Hernias - Surgery

Question 1

What is a hernia?

Answer 1

Protrusion of a viscus or part of a viscus through the wall of its containing cavity into an abnormal position.

Question 2

What is a reducible hernia?

Answer 2

Sac can return to the abdominal cavity either spontaneously or with manipulation

Question 3

What is a irreducible hernia?

Answer 3

Sac cannot be reduced despite pressure or manipulation

Question 4

Strangulated hernia?

Answer 4

Blood supply of contents is compromised due to pressure at the neck of the hernia

Risks ar 3% and more common in indirect hernias.

Question 5

Sliding hernia?

Answer 5

Part of sac is formed by bowel (caecum or sigmoid) Take care when excising the sac.

Question 6

What is Maydl’s hernia?

Answer 6

Herniating double loop of bowel. Strangulated portion may reside as a single loop inside the abdomen

Question 7

What is Littre’s hernia?

Answer 7

Hernial sac containing strangulated Meckel’s diverticulum

Question 8

What is Amyand’s hernia?

Answer 8

Inguinal hernia containing strangulated appendix

Question 9

What is Richter’s hernia?

Answer 9

Only part of circumference of bowel is within the sac.
Most commonly seen with femoral hernia
Can strangulate without obstructing.

Question 10

What is a pantaloon hernia?

Answer 10

Direct + indirect hernia

Question 11

Herniotomy?

Answer 11

Excision of hernial sac

Question 12

Heniorrhaphy?

Answer 12

Suture repair of hernial defect

Question 13

Hernioplasty?

Answer 13

Mesh repair of hernial defect

Question 14

What is the epidemiology of an inguinal hernia?

Answer 14

• 3% of adults will require hernioplasty
• 4% of male neonates have hernia (higher in prems)
• M»F (:1 (descent of testes
• Majority present in 50s

Question 15

Pathology of inguinal hernia?

Answer 15

Commoner in R (damage to ilioinguinal N @ appendicectomy –> muscle weakness).

5% bilateral

8-15% present as emergency with strangulation/obstruction.

Question 16

Aetiology of inguinal hernia?

Answer 16

Congenital: patent processus vaginalis. This requires immediate repair.
- Processus vaginalis should obliterate following descent of testes
- If it stays patent it may fill with
Fluid – hydrocele
- Bowel/omentum –> Indirect hernia

Question 17

Acquired inguinal hernia?

Answer 17

Mainly things with increased the intra-abdominal pressure

• Chronic cough: COPD, asthma
• Prostatism
• Constipation
• Severe muscular effort: heavy lifting
• Previous incision/repair
• Ascites/obesity
• Appendicectomy

Question 18

Classification of inguinal hernias?

Answer 18

Indirect or direct

Question 19

What is an indirect hernia?

Answer 19

• 80%: commoner in young
• Congenital patent processus vaginalis
• Emerge through the deep ring
• Same 3 coverings as cord and descend into the scrotum
  Can strangulate.

Question 20

What is an direct hernia?

Answer 20

20%: common in elderly
Acquired
- Emerge through Hesselbach’s triangle (passes medial to the inferior epigastric artery). Rectus abdominis is medial. Inguinal ligament inferior. INferior epigastric vessels.
- Can acquire internal and external spermatic fascia
Rarely descend into scrotum
Rarely strangulate

Question 21

What are the clinical features in children of an inguinal hernia?

Answer 21

• Lump in groin which may descend into scrotum
• Exacerbated by crying
• Commonly obstruct

Question 22

Clinical features in adults of an inguinal hernia

Answer 22

• Lump in groin, exacerbated by straining/cough.
• May be clear ppting event: e.g heavy lifting
• Dragging pain radiating to groin.
  May present with obstruction/strangulation.

Question 23

Difference between direct and indirect inguinal hernia?

Answer 23

Direct

• Protrudes through Hesselbach triangle - medial to the inferior epigastric artery.
• Weakness in transversalis fascia area of the HEsselbach triangle
• Low risk of strangulation
• Seen in adults
• Much more in males.

