Hernias

Question 1

What is a hernia?

Answer 1

• a protrusion of viscus from its surrounding tissue walls

Question 2

How are hernias classified in terms of their status?

Answer 2

• reducible: when the herniated sac is soft and easy to replace back through the defect
• incarcerated: when the sac is firm, painful, and nonreducible by direct manual pressure
• strangulated: (a consequence of incarceration) herniated contents have impaired blood flow and ischemia begins

Question 3

What are the major types of hernias? Which is the most common?

Answer 3

• indirect inguinal hernias (most common), direct inguinal hernias (second most common), ventral hernias, incisional hernias, and umbilical hernias are relatively more common
• femoral hernias, spigelian hernias, and obturator hernias are less common
• sliding hiatus hernias and rolling (paraesophageal) hiatus hernias

Question 4

Which hernias have a gender predilection?

Answer 4

• inguinal hernias are much more common in men
• femoral hernias are much more common in women
• (inguinal hernias are still the most common in both sexes though)

Question 5

Direct Inguinal Hernia

Answer 5

• herniation through a weakened transversalis fascia in the Hesselbach triangle
• the herniation bulges into the inguinal canal and can make its way through the external (superficial) inguinal ring, but usually does not reach the scrotum in men
• (Hesselbach triangle: medial border is rectus sheath, lateral border is inferior epigastric arteries, inferior border is inguinal ligament)
• occurs medially to the inferior epigastric arteries

Question 6

Indirect Inguinal Hernia

Answer 6

• herniation through a patent process vaginalis
• herniated sac passes through the internal (deep) inguinal ring and into the scrotum through the external (superficial) inguinal ring
• occurs laterally to the inferior epigastric arteries

Question 7

Femoral Hernia

Answer 7

• occurs in the femoral triangle; herniation can enter the empty space of the femoral canal
• (femoral triangle: medial border is adductor longus, lateral border is sartorius, base is inguinal ligament)
• these occur below the inguinal ligament

Question 8

Sliding Hiatus Hernia

Answer 8

• when the hiatus (hole for esophagus) is too wide or loose, the gastroesophageal junction can be displaced, resulting in the cardia of the stomach being pulled up through the esophageal hiatus
• increases risk for GERD

Question 9

Rolling Hiatus Hernia

Answer 9

• AKA paraesophageal hiatus hernia
• when the hiatus is too wide of loose, the fundus of the stomach can herniate out BESIDE the esophagus
• very dangerous, as there is a large risk for strangulation of this hernia

Question 10

DDx of Hernia-Like Symptoms

Answer 10

• lymphadenopathy, femoral artery aneurysm, undescended testis, lipoma, hydrocele, acute epididymitis, testicular torsion
• (if the lump is hard: malignant)
• (if the lump is pulsing/thrill: aneurysm)

Question 11

What is a herniotomy? A herniorrhaphy? A hernioplasty?

Answer 11

• herniotomy: removal of the herniated sac
• herniorrhaphy: herniotomy + repair of the posterior wall of the inguinal canal
• hernioplasty: herniotomy + reinforcement of the posterior wall of the inguinal canal