Surgery Hernias

Question 1

Types of Hernia

Answer 1

Femoral

• Infero-lateral to pubic tubercle
• i.e. go to the thigh

Inguinal

• Supero-medial to pubic tubercle
• i.e. go to the genitalia
• Direct or indirect

Others…

Question 2

Anatomy

Answer 2

Inguinal anatomy

Medial to inf. epigastric vessels
DIRECT

• Pushes directly through abdominal wall to join inguinal canal

Lateral to inf. epigastric vessels
INDIRECT

• Swerves indirectly up and along next to spermatic cord

Question 3

Scrotal anatomy

Answer 3

Other points to consider

•Mid-inguinal point

• Halfway between ASIS and pubic symphysis
• Femoral artery

•Mid point of inguinal ligament

• Halfway between ASIS and pubic tubercle
• Deep (internal) inguinal ring
• Useful for hernia type

•Length of inguinal canal

• ~4cm

Question 4

History

Answer 4

• How long?
• Painful?
• Single/multiple?
• Changing? How?
• Family history
• Foreign travel
• Associated symptoms/fit and well?

Question 5

Examination

Answer 5

• Size
• Site
• Shape
• Smoothness
• Surface
• Surroundings

Other questions:

• Transillumination?
• Fixed or mobile?
• Fluctuant?
• Pulsatile?
• Painful?
• Temperature
• Colour
• Bruit

Question 6

Anatomy

Answer 6

Hernias

Question 7

Hernias

Answer 7

• “The protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it”
• i.e. peritoneum through abdominal wall which may or may not have bowel in it, which may or may not be stuck, ischaemic or obstructed

Question 8

Definitions

Answer 8

Irreducible

• Unable to push back to normal position

Incarcerated

• Sac contents stuck by adhesions

Strangulated

• Sac contents become ischaemic

Obstructed

• Bowel in hernia unable to allow contents to pass through

Question 9

Inguinal hernias

Answer 9

Direct or indirect

• Risk factors: chronic cough, constipation, urinary obstruction, heavy lifting, ascites, previous abdo surgery

Examine:

• Look for scars, feel other side, examine external genitalia
• Ask if visible and ask pt. to reduce, then cough

Direct vs. indirect

• Reduce, obstruct internal ring, get pt. to stand
• If pops out -> direct, if not -> indirect

Question 10

Other hernias

Answer 10

Femoral
Paraumbilical

• Rectus sheath

Epigastric

• Linea alba

Incisional
Spigelian
Semilunaris
Obturator
Obturator canal
Diaphragm

Question 11

Involving bowel

Answer 11

Richter’s

• Bowel wall, no lumen

Maydl’s

• Double loop

Littre’s

• Strangulated Meckel‟s diverticulum

Question 12

Elective surgery

Answer 12

20 million groin hernias are repaired worldwide
•Risk of incarceration is 4 per 1,000 patients with a hernia p.a.
•Risk factors for incarceration:
▫>60 years
▫Femoral hernia
▫Duration of signs less than 3 months
▫Recurrence
▫Book electively
•Low risk
▫Asymptomatic
▫<50 years
▫ASA 1 or 2
▫Inguinal hernia
▫>3 months history
▫Watchful waiting

Question 13

Emergency surgery

Answer 13

Increased morbidity and mortality
Persist for the year following the surgery
Strangulation increases post-op morbidity by 2.67 and mortality by 10
Do emergently if emergent problems:

• Incarcerated + bowel obstruction
• Strangulated

Question 14

Types of repair

Answer 14

Open

• Multi-layered suture repair (recurs 10%)
• Mesh repair (recurs 2%)

Laparoscopic

• Similar recurrence rates
• Less post op pain
• Earlier return to work
• Identify other pathology

Question 15

Scrotal lumps

Answer 15

Can you get above it?

No: Inguino-scrotal hernia Hydrocele (large)

Yes:

Separate from testis?

Y N

Is it reducible?