Hernias

Front 1

What % of adult hernias are incisional?

Back 1

10%

Front 2

Clinical presentation of inguinal hernias?

Back 2

acute intestinal obstruction or chronic recurrent abdominal pain and vomiting due to incomplete+ intermittent intestinal obstruction

Front 3

What is a Richter's hernia?

Back 3

only part of the circumference of the bowel is trapped within the hernial sac- lumen of the bowel is not occluded so obstruction does not occur. Few Sx until the ischemic part perforates

Front 4

Pathophysiology of strangulation

Back 4

initially venous channels become obstructed then arterial

Front 5

What constitutes an attempt at a reduction of a hernia?

Back 5

elevate foot of bed
warm the patient
opioid analgesia preferred
firm pressure applied after 20-30 min of the above

Front 6

Relationship of direct and indirect inguinal hernias to the epigastric vessels?

Back 6

direct- medial to epigastric
indirect- lateral to epigastric

Front 7

What is more common; direct or indirect inguinal hernias?

Back 7

inidrect 4x direct- occurs any time throughout life and is 10x more common in males

Front 8

In what scenarios are direct ingional hernias more common

Back 8

rare in children and in females
more common on RHS after appendicectomy suggesting role for damage to ilioinguinal and iliohypogastric nerves leading to weakness of internal oblique

Front 9

How do you prevent an indirect inguinal hernia from protruding?

Back 9

apply pressure over the deep inguinal ring. If a hernia appears medially to your fingers it is direct.
Indirect are more likely to strangulate as they have a narrower neck

Front 10

What is a sliding inguinal hernia?

Back 10

part of a viscus forms part of the hernial sac (which may contain another viscus)
More common on the lHS than on the right (contain caecum rather than sigmoid)
May be direct or indirect
most of the time occurs in males

Front 11

What % of hernias in children occur in males?
Which side are these usually on?

Back 11

90% in males
Usually on RHS due to later descent of right testis; 10-20% bilateral and PPV is found in contralateral testis in 50% of cases if this is explored

Front 12

Management of inguinal hernias in children?

Back 12

mobilise and ligate sac through the superficial inguinal ring which lies almost directly ober the deep inguinal ring in children

Front 13

Management of indirect versus direct inguinal hernias

Back 13

indirect- sac excised (herniotomy)
direct- sac not excised; do herniorrhaphy (posterior wall and aponeurotic repair) or hernioplasty (mesh insertion to support posterior wall of inguinal canal)

Front 14

How does a hernioplasty work

Back 14

two arms of the mesh encircle cord at the level of the deep inguinal ring- and are sutred to posterior wall behind the cord. Strengthens the posterior wall of the inguinal canal.

Front 15

Disadvantages of laproscopic hernia repair?

Back 15

increased incidence of femoral nerve and spermatic cord damage
increased adhesions in transperitoneal procedures

Front 16

How long do you avoid activity for after a hernia repair?

Back 16

straining and lifting- 4 weeks
heavy physical work 6-8 weeks

Front 17

How does a hernioplasty work

Back 17

two arms of the mesh encircle cord at the level of the deep inguinal ring- and are sutred to posterior wall behind the cord. Strengthens the posterior wall of the inguinal canal.

Front 18

Disadvantages of laproscopic hernia repair?

Back 18

increased incidence of femoral nerve and spermatic cord damage
increased adhesions in transperitoneal procedures

Front 19

How long do you avoid activity for after a hernia repair?

Back 19

straining and lifting- 4 weeks
heavy physical work 6-8 weeks

Front 20

Are femoral or inguinal hernias more common in females?

Back 20

inguinal

Front 21

Do femoral hernias occur more on the right or on the left hand side?

Back 21

60% RHS, 30% LHS, 10% bilateral

Front 22

Commonest site for a richter's hernia?

Back 22

femoral

Front 23

Approaches to a femoral hernia repair?

Back 23

low approach (small)
high (emergency, complicated) --> resection of bowel and excision of sac

Front 24

Incidence of incisional hernia?

Back 24

5% at 5 years
10% at 10 years

Front 25

Natural progression of incisional hernias

Back 25

Start with nagging discomfort at site of incision
Size increases with time and frequently become irreducible

Front 26

What are some poor surgical techniques that contrinute to incisional hernias

Back 26

parallel incisions
devitillized tissue in the wound
parallel incisions

Front 27

Treatment of incisional hernia

Back 27

pre-op wt reduction in obese- or will recur
if v. marrive: 1-2 weeks of pre-operative pneumoperitoneum so will fit
If can close defect primarily- sew with non-abs sutres, if can't then use mesh (requires prophylactic antibiotics)

Front 28

What is actually protruding in an epigastric hernia?

Back 28

extraperitoneal fat and peritoneum protruding through linea alba
fit young males with epigastric pain
usually irriducible, may be multiple

Front 29

Management of epigastric hernia?

Back 29

surgery if symptomatic
mark pre-op as may disappear when abdo muscles relaxed
Types of repairs: keel repair for multiple (vertical incision); Mayo repair for single (transverse incision, interrupted sutres)

Front 30

Incidence of umbilical hernias in infants?

Back 30

5-10% of caucasian infanmts at birth
1/3 close within 1 month
rarely persist beyong 3-4
expectent management unless large, persists past age 4
repair through short, transverse supraumbilical incision

Front 31

Why are para-umbilical hernias irriducible?

Back 31

extraperitoneal fat and peritoneum protrudes through 1 side of umbilical ring- adheres and becomes loculated and irreducible

Front 32

Management of paraumbilical hernias

Back 32

surgical- due to risk of obstruction, strangulation and excoriation of skin
manage with a mayo repaur and sometimes a mesh

Front 33

Incidence of stoma related hernias

Back 33

10-30%
related to surgical technique: should not be sited in wound/umbilicus
Should come through aponeurosis not muscle

Front 34

Indications for operation with stoma-related hernias?

Back 34

if bulge interferes with stoma function or if strangulated

Front 35

Why are para-umbilical hernias irriducible?

Back 35

extraperitoneal fat and peritoneum protrudes through 1 side of umbilical ring- adheres and becomes loculated and irreducible

Front 36

Management of paraumbilical hernias

Back 36

surgical- due to risk of obstruction, strangulation and excoriation of skin
manage with a mayo repaur and sometimes a mesh

Front 37

Incidence of stoma related hernias

Back 37

10-30%
related to surgical technique: should not be sited in wound/umbilicus
Should come through aponeurosis not muscle

Front 38

Indications for operation with stoma-related hernias?

Back 38

if bulge interferes with stoma function or if strangulated

Front 39

What is a spigelian hernia

Back 39

Hernia through the linea semilunaris
Up to 20% will present incarcerated
Operative repair is mandatory