Hernias (GI)

Question 1

Define hernia.

Answer 1

Part of an organ is displaced and protrudes through the wall of the cavity containing it

Question 2

What are some different types of hernia? (8)

Answer 2

• inguinal - superomedial to pubic tubercle
• femoral - inferolateral to pubic tubercle
• umbilical - umbilicus (symmetrical)
• paraumbilical - asymmetrical, above/below umbilicus
• epigastric - midline between umbilicus and xiphisternum
• incisional
• obturator - passes through obturator foramen
• Richter - only the antimesenteric border of the bowel herniates through the fascial defect –> strangulation without obstruction

Question 3

Define an epigastric hernia.

Answer 3

Midline, through linea alba, between umbilicus and xiphisternum

Question 4

Define umbilical hernia.

Answer 4

Midline, through anterior abdominal fascia, usually bowel/fat

Question 5

Define inguinal hernia.

Answer 5

Abdominal or pelvic contents protrude through inguinal canal - most common hernia (75%)

Question 6

Who are inguinal hernias more common in?

Answer 6

M>F due to larger and more prominent inguinal canal

Question 7

What are the two types of inguinal hernias?

Answer 7

Direct and indirect

Question 8

What is a direct inguinal hernia?

Answer 8

Protrusion DIRECTLY through posterior wall of inguinal canal and MEDIAL to inferior epigastric vessels

Question 9

How are direct inguinal hernias developed?

Answer 9

Acquired - occur over time due to weakness and straining in abdominal muscles

(Increased abdominal Pa –> degeneration and weakening of transversalis fascia)

Question 10

Who does direct inguinal hernias occur in?

Answer 10

Older men, rare in children

Question 11

What is an indirect inguinal hernia?

Answer 11

Protrusion into inguinal canal through deep inguinal ring LATERAL to inferior epigastric vessels

INDIRECTLY protrudes inguinal canal (does not protrude directly through wall)

Question 12

How are indirect inguinal hernias acquired?

Answer 12

Congenital - defect in abdominal wall typically present since birth

Question 13

Who does indirect inguinal hernias occur in?

Answer 13

May occur in infants

Question 14

How do direct and indirect inguinal hernias differ on palpation?

Answer 14

When reduced and pressure is applied to deep inguinal ring (occluding it), indirect hernia will remain reduced but direct hernia reappears

Question 15

What are some risk factors for inguinal hernias? (10)

Answer 15

• male
• older age (direct hernia)
• Fx
• prematurity (indirect)
• AAA
• Marfan syndrome
• Ehlers-Danlos syndrome
• defective transversalis fascia (direct)
• lathyrism - neurotoxic disease by ingestion of certain legumes
• increased intra-abdominal Pa - chronic bronchitis/emphysema, pregnancy, ascites, obesity, BPH, urethral stricture, constipation

Question 16

What are femoral hernias?

Answer 16

• contents pass through femoral canal (inferolateral to pubic tubercle)
• most common in women
• only 5% of hernias

Question 17

Define incisional hernia.

Answer 17

Contents herniate through scar from previous surgery

Question 18

Define incarcerated hernias.

Answer 18

Hernias that cannot be reduced and no systemic features (complicated hernia)

Question 19

Define strangulated hernias.

Answer 19

Blood supply cut off to hernia leading to ischaemia - more common with femoral hernias

Question 20

How may patients with a strangulated hernia present? (5)

Answer 20

• tender, distended abdomen with guarding
• absent bowel sounds
• systemic features
• bowel obstruction e.g. distension, N&V
• bowel ischaemia e.g. bloody stools

Question 21

What is the difference between an uncomplicated vs complicated hernia?

Answer 21

• uncomplicated - reducible (can push it back in)
• complicated - irreducible, incarcerated (cannot push it back in)
  
  • reduced blood and lymphatic flow –> oedema –> strangulation (cut off blood supply) –> ischaemia and necrosis
  • untreated –> perforation –> localised peritonitis –> generalised peritonitis

Question 22

What is the most common hernia type in men vs women?

