Hernias

• What are the common locations for hernias?

  Groin (inguinal)

  Upper thigh (femoral)

  Abdomen

  Hiatus hernia
• What are the RFs for hernias?

  Obesity

  Heavy lifting

  Chronic coughing

  Straining during defecation
• What are the typical features of an abdo wall hernia?

  Soft lump protruding from abdo wall

  Lump may be reducible (can be pushed back)

  Lump protrudes on coughing or standing

  Aching, pulling or dragging sensation
• What are the possible hernia complications?

  Incarceration

  Obstruction

  Strangulation
• What is incarceration?


  Hernia cannot be put back into proper position

  Bowel is trapped in herniated position

  Can lead to obstruction & strangulation
• What is obstruction (hernia)?

  Hernia causes blockage in passage of faeces through bowel

  Presentation = vomiting, generalised abdo pain, absolute constipation (no faeces or flatus)
• What is strangulation (hernia)?

  Hernia is non-reducible AND base of the hernia becomes so tight that is becomes ischaemic

  Surgical emergency (bowel will die within hours if not corrected)

  Presentation = signif pain/tenderness
• Wide neck hernias have a lower risk of complications.
• What is the management of abdominal wall hernias?

  Leave hernia alone (if wide neck & pts not good candidates for surgery)

  Tension-free repair (surgery)

  • placing mesh over defect in abdo wall
  • prevents herniation of cavity contents
  • over time, tissues grow into mesh & provide extra support
  • lower recurrence rate
  • comp = chronic pain

  Tension repair (surgery)

  • suture muscles & tissues back together
  • rare
  • high recurrence rate
• Inguinal hernia - presentation

  Soft lump in groin
• What are the 2 types of inguinal hernia?

  Indirect

  • bowel herniates through inguinal canal

  Direct

  • due to weakness in abdominal wall at Hesselbach's (inguinal) triangle
• What are the DDx of lump in inguinal region?

  Femoral hernia

  Lymph node

  Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)

  Femoral aneurysm

  Abscess

  Undescended/ectopic testes

  Kidney transplant
• What can be done to differentiate between an indirect & direct inguinal hernia?

  When an indirect inguinal hernia is reduced & pressure is applied (2 fingers) to the deep inguinal ring (midway between ASIS & pubic tubercle) -> hernia will remain reduced

  In direct, hernia still protrudes
• What are the borders of Hesselbach's triangle?

  Rectus abdominis muscle -> medial border

  Inferior epigastric vessels -> superior/lateral border

  Poupart's ligament (inguinal ligament) -> inferior border
• What is the aetiology of direct & indirect inguinal hernias?

  Direct

  • typically acquired (raised intra-abdominal pressure (chronic cough), constipation, heavy lifting, obesity)

  Indirect

  • generally congenital (due to patent processus vaginalis)
• What are the Inx for hernias?

  Mainly clinical

  Possible bloods (VBG, FBC, CRP) if suspicious of strangulation

  USS if diagnosis uncertain

  Abdominal XR & CXR -> if obstruction/perforation suspected
• What are femoral hernias?

  Herniation of abdominal contents through the femoral canal

  At high risk of incarceration, obstruction & strangulation
• What are the boundaries of the femoral canal?

  Femoral vein - lateral

  Lacunar ligament - medial

  Inguinal ligament - anterior

  Pectineal ligament - posterior

  NOTE: the femoral canal is NOT the same as the femoral triangle
• What is the presentation of femoral hernias?

  Tender, irreducible lump inferior to the inguinal ligament

  Usually smaller than inguinal hernias

  May be associated with a Hx of sudden increase in intra-abdominal pressure (straining, lifting, coughing)
• Who are femoral hernia most commonly seen in?

  Elderly women
• What are the DDx of femoral hernias?

  Lymphadenopathy

  Abscess

  Femoral artery aneurysm

  Hydrocele or varicocele (males)

  Lipoma

  Inguinal hernia
• What is an incisional hernia?

  Hernia at site of incision from previous surgery
• What are umbilical hernias? Who are they most common in?

  Protrusion of abdominal contents around umbilicus

  Common in neonates & can resolve spontaneously