Hernias

Question 1

What is a hernia?

Answer 1

• Protrusion of abdominal contents through a weakness in the abdominal wall
• Common types: inguinal, umbilical, epigastric

Question 2

RF for inguinal hernias

Answer 2

1. Boys (8:1)
2. MC in preterm infants
3. FH

Question 3

RF for umbilical hernias

Answer 3

1. MC in girls
2. MC in preterm + LBW babies
3. African descent

Connective tissue disorders can also increase the risk of other hernias

Question 4

Sx of hernias

Answer 4

1. Reducible swelling in groin (inguinal)/belly button (umbilical)
2. Swelling increases on crying/straining
3. May be asx

Question 5

Red flags

Answer 5

1. Irreducible
2. Tender
3. Vomiting

This indicates incarceration or strangulation

Question 6

Ix

Answer 6

Mainly a clinical diagnosis - abdominal US if atypical or uncertain

Question 7

Mx of inguinal hernias?

Answer 7

1. Surgical repair ASAP

NOTE: ASAP due to the risk of incarceration

Question 8

Mx of umbilical hernia

Answer 8

1. Watchful waiting until 4-5 years
2. Surgery if the umbilical hernia persists or there are complications

Umbilical hernias <1.5–2 cm in toddlers → usually self-resolve

Question 9

3 complications of hernias

Answer 9

1. Incarceration → obstruction
2. Strangulation → ischaemia, necrosis
3. Recurrence after surgery (rare if properly repaired)

Question 10

What is an incarcerated hernia?

Answer 10

• Hernia cannot be pushed back into the abdomen
• May cause pain, swelling, obstruction
• Urgent, but not yet ischaemic

Question 11

What is a strangulated hernia?

Answer 11

1. Blood supply to the herniated tissue is cut off → tissue ischaemia/necrosis
2. Presents with severe pain, redness, vomiting, systemic signs
3. Surgical emergency

All strangulated hernias are incarcerated, but not all incarcerated hernias are strangulated.

Question 12

What are the 2 types of inguinal hernias and which is the MC in children?

Answer 12

Direct and Indirect
MC - indirect inguinal hernias

Question 13

Pathophysiology of indirect inguinal hernias?

Answer 13

Abdominal contents herniate through deep → superficial inguinal ring

Caused by persistent processus vaginalis after testicular descent
→ processus vaginalis usually closes after birth

Question 14

What are direct inguinal hernias?

Answer 14

• MC in adults
• Herniation through Hesselbach’s triangle due to a weakness of the abdominal wall muscles
• Usually medial to inferior epigastric vessels

Hesselbach’s triangle borders:
- Medial: lateral edge of rectus abdominis
- Lateral: Inferior epigastric vessels
- Inferior: Inguinal ligament

Question 15

Inguinal hernias O/E

Answer 15

• Inguinal/inguino-scrotal mass (reducible when lying flat)
• No transillumination (ddx - hydrocele)
• Positive cough reflex

70% of inguinal hernias are right-sided