2a.) Hernias

Question 1

Describe how visceal pain will present in GI tract

Answer 1

• Viscera is innervated by sympathetic system (the greater, lesser and least splanchnic nerves)
• Pain information is is transmitted back to corresponding spinal level (e.g. T5-T9 for greater splanchnic)
• Brain interprets this as pain in corresponding dermatomes

Hence pain is poorly diffused and often in midline. Nausea, vomiting and sweating may accompany pain

Question 2

Why is visceral abdominal pain often poorly localised and in the midline

Answer 2

• Poorly localised as pain corresponds to dermatomes
• Midline as spinal nerves either side send signals

Question 3

Define a hernia

Answer 3

Bulge or protrusion of an organ through a structure or muscle that normally contains it

Question 4

Define an inguinal hernia

Answer 4

Protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall

Question 5

Hernias can be stuck or unstuck; explain what is meant by this and how to differentiate between the two

Answer 5

Stuck/incarcerated

• Cannot be moved
• Symptoms: pain, cannot be moved, nausea & vomitting, systemic problems if bowel become ischaemic

Unstuck

• Can be moved
• Symptoms: fullness/swelling, gets larger as intrabdominal pressure increases, aches

Question 6

State some possible causes of abdominal hernias

Answer 6

• Weakness in cavity
  
  • Congenital
  • Post surgery leading to incisional hernia
  • Normal points of weakness e.g. Hesselbach’s triangle
• Increases in intra-abdominal pressure
  
  • Obesity
  • Weight lifiting
  • Chronic cough or constipation

Question 7

State the 3 parts of a hernia

Answer 7

• Sac
• Contents
• Coverings of sac

Question 8

For an abdominal hernia state what usually forms the:

• Sac
• Contents of sac
• Coverings of sac

Answer 8

• Sac: pouch of peritoneum
• Contents: any structure in abdominal cavity e.g. loops of bowel, omentum
• Coverings: layers of abdominal wall through which the hernia has passed

Question 9

State 4 points of weakness in the abdominal wall

Answer 9

• Inguinal canal
• Femoral canal
• Umbilicus
• Previous incisions

Question 10

What is the inguinal canal?

Answer 10

Oblique passage through lower part of abdomen wall

Question 11

State some risk factors for inguinal hernias

Answer 11

• Male
• Age
• Obesity

Question 12

Describe under what circumstances a scrotal hernia may develop

Answer 12

If processesus vaginalis doesn’t degenerate there will be a connection betwen abdomen and scrotal sac through which a hernia may develop

Question 13

What is the function of the inguinal canal?

Answer 13

Passage through which structures can pass from abdomen to external genitalia

Question 14

State the boundaries of the inguinal canal

Answer 14

• Anterior: aponeurosis of external oblique reinforced by internal oblique muscle laterally
• Posterior: transversalsis fascia and conjoint tendon medially
• Roof: transversalsis fascia, internal oblique, transversus abdominis
• Floor: inguinal ligament thickened medially by lacunar ligament

Superficial and deep rings are openings

Question 15

State the contents of the inguinal canal

Answer 15

• Spermatic cord (MALES)
• Round ligament (FEMALE)
• Ilioinguinal nerve
• Genital branch of genitofemoral nerve

Question 16

Describe where the deep and superficial inguinal rings can be found

Answer 16

• Deep: above midpoint of inguinal ligament, lateral to epigastric vessels
• Superficial: superior to pubic tubercle

Question 17

For both the superficial and deep inguinal ring state what they are made of

Answer 17

• Superficial: triangle shaped evagination of external oblique
• Deep: transversalis fascia (which invaginates to form a covering of contents of inguinal canal)

Question 18

What is the conjoint tendon/inguinal falx?

Answer 18

Combined fibres from the lower internal oblique and aponeurosis of transversus abdominis muscle. Inserts onto pubic crest

Question 19

What is the most common type of abdominal wall hernia?

