Hernias

Question 1

What are the typical features of an abdominal wall hernia?

Answer 1

Soft lump protruding

Reducible lump

Lump protrudes on raised intra-abdominal pressure

Aching, pulling or dragging sensation

Question 2

What is incarceration of a hernia?

Answer 2

Hernia cannot be reduced back into proper position

Bowel is trapped in herniated position

Question 3

What is obstruction of a hernia?

Answer 3

Hernia causes a blockage in the passage of faeces through the bowel

Question 4

What is strangulation of a hernia?

Answer 4

Non-reducible hernia, blood supply is cut off causing ischaemia

Bowel will die quickly- emergency

Question 5

What is a Richter’s hernia?

Answer 5

Can occur in any abdominal hernia

Only part of the bowel wall and lumen herniate through defect

Other side of bowel remains in peritoneal cavity

Can become strangulated

Question 6

Why do you operate immediately on a Richter’s hernia?

Answer 6

Can progress very rapidly to ischaemia and necrosis

Question 7

What is a Maydl’s hernia?

Answer 7

Two different loops of bowel contained in the same hernia

Question 8

What are the general management options of abdominal wall hernias?

Answer 8

Conservative management
Leaving hernia alone, most appropriate with wide neck hernia

Tension-free repair
Mesh over defect in abdominal wall, mesh sutured to muscles and tissues on either side

Tension repair
Operation to suture muscles and tissue on either side of defect back together

High recurrence rate

Question 9

What are the differential diagnoses for a lump in the inguinal region?

Answer 9

Femoral hernia
Lymph node
Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
Femoral pseudoaneurysm- not a true aneurysm
Abscess
Undescended testes
Kidney transplant

Question 10

What happens in an indirect inguinal hernia?

Answer 10

Bowel herniates through inguinal canal

Younger patients due to incomplete closure of processus vaginalis

More common

Question 11

What specific finding will help you differentiate an indirect inguinal hernia from a direct?

Answer 11

Indirect hernia is reduced and pressure is applied to the deep inguinal ring the hernia remains reduced

Essentially you are blocking the inguinal canal, so a direct goes through hesselbachs and when you cough it doesnt get blocked

In an indirect you’re blocking the exit so it won’t come out

Mid-point of the inguinal ligament and ask patient to cough

Question 12

What happens in a direct inguinal hernia?

Answer 12

Passes through Hesselbach’s triangle

Older patients
Abdominal wall laxity or significant increased intra-abdominal pressure

Lateral rectus abdominis

Inferior epigastric vessels

Inguinal ligament

Question 13

What are the clinical features of an inguinal hernia?

Answer 13

Lump in the groin which reduces when a patient lies down, worse on standing

Question 14

What should be done when examining a groin lump?

Answer 14

Cough impulse - irreducible hernia will not have a cough impulse

Location - Inguinal herniae are superomedial to the pubic tubercle

Femoral are infernolateral to the pubic tubercle

Reducible

Question 15

What is a femoral hernia?

Answer 15

Herniation of abdominal contents through the femoral canal

Question 16

Why are femoral hernias more common in women?

Answer 16

Wide pelvis

Question 17

What is the opening between the peritoneal cavity and femoral canal called?

Answer 17

Femoral ring

Question 18

What are the borders of the femoral canal?

Answer 18

Femoral vein
-laterally

Lacunar ligament
-medially

Inguinal ligament
-anteriorly

Pectineal ligament
-posteriorly

Question 19

What are the risk factors for developing a femoral hernia?

Answer 19

Female
Pregnancy (higher risk in multiparity)
Raised intra-abdominal pressure
Increased age

Question 20

Why are femoral hernias an emergency?

Answer 20

Femoral canal is very narrow can cause strangluation very easily

Tightness of femoral ring can make it very unlikely to be reducible

Question 21

Where are femoral hernias found in relation to inguinal hernias?

Answer 21

Femoral
Infero-lateral to pubic tubercle (medial to femoral pulse)

Inguinal
Supero-medial to pubic tubercle

Question 22

How are femoral hernias managed?

Answer 22

All surgically

Fixed within 2 weeks due to high strangulation risk

Low approach - Lockwood, incision under inguinal ligament

High approach- McEvedy, above inguinal ligament, does not compromise posterior wall of inguinal canal Preferred in emergency

Inguinal approach

Question 23

What are the complications of fermoral hernias?

Answer 23

Strangulation

Risk of obstruction

Question 24

What is an incisional hernia?

Answer 24

Site of incision from previous surgery due to weakness of muscles and tissues closed after surgery

Bigger the incision, the higher the risk of a hernia forming

Question 25

What is a spigelian hernia?

Answer 25

Occurs between the lateral border of the rectus abdominis and the linea semilunaris This is the site of the spigelian fascia (an aponeurosis between the muscles of the abdominal wall) Narrower base, higher risk of strangulation

Question 26

What is a diastasis recti?

Answer 26

Widening of the linea alba forming a larger gap between rectus muscles Most prominent when patient lies on their back and lifts their head Protruding bulge along middle of abdomen

Question 27

What happens in an epigastric hernia?

Answer 27

Hernia through fibres of the **linea alba** Requires surgical repair with mesh

Question 28

What is an obturator hernia?

Answer 28

Abdominal or pelvic contents herniate through the obturator foramen More common in - Women - Older age - Multiparity and vaginal delivery Can irritate the obturator nerve

Question 29

What is a Howship-Romberg sign?

Answer 29

Pain extending the inner thigh to the knee when the hip is internally rotated due to obturator nerve compression

Question 30

What is a hiatus hernia?

Answer 30

Herniation of the stomach through the hiatus of the diaphragm

Question 31

What are the 4 types of hiatus hernia?

Answer 31

**Type 1** Sliding **Type 2** Rolling **Type 3** Combination of sliding and rolling **Type 4** Large opening with additional abdominal contents entering thorax

Question 32

What is a sliding hiatus hernia?

Answer 32

Stomach slides up through diaphragm into thorax

Question 33

What is a rolling hiatus hernia?

Answer 33

Separate portion of stomach e.g. fundus folds around enters hiatus alongside oesophagus

Question 34

What is a type 4 hiatus hernia?

Answer 34

Large hernia that lets other organs through e.g. pancreas or omentum

Question 35

What happens in a gastric volvulus?

Answer 35

Stomach twists on itself by 180 degrees Obstruction and tissue necrosis **_Borchardt's triad_** - Sudden severe epigastric pain - Retching without vomiting - Inability to pass an NG tube Needs urgent CT scan

Question 36

What are the key risk factors of hiatus hernias?

Answer 36

Age-related loss of diaphragmatic tone Anything that increases intrabdominal pressures Previous oesophageal and stomach surgery Obesity Pregnancy

Question 37

What symptoms do patients with hiatus hernias present with?

Answer 37

Heartburn Reflux Food reflux Burping Bloating Halitosis

Question 38

What may hiatus hernias be seen on?

Answer 38

CXR CT scans GI endoscopy Barium swallow testing

Question 39

What inviestgations are used for a hiatus hernia?

Answer 39

OGD - shows upward displacement of the GOJ (Z-line) Oesophageal manometry Abulatory 24-hour oesophageal pH monitoring Contrast swallow or meal

Question 40

What is the surgical management of hiatus hernias?

Answer 40

Fundoplication Cruroplasty - hernia reduced and hiatus re-approximated with a mesh