Indirect

• Protrudes through the inguinal ring
• Passess lateral to the inferior epigastric artery

Failure of the processus vaginalis to close.
Low risk of strangulation

Question 24

Internal ring test?

Answer 24

• Ask patient to reduce the hernia.
• Feel the abductor longus. Bony prominence and pubic tubercle.
• Internal ring surface anatomy is midway between pubicle tubercle and ASIS.
• then ask patient to stand. Then to cough. The hernia does not exit.

Question 25

Mid-inguinal point

Answer 25

BEtween ASIS and Pubic Symphysis

Question 26

Midpoint of the inguinal ligament

Answer 26

Pubile tubercule and ASIS

Question 27

What is the inguinal canal consisting of?

Answer 27

- Anterior: External oblique + internal oblique for lateral 3rd - Posterior: transversalis fascia + conjoint tendon for medial 3rd - Floor: Inguinal ligament - Roof: arching fibres of transversus and internal oblique.

Question 28

How to examine inguinal hernia?

Answer 28

Expose pt from umbilicus to knees Begin with patient standing ``` Inspection - Look for any masses in groin. Ask patient to cough. Comment on appearance of mass -Site, size. - Features of inflammation ``` - Look for any scars Previous hernia operations. ``` Palpation - Check if patient in any patin - Palpate from the side of the patient - Palpate mass for cough impulse - Define anatomy: relation to pubic tubercle? Above and medial: inguinal hernia. ``` Does mass extend into scrotim? - Inguinoscrotal hernia are more likely to be indirect. Ausculate for bowel sounds - Hernia may lack bowel sounds if it just contains fat. Repeat inspection + palpate with patient supine. - Does the mass disappear when lying down. Test for direct vs indirect hernia - Ask patient to reduce hernia - Place 2 fingers over deep ring and ask patient to cough. - Mid point of inguinal ligament or 1/5cm above femoral pulse. Hernia controlled = indirect Not controlled = direct. Wash hand + complete exam.

Question 29

Surgical management of inguinal hernias?

Answer 29

Non-surgical - Rx RF: cough, constipation - Loss weight - Can use a truss for patients are are unfit for surgery. Surgical management - Tension-free mesh (Lichtenstein repair) better than suture repair. - Open approach can be done under LA or GA. - Lap approach allows bilateral repair and improved cosmetics. - primary unilateral repairs should be open. Children only require sac excision. Patients should return to non-manual work after 2-3 weeks and following laparoscopic reapir 1-2 weeks.

Question 30

Complications of inguinal hernia?