Answer 19

Inguinal

Question 20

State two types of inguinal hernias and state which is more common

Answer 20

• Direct
• Indirect (more common)

Question 21

On which side are inguinal hernias more common?

Answer 21

Right

Question 22

Describe the pathway of indirect inguinal hernias

Answer 22

• Exit abdomen through deep inguinal ring
• Pass into inguinal canal- either partially into or all the way into scrotum depending on whether processus vaginalis was obliterated

Question 23

Describe the pathway of direct inguinal hernias

Answer 23

Pass directly through abdominal wall in an area of potential weakness called Hesselbach’s triangle

Question 24

Describe where each of the following passes in relation to the inferior epigastric vessels:

• Indirect inguinal hernia
• Direct inguinal hernia

Answer 24

Question 25

Describe the pathway of femoral hernia

Answer 25

* Through femoral ring * Into femoral canal * Out of saphenous opening

Question 26

Which gender are femoral hernias more common in? What are they at risk of?

Answer 26

More common in females as the femoral ring is generally wider in females. At risk of incarceration

Question 27

Describe what omphalocele is, include: * Why it may occur * Any problems associated with it

Answer 27

* Failure of midgut to return to abdomen during devlopment hence viscera persists outside abdomen within umbilical ring. Viscera **are covered in peritoneum** * May occur if abdominal cavity not big enough to accomodate viscera * Feeding is fine as gut still develops relatively normally but there are often other genetic problems hence mortality is high

Question 28

Describe what gastroschisis is, include: * Are viscera covered in peritoneum * Any associated problems * Survival

Answer 28

* Defect in ventral abdominal wall * Viscera are not covered in peritoneum hence they are exposed to amniotic fluid. * Get problems with gut development and feeding * Survival better than omphalocele as you there are less associated genetic complications

Question 29

Describe what an umbilical hernia is, include is it painful and at what age it usually closes by

Answer 29

Hernia at site of umbilicus, often in infants, that isn't usually painful and the majority of them close by age 3

Question 30

Describe what a para umbilical hernia is, include: * What it is * Who comon in * Risk factors * Potential complications * Symptoms

Answer 30

* Hernia in umbilicus region in ADULTS. Herniates through linea alba in region of umbilicus * More common in females * Risk factor= obesity * Risk of strangulation * Symptoms: pain, vomitting sepsis

Question 31

How can you differentiate between direct and indirect inguinal hernia?

Question 32

Describe the presentation of femoral hernia

Answer 32

Small lump in groin (inferolateral to pubic tubercle)

Question 33

How do inguinal hernias present?

Answer 33

Lump in groin above inguinal ligament

Question 34

State the borders of Hesselbach's triangle

Answer 34

* Medial: lateral border of rectus abdominis * Lateral: inferior epigastric vessels * Inferior: inguinal ligament

Question 35

What is an alternative name for Hesselbach's triangle?

Answer 35

Medial inguinal fossa

Question 36

What is Hesselbach's triangle?

Answer 36

Weakness in abdominal wall- common place for direct inguinal hernias

Question 37

Why can clinical presentation of an indirect and direct inguinal hernia can be so similar

Answer 37

They both protrude in the samem area (around superficial ring)

Question 38

Describe how, by examination, you could differentitate between direct and indirect inguinal hernia

Answer 38

* Push hernia back in * Press on deep inguinal ring * Ask patient to cough * If the bulge protrudes again it must be a direct inguinal hernia * If the bulge does not protrude again it must be an indirect inguinal hernia

Question 39

How do we describe a hernia *(think about why we say indirect hernia is lateral to epigastric vessels when in actual fact the protrusion isn't lateral)*

Answer 39

We describe a hernia based on the point at which it leaves it's containing cavity

Question 40

In relation to inguinal ligament, how do inguinal hernias differ from femoral hernias?

Answer 40

* Inguinal: above the inguinal ligament & more medial * Femoral: below inguinal ligament & more lateral