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Flashcards in Abdominal wall hernias Deck (36):

Define hernias of the abdominal wall

An abnormal protrusion of abdominal contents though the fascia of the abdominal wall


List the contents of a hernia

Always contains a portion of the peritoneal sac
May contain viscera, usually small bowel and omentum


Describe the aetiology of congenital abdominal hernias

Associated with developmental disorders e.g. persistent processus vaginalis, failure of complete obliteration of the umbilical opening


Describe the aetiology of acquired abdominal hernias

Weakness of the abdominal wall due to ageing or previous surgery.

Risk increased in conditions that increase intra-abdominal pressure.


What terms are used to describe an abdominal hernia?

Reducible: contents can be fully restored to the abdominal cavity, spontaneously or with manipulation.
Incarcerated: part or all of the contents cannot be reduced due to narrow neck and/or adhesions.
Strangulated: twisting or entrapment compromises blood supply to the hernia ➔ obstruction and infarction


What may be seen on examination of a hernia?

Occur at weak spot
May reduce on lying down, or with direct pressure
May have expansile cough impulse


Name 5 common types of abdominal wall hernias

Inguinal hernia (commonest)
Femoral hernia
Incisional hernia
Epigastric hernia
Umbilical hernia


What is the commonest type of abdominal hernia?

Inguinal hernia


What is the M:F ratio for inguinal hernias?



How can inguinal hernias be classified?

Direct: medial to inferior epigastric artery
Indirect: lateral to inferior epigastric artery


Differentiate between an indirect and direct inguinal hernia

Indirect: occurs at any age (usually young), congenital, lateral to inf epigastric a, often descend to scrotum, narrow neck ➔ more likely to strangulate

Direct: uncommon in children and young adults, acquired, medial to inf epigastric a, rarely descend to scrotum, wide neck ➔ rarely strangulate


Name 2 risk factors for indirect inguinal hernias



Name 3 risk factors for direct inguinal hernia

Chronic cough
Heavy lifting


Describe the presentation of inguinal hernias

Lump in the groin
May have sudden pain
Expansile cough impulse
Ache or dragging sensation, especially at the end of the day


Outline the management of inguinal hernias

Reassurance if small and asymptomatic
Symptomatic hernias or Hx of incarceration or bowel obstruction ➔ offered hernia repair
-Consider hernia truss: supports tissue and relieves pain

Hernia repair: reduction or excision of sac, closure of defect with minimal tension.


What structure do indirect inguinal hernias travel through?

Inguinal canal: transmits the spermatic cord/round ligament, and the ilioinguinal nerve.


What is the content of the spermatic cord?

Vessels: testicular a, cremasteric a, artery of vas deferens
Nerves: genital branch of genitofemoral, autonomic supple to testicles, ilioinguinal n
Structures: vas deferens, pampiniform venous plexus, testicular lymphatics
Coverings: external spermatic fascia, cremasteric fascia, internal spermatic fascia


What anatomical location is most commonly associated with direct inguinal hernias?

Hesselbach's triangle:
-Inguinal ligament (inferiorly)
-Inferior epigastric artery (laterally)
-Lateral border of rectus abdominis (medially)


Outline the anatomy of the femoral canal

Anterior: inguinal ligament
Posterior: pectineal ligament
Medial: lacunar ligament
Lateral: femoral vein


Which sex is most likely to have a femoral hernia?



Describe the presentation of femoral hernias

Lump in the groin, lateral and inferior to the pubic tubercle, medial to femoral pulse
Lower abdominal pain if incarcerated

*30% present as emergencies due to high risk of strangulation


Name 3 differentials for femoral hernias

Low presentation of inguinal hernia
Femoral canal lipoma
Saphena varix (dilatation of proximal long saphenous v)
Spermatic cord hydrocele
Psoas abscess


What is the most concerning complication of femoral hernia?

Strangulation of the femoral hernia. High risk due to the narrow opening and rigid boundaries of the femoral canal.


Describe the presentation of a strangulated hernia

Red and tender
Tense and irreducible
Colicky abdominal pain


Outline the treatment of femoral hernias

Due to high risk of strangulation, all femoral hernias should be repaired as an elective process.
-Low approach (Lockwood's)
-Trans-inguinal approach (Lotheissen's)
-Thigh approach (McEvedy's)

Truss (conservative) has no place in management


What can be done to reduce the rate of recurrence of femoral hernias?

Narrowing of the femoral canal after hernia repair


State 3 differences between true umbilical hernias and paraumbilical hernias

True: occur through the umbilical cicatrix, almost always congenital, commoner in Afro-Caribbean races.

Para: occur through the paraumbilical tissue, acquired, common in obese and parous women.


Describe the pathophysiology of epigastric hernias

Defects in the line alba between the xiphisternum and umbilicus, at sites of penetration of nerves and vessels.


Describe the presentation of umbilical hernias

Small, centrally places within the umbilicus
Often contains pre-peritoneal fat
Rarely contains bowel or omentum
May be painful, but rarely strangulates


Describe the presentation of paraumbilical hernias

Variable size, up to moderate
Many potential locations
Distorts shape of umbilicus
May contain bowel or omentum
Often painful and occasionally strangulates


Describe the presentation of epigastric hernias

Variable size, up to large
Always along midline
Most frequently only contains pre-peritoneal fat
Moderate risk of strangulation


Outline the management of umbilical hernias

<1cm ➔ almost always spontaneously close by 5yr
>1.5cm or in child >4yr ➔ repair
Symptomatic hernias or high risk complications ➔ repair


Name 3 factors that predispose to incisional herniation?

Wound infection
Steroid use, anaemia, or malnutrition pre-op
Midline laparotomy
Poor surgical technique in abdominal closure


When do incisional hernias most commonly present?

Up to 5yr post-op


What significant complication can occur following large incisional herniation?

Viscera are often permanently herniated
If this occurs for a long period of time, the abdominal wall muscles retract ➔ small abdominal cavity that may not contain all the retracted viscera.


Outline the management of incisional hernias

<4cm (S) ➔ simple sutured repair
>4cm (M or L) ➔ mesh repair
-Above umbilicus: between post rectus sheath and rectus abdominis muscle
-Below umbilicus: pre-peritoneal space
*Arcuate line