Answer 30

``` - Early Haematoma/seroma formation: 10% - Intra-abdominal injury (lap) - Infection: 1% - Urinary retention ``` Late - recurrence (<2%) - Ischaemic orchitis - Chronic groin pain.

Question 31

What is a femoral hernia?

Answer 31

Protrusion of viscu through the femoral canal Epidemiology - F>M - Middle aged and elderly

Question 32

What is the aetiology in femoral?

Answer 32

Acquired: increased intra-abdominal pressure | - Femoral canal larger in females due to shape of pelvis.

Question 33

Clinical features of femoral hernia?

Answer 33

Painless groin lump - Neck inferior and lateral to the pubic tubercle - Cough impulse - Often irreducible Commonly present with obstruction or strangulation - Tender, red, hot - Abdo pain, distension, vomiting, constipation

Question 34

Management of femoral hernia?

Answer 34

50% risk of strangulation within 1 month. Urgent surgery. Surgery - Elective: lockwood approach = Low incision over hernia with herniotomy and herniorrhaphy (suture ing. ligt. to pectineal ligt) - Emergency: McEvedy Approach - High approach in inguinal region to allow inspection and resection of non-viable bowel - Then herniotomy and herniorrhaphy.

Question 35

Incisional hernia definition?

Answer 35

Hernias arising through a previously acquired defect Epidemiology - 6% of surgical incisions

Question 36

Risk factors for incisional hernias?

Answer 36

Pre-operative - Increased age - Obesity or malnutrition - Comorbidities: DM, renal failure, malignancy - Drugs: Steroids, chemo, radio Intraoperative - Surgical technique/skill (major factor) - Too small suture bites - Inappropriate suture material - Incision type - Placing drains through wounds Post-operative - Increased IAP: chronic cough, straining, post-op ileus - infection - Haematoma

Question 37

Management of incisional hernias?

Answer 37

Surgery is not appropriate for all patients Must balance risk of operation and recurrence with risk of obstruction/strangulation and pt chice. - Usually broad-neck. Conservative - manage RF e.g constipation, cough - Weight loss - Elasticated corset Surgical - Pre-op Optimise cardiorespiratory function - Encourage weight loss Nylon mesh repair: open or lap.

Question 38

What is an umbilical hernia?

Answer 38

Congenital - Manage conservatively. 3% of LBs Defect in umbilical scar Risk factors - Afro-caribbean - trisomy 21 - Congenital hypothyroidism Management - Usually resolves by 2-3 yrs - Mesh repair is no closure - Can recur in adults: pregnancy or gross ascites

Question 39

What is a paraumbilical hernia?

Answer 39

Features - Acquired: middle aged obese man - Defect through linea alba just above or below umbilicus - Small defect --> strangulation (often omentum) Risk factors - Chronic cough - straining Management - Mayo (Double-breast linea alba with sutures) mesh repair

Question 40

Epigastric hernia?

Answer 40

- Young M > F - Pea-sized swelling caused by defect in linea alba above the umbilicus - Usually contains omentum: can strangulate. Mesh repair

Question 41

Spigelian hernia?

Answer 41

Hernia through linea semilunaris Hernia lies between layer of abdo wall Palpable mass more likely to be colon ca

Question 42

Obturator hernia?

Answer 42

Old age F>M Sac protrudes through obturator foramen Pain on inner aspect of thigh or knee Frequently present obstructed/strangulated

Question 43

Lumbar hernia?

Answer 43

- Middle aged M>F Typically follow loin incisions Hernia through sup/inf lumbar triangles

Question 44

Sciatic hernia?

Answer 44

- Hernia through lesser sciatic foramen | - Usually presents with a SBO + gluteal mass

Question 45

Gluteal hernia?

Answer 45

Hernia through greater sciatic foramen | Usually presents as SBO + gluteal mass

Question 46

Saphena varix?

Answer 46

Varicose vein in the thigh

Question 47

Renal transplant?

Answer 47

Patients with end stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant. Exclusion criteria include; active malignancy, old age (due to limited organ availability). Patients are medically optimised. The kidney once removed is usually prepared on the bench in theatre by the transplant surgeon immediately prior to implantation Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped. Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped. ATN occurs immediately and resolves.

Question 48

Raised amylase?

Answer 48

``` Infection Intra-abdominal pathology Drugs Renal failure Congenital hyperamlyasaemia. ```

Question 49

Nerve lesion during surgery?

Answer 49

Posterior triangle lymph node biopsy and accessory nerve lesion.

Question 50

Lloyd Davies stirrups nerve injury

Answer 50

common peroneal nerve.

Question 51

Thyroidectomy nerve injury

Answer 51

laryngeal nerve

Question 52

Anterior resection of rectum

Answer 52

hypogastric autonomic nerves.

Question 53

Axillary node clearance

Answer 53

long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve.

Question 54

Inguinal hernia surgery nerve injury

Answer 54

ilioinguinal nerve.

Question 55

Varicose vein surgery nerve injury

Answer 55

sural and saphenous nerves.

Question 56

Posterior approach to the hip nerve injury

Answer 56

Sciatic nerve

Question 57

Carotid endarterectomy

Answer 57

hypoglossal nerve. Hypoglossal nerve supplies ipsilateral motor component to tongue therefore deviates to the damaged side.

Question 58

Best long term option to feed patient with stroke with unsafe swallow?

Answer 58

PEG tube.