Hernias

Question 1

What is visceral pain?

Answer 1

• Pain that results from visceral stretching, inflammation or ischaemia
• Pain is diffuse and midline
• Nausea, vomiting, sweating
• Very common presentation
• Difficult to diagnose

Question 2

What is a hernia?

Answer 2

• A protrusion of part of the abdominal contents beyond the normal confines of the abdominal cavity

Question 3

What are the symptoms of a hernia that isn’t stuck?

Answer 3

• Fullness or swelling
• Gets larger when intra-abdominal pressure increases
• Aches

Question 4

What are the symptoms of a hernia that is incarcerated?

Answer 4

• Pain
• Cannot be moved
• Nausea and vomiting
• Systemic problems if bowel has become ischaemic

Question 5

What are the causes of hernia?

Answer 5

• Weakness in containing cavity
• Can be congenital, post-surgery (incisional), normal points of weakness
• Due to things that increase intra-abdominal pressure e.g. obesity, weightlifting,

Question 6

What forms the sac of a hernia?

Answer 6

• A pouch of peritoneum

Question 7

What are the contents of the sac of a hernia?

Answer 7

• Any structure found within the abdominal cavity e.g. loops of bowel, omentum

Question 8

What are the coverings of the coverings of the sac of a hernia?

Answer 8

• Consists of the layers of the abdominal wall through which the hernia has passed

Question 9

Where are the naturally occurring weaknesses 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 abdominal wall
• Very short
• In men structures pass through from abdomen to testis (acts as a passageway from inside peritoneal cavity to scrotum)
• In women round ligament goes from uterus to labium majus

Question 11

What congenital abnormality makes males more susceptible to hernias?

Answer 11

• Processus vaginalis is an outpouching of peritoneum
• During normal development, this obliterates
• If Processus vaginalis doesn’t obliterate, a pathway is created from inside peritoneal cavity to external scrotum, through which fluid can pass.

Question 12

What forms the inguinal ligament?

Answer 12

• Inguinal ligament is the rolled and thickened edge at the bottom of the external oblique

Question 13

What is the conjoint tendon?

Answer 13

• Where the internal oblique and transverse abdominus have fused together.

Question 14

What forms the floor of the inguinal canal?

Answer 14

• Inguinal ligament
• Lacunar ligament (medially)

Question 15

What forms the roof of the inguinal canal?

Answer 15

• Internal oblique/transverse abdominus
• Muscular arches and aponeurosis

Question 16

What forms the posterior wall of the inguinal canal?

Answer 16

• Transversalis fascia
• Conjoint tendon medially reinforces posterior wall

Question 17

What forms the entrance to the inguinal canal?

Answer 17

• Deep ring

Question 18

What forms the anterior wall of the inguinal canal?

Answer 18

• Aponeurosis of external oblique

Question 19

What forms the exit of the inguinal canal?

Answer 19

• Superficial ring
• Exit to scrotum or labia majora

Question 20

Describe the properties of inguinal hernias

Answer 20

• 75% of hernias are inguinal
• 50% indirect, 25% direct
• M>F
• Mainly right sided

Question 21

Which type of hernia often strangulates?

Answer 21

• Femoral (3-5% of hernias)

Question 22

Where would you say the location of a hernia is?

Answer 22

• Where is begins, not where it shows up
• This is because hernias can travel quite a long distance away from their origin

Question 23

Which structures form the borders of Hesselbach’s triangle?

Answer 23

• Rectus abdominis muscle
• Inguinal ligament
• Inferior epigastric vessels

Question 24

What pathway is taken by an indirect inguinal hernia?

Answer 24

• Passes through deep inguinal ring
• Through inguinal canal
• Exits through superficial inguinal ring
• Can potentially descend into scrotum if processus vaginalis wasn’t obliterated

Question 25

What is the relationship between Hesselbach's triangle and the inguinal canal?

Answer 25

- Superficial inguinal ring sits in the centre of Hesselbach's triangle

Question 26

What pathway is taken by a direct inguinal hernia?

Answer 26

- Bulges through Hesselbach's triangle - Doesn't travel through inguinal canal - Generally emerges in the vicinity of the superficial inguinal ring

Question 27

What is the anatomical difference between indirect inguinal hernias and direct inguinal hernias?

Answer 27

- Indirect inguinal hernias arise lateral to the inferior epigastric vessels - Direct inguinal hernias arise medial to the inferior epigastric vessels

Question 28

Outline the properties of femoral hernias

Answer 28

- More common in females - Can easily get incarcerated - Hernia comes down femoral canal and exits at saphenous opening

Question 29

Outline the properties of an umbilical hernia

Answer 29

- 10% of all hernias are umbilical - Commonly found in infants - Not usually painful - 80-90% self-resolve by age 3

Question 30

What is a para-umbilical hernia?

Answer 30

- Hernia goes through defect in linea alba in region of umbilicus - F>M - Obesity - Risk of strangulation because defect is often small

Question 31

What does it mean if a hernia is incarcerated?

Answer 31

- Hernia is stuck, irredducible

Question 32

What does it mean if a hernia is strangulated?

Answer 32

- Blood supply is disrupted - Can lead to tissue necrosis