Answer 22

• men - inguinal hernia
• women - femoral hernia

Question 23

What are the clinical features of inguinal hernias? (5)

Answer 23

• lump in groin (belly button, tummy = other type)
• groin discomfort/pain - dull, heaviness, dragging
• pain improves when hernia does not bulge
• bowel obstruction - N&V, constipation, acute abdomen
• reducible / irreducible

Question 24

What are the clinical features of a femoral hernia? (2)

Answer 24

• typically non-reducible
• cough impulse more likely to be absent than inguinal, but can still be +ve

Question 25

What might you find on examination of hernias? (4)

Answer 25

- visible or palpable mass - soft and pliable, may enlarge with standing/Valsalva manoeuvre (forced expiration through closed airway) - incarcerated: painful, tender and erythematous - strangulated: systemic Sx (pyrexia, tachycardia) - reducible? - press down on deep inguinal ring with 2 fingers to occlude + ask patient to cough/stand - if hernia reappears --> direct - if hernia does not reappear --> indirect

Question 26

How are hernias usually diagnosed?

Answer 26

Clinical diagnosis via observation and palpation

Question 27

What scans may be useful to diagnose a hernia? (3)

Answer 27

- ultrasound of groin when diagnostic uncertainty - CT useful in very obese patients; do if complicated (irreducible), obstructed or strangulated - MRI of groin

Question 28

What do we look for in bloods when suspecting a strangulated hernia? (2)

Answer 28

Leukocytosis + raised lactate

Question 29

What special tests can we do to investigate a hernia?

Answer 29

Valsalva manoeuvre (forced expiration through a closed airway) + cough impulse

Question 30

What are some differential diagnoses for hernias? (7)

Answer 30

- undescended testis - lymphadenopathy - femoral aneurysm - psoas abscess - hydrocoele - spermatocele - lipoma of spermatic cord

Question 31

What is the main method of hernia management?

Answer 31

Surgical mesh repair (even in medically fit patients if asymptomatic): - herniotomy: use mesh patches to repair the defect/wall through which herniation occurred - herniorrhaphy: stitch the healthy ends of tissue/muscle together using a mesh

Question 32

How do we manage a small, asymptomatic inguinal hernia?

Answer 32

Watchful waiting

Question 33

How do we manage a large/symptomatic uncomplicated inguinal hernia?

Answer 33

- unilateral inguinal hernia - open-mesh approach - bilateral/recurrent inguinal hernia - laparoscopic mesh repair

Question 34

How do we manage incarcerated/strangulated inguinal hernias?

Answer 34

- surgical repair + supportive + consider prophylactic Abx - not strangulated: laparoscopic - strangulated: open (as bowel may necrose) - mesh repair if bowel viable, non-mesh repair if gangrenous bowel

Question 35

When can inguinal hernias be left?

Answer 35

If patient not fit for surgery - can use Truss support belt

Question 36

What type of hernia definitely needs repair?

Answer 36

Femoral hernia due to risk of strangulation

Question 37

How do we manage umbilical hernias?

Answer 37

- small asymptomatic - observation until 4/5y, spontaneous reduction in 80% - incarcerated - surgical repair following attempted reduction - large symptomatic OR small asymptomatic but no spontaneous reduction - surgical repair due to risk of incarceration

Question 38

How do we manage obstructed/strangulated hernias?

Answer 38

Emergency laparotomy

Question 39

What are some post-operative complications of hernias? (6)

Answer 39

- urinary retention - wound seroma (fluid collection) - inguinal wound haematoma - wound infection - bowel obstruction - vas deferens division or vascular injury (fertility issues)

Question 40

What are some complications of hernias? (4)

Answer 40

- incarceration - strangulation (Maydl's hernia - strangulated W-shaped loop of small bowel) - bowel obstruction - perforation --> peritonitis

Question 41

Describe the prognosis of hernias.

Answer 41

Excellent after surgical repair