Paraumbilical vs umbilical hernia
Umbilical hernia: umbilicus everts as a round central lump, with skin of the center of the umbilicus attached to the center of the sac
Paraumbilical hernia has the umbilicus is pushed to one side and stretched into a crescent shape pit. The umbilical skin is pushed to the side of the sac (and not center of the sac) If the umbilical pit is too deep to clean, it may produce foul-smelling discharge or dried sebaceous secretion (ompholith)
Paraumbilical hernia RF
middle and old age, more common in women, obese, multiparity
Contents of paraumbilical hernia
Contains extraperitoneal fat and omentum
does not cause IO
Umbilical hernia RF/Causes
Acquired: raised intra-abdominal pressure
Congenital: usually disappear spontaneously during the first few years of life
- if >3cm, >3yo - sx
- no symptoms
Hernia mgx
- RF management: weight loss, change jobs, avoid weight lifting. tx chronic cough/constipation
- Binder (truss)
- Pt education - RF, Cx (IO)
surgical repair
Parastoma hernia RF
Patient factors: - poor wound healing: age, DM, cancer, steroids, immunosupp, smoking, malnutrition - increased Intra ab pr - Early mobilisation post op Technical factors - type of sx: e op - type of stoma: colo > ileo, loop > end - wound infection
sx: if incarcerated, causes stoma leakage, dysfunction, skin excoriation
Contents of spermatic cord
3 layers: external spermatic fascia, cremasteric fascia, internal spermatic fascia
3 veins: testicular vein (pampiniform plexus), vas deferens, cremasteric vein
3 arteries: testicular, vas deferens, cremasteric
3 nerves: ilioinguinal n, sympathetic fibres, n to cremaster (genital br of genitofemoral n)
3 others: remains of procesus vaginalis, vas deferens, lymphatics
Inguinal canal boundaries
MALT (sup>ant>lower>pos) Superior: - internal oblique muscle - transversus abdominis Anterior: aponeurosis - Apo of ext oblique - Apo of int oblique Lower: 2 Ligaments - inguinal lig - lacunar lig Posterior: 2Ts - trasnversalis fascis - conjoint tendon
Contents of inguinal canal
Male: spermatic cord + ilioinguinal n
Females: round ligament of uterus + ilioinguinal n
What is a
- pantaloon hernia
- sliding hernia
- littre hernia
- amyand hernia
- both direct and indirect inguinal hernia
- retroperitoneal structures makes up part of the wall of the hernia through abdominal wall defect (e.g. bladder, caecum, sigmoid)
- contain meckel diverticulum
- contain appendix
Differentials for groin lump
Hernia - femoral, inguinal
Vascular - femoral artery aneurysm, saphena varix
Lymphatics - LN, lymphoma
ST/bone - lipoma, groin abscess, rhabdomyosarcoma
Nerve - neuroma
Others - undescended testes, hydrocele of the spermatic cord
What is a
- epigastric hernia
- Richter hernia
- spigelian hernia
- obturator hernia
- hernia through weakened linea alba
- hernia involving only part of bowel (knuckle)
- hernia of the semi-lunaris (lat border of rectus abdominis) *read spigelian belt
What is a lumbar hernia
herniation through superior vs inferior lumbar triangle
Superior: Grynfelt (more common)
Inferior: Little
Obturator hernia associations
- elderly lady, thin
- presents as IO
- Howship Romberg sign: pain in medial thigh extending to knee due to compression of obturator nerve
- Hannington-kiff sign: absent adductor reflex and positive patellar reflex
Boundaries of Hesselbach triangle
Medial: lateral border of rectus abdominis
Inferior: inguinal ligament
Lateral: inferior epigastric artery
recurrent hernias tend to be?
direct
where is the
- inguinal ligament
- deep ring
- superficial ring
- mid-inguinal point
- betw pubic tubercle and ASIS
- 2cm above midpoint of inguinal ligament
- above and medial to pubic tubercle
- between pubic symphysis and ASIS (femoral pulse)
Direct vs indirect hernia
medial | lateral to inferior epigastric artery
within | out of hesselbach triangle
Reduces:
- upwards and straight backwards, readily on lying down
- upward, laterally, backwards, not readily
Controlled:
- pressure over superficial
- pressure over deep ring
not in | in scrotum
less risk | more risk of strangulation
Epidemiology:
old men | young adults/infants
Layers of abdominal wall
Skin Camper Fascia Scarpa Fascia External Oblique Aponeurosis Internal Oblique Transverses Abdominis Transversalis Fascia Pre-peritoneal Fat Peritoneum
Acute mgx of obstructed/ strangulated hernia
NBM IV drip NG tube on suction IV Abx E-OT: hernia repair
Open vs Lap hernia repair
Patient factors
-Do they have CI to lap sx?
(Previous sx involving pre-peritoneal space/ cx inguinal hernia/ ascites, intolerance to GA)
-Presence of co-morbidities: Lap needs GA, open can be under LA
Disease factors
-Primary unilateral inguinal hernia: open/ lap
-Femoral hernia: lap
-Bilateral hernias: lap
-Recurrent hernia: open if previously lap, lap if previously open
Surgeon factors: expertise
Surgical techniques of hernia repair
Open
- Mesh: tension free mesh repair (Lichtenstein)
- Non mesh: primary tissue approximation non mesh repair (shouldice)
Lap
- Totally extraperitoneal repair (TEP)
- Transabdominal preperitoneal patch repair (TAPP)
what is the difference between herniotomy, herniorrhaphy, hernioplasty
- Herniotomy: removal of hernia sac only
- Herniorrhaphy: herniotomy + repair of posterior wall of inguinal wall (shouldice)
- Hernioplasty: reinforcement of the posterior inguinal canal wall with a synthetic mesh (Lichtenstein)
Cx of hernia repair
- GA: AMI, CVA
- Immed: ARU, bruising, bleeding, scrotal hematoma, injury to surrounding structures: paraesthesia, impotence
-Early
o Infx of wound/mesh
o Hematoma (10%) – hard, non reducible, no cough impulse
o Wound dehiscence
o pain
-Late
o Chronic post op groin pain
o Recurrence
o Ischemic orchitis – thrombosis of pampiniform plexus
o Testicular atrophy – test art damage
