Hernias

Question 1

define hernia

Answer 1

Protrusion of any viscus from its proper cavity

Question 2

What can a hernia lead to?

Answer 2

Can lead to an incarcerated & often obstructed bowel or a strangulated bowel w/ a compromised blood supply

Question 3

What is a reducible hernia?

Answer 3

A hernia sac & contents that move freely in & out of the fascia

Question 4

What is an incarcerated hernia?

Answer 4

When a hernia & contents are not reducible = “incarcerated”

Question 5

What can incarcerated hernia lead to?

Answer 5

1. When a sac content is incarcerated, risk that it can become “strangulated”
   A. Requires emergent surgery
   B. (+) signs of bowel obstruction (pain, N/V, toxic appearance, fever)

Question 6

What is an epigastric hernia?

Answer 6

Located on the front abdominal wall from the sternum to the navel

Question 7

What is an umbilical hernia?

Answer 7

A. appears as a bulge at umbilicus
B. It occurs when the muscle around the navel doesn’t close completely
C. Common & typically harmless condition
D. Umbilical hernias are most common in infants, but can affect adults as well
-In an infant, an umbilical hernia may be especially evident when the infant cries, causing the baby’s bellybutton to protrude.

Question 8

What is an incisional hernia?

Answer 8

1. can occur through an incision site post laparotomy
2. At sites of prior abdominal surgery, usually asymptomatic
3. Patients present w/ a bulge at the site
4. The bulge may become larger upon standing or w/ increased intra-abdominal pressure

Question 9

What is a femoral hernia?

Answer 9

1. Appears as a bulge in the upper thigh
2. F > M
3. Occur just below the inguinal ligament, when abdominal contents pass thru femoral canal
4. Exits from the retroperitoneal space along the femoral vessels in the femoral canal
   A. Occasionally confused w/ inguinal canal hernia

Question 10

What is an inguinal hernia?

Answer 10

1. Appears as a bulge in the groin.  	
A. M > F
B. May extend into scrotum
		-Direct
		-Indirect

Question 11

Describe an obturator hernia

Answer 11

1. An obturator type of abdominal wall hernia in which abdominal content protrudes through the obturator foramen
   A. May not have local swelling, because hernia is hidden w/in deeper structures
   B. May c/o abdominal pain or medial thigh pain, weight loss, or recurrent episodes of SBO

C. Pressure on the obturator nerve causes pain in medial thigh that is relieved by thigh flexion

D. Pain may be exacerbated by extension or external rotation of the hip (Howship-Romberg sign)

Question 12

Describe a spigelian hernia?

Answer 12

1. Spigelian hernia (Lateral ventral hernia, Semilunar hernia)
   A. Abdominal wall hernia that occurs through a defect in the spigelian fascia
   B. Lateral edge of the rectus muscle at the semilunar line (costal arch to the pubic tubercle)

Question 13

What is a spigelian hernia at risk for?

Answer 13

Usually small and therefore ↑ risk of strangulation

Question 14

What are the predisposing factors for hernias?

Answer 14

1. Chronic constipation, straining w/ BM
2. Chronic cough
3. Cystic fibrosis
4. Enlarged prostate, straining to void
5. Extra weight
6. Heavy lifting
7. Poor nutrition
8. Smoking
9. Overexertion
10. Cryptorchidism (undescended testicle)
11. Genetic predisposition

Question 15

What are the sxs of hernias?

Answer 15

1. Most often there are no symptoms
2. Sometimes there may be discomfort or pain
3. Pain can worsen w/ standing, straining, or lifting heavy objects
4. Patients can c/o of a visual bulge

Question 16

When is surgery indicated for for umbilical hernias?

Answer 16

1. Many umbilical hernias close on their own by age

A. If doesn’t resolve by age 3 or those that appear during adulthood may need surgical repair

Question 17

Describe a direct inguinal hernia

Answer 17

1. Develops medial to the internal inguinal ring
   Posterior wall weakens as the transversalis fascia thins, & a bulge results
2. Usually contain properitoneal fat & bladder wall
   A. Rarely found to extend into the scrotum

Question 18

Describe indirect inguinal hernia

Answer 18

1. Due to a persistence of the processus vaginalis through the internal ring along the course of the spermatic cord or round ligament. a portion of the small intestine enters the inguinal canal
2. The processus vaginalis is located anterior and medial to the structures of the spermatic cord or round ligament
3. With time, pressure applied by the intra-abdominal contents in the sac causes enlargement of the sac & dilation of the internal inguinal ring

Question 19

How are hernias diagnosed?

Answer 19

1. Diagnosis by H & P
2. The mass may increase in size when coughing, bending, lifting, standing or straining
3. The hernia may not be obvious in infants & children, except when the child is crying or coughing

Question 20

Where is Hesselbach’s triangle? Why is it important?

Answer 20

1. Area of the anterior abdominal wall bounded by the inferior epigastric vessels, inguinal ligament and the lateral border of the rectus abdominis
2. Direct inguinal hernias leave the abdomen through this triangle

Question 21

What are the physical exam pearls for hernias?

Answer 21

1. For inguinal hernias, place a fingertip into the scrotal sac and advance up into the inguinal canal
2. If hernia comes from superolateral to inferomedial and strikes the distal tip of the finger, it most likely is an indirect hernia
3. If hernia strikes the pad of the finger from deep to superficial, it is more consistent w/ a direct hernia
4. A bulge felt below the inguinal ligament is consistent w/ a femoral hernia
5. In general, the physical examination should be performed w/ the patient in both the supine & standing positions, w/ & w/out Valsalva maneuver

Question 22

What are the dx studies for hernias?

Answer 22

1. Ultrasound
2. CT
3. MRI (rare)

Question 23

How are hernias managed?

Answer 23

1. If the hernia is not painful & doesn’t interfere w/ ADL’s, no treatment other than education & prn follow up is required
2. If the patient experiences pain or if the hernia is not reducible, a surgical consult should be made