
What is the rate of incarceration in lumbar hernias?
incarceration / strangulation in 10%
giant lumbar hernias: unlikely to strangulate & have a high recurrence rate if operated on… so usually don’t operate
What is an oberturator hernia?
How common are obturator hernias? In whom are they most commonly seen?
Are obturator hernias more common on the right or the left?
Herniation through the obturator cana
Rare
Most frequently seen in elderly women, who have lost weight
More common on the RHS
How long is the obturator canal?
Where does it start and exit the abdominal cavity?
2-3 cm long tunnel
Starts in pelvic → exist into the medial upper thigh
What are the boundaries of the deep opening of the obturator canal?
Supero-laterally: obturator groove pubic bone
Inferiorly: Free edge of obturator membrane, obturator internus + externus
What are the boundaries of the superficial opening of the obturator canal?
Under pectineus muscle, medial to femoral vein
What are the contents of the obturator canal?
Obturator nerve, vein and artery
What is the origin and course of the obturator artery?
What anatomical variant may be encountered?
The obturator Artery arises from the internal iliac artery. It is found laterally in canal below obturator nerve
Anatomical variants: Aberrant obturator artery Ext iliac via inf. Epigastric
What is the corona mortis?
Corona mortis, also known as the crown of death, refers to common variant arterial and venous anastomoses that cross the space of Retzius posterior to the superior pubic ramus. The arterial anastomosis is between either the external iliac artery or deep inferior epigastric artery and the obturator artery whereas the venous anastomosis is between the obturator vein and either the external iliac vein or inferior epigastric vein 6. Injury to these vessels can cause severe haemorrhage which can be difficult to control.
