Contents
Introduction and Definitions
- A hiatus hernia occurs through a different mechanism – where the stomach passes up into the chest cavity through the diaphragm.
- Heavy lifting is not conclusively proven to be a risk factor. It is believed that an actual of heavy lifting can cause the hernia to present to the patient, but is not actually the cause and that the defects that result in a hernia are more chronic
- There is roughly a 1% chance per year that any given hernia can become strangulated
- As such, it is usually recommended that all hernias undergo surgical repair
- In some older, sedentary patients, conservative management may be appropriate
A typical hernia repair is a relatively minor surgery that involve sewing together the defect in the abdominal wall, and the placement of some sort of mesh at the site of the defect to prevent recurrence in the event that repair defect splits open again.
- Recurrence rates are about 10-15%
Recovery is typically 6 weeks of avoiding certain activities – such as lifting and squatting. This can mean a long time off work for those with a manual job – and unfortunately hernias are also more common in those with manual jobs!
- Reducible – the contents of the hernia can be pushed back to where its supposed to be
- Irreducible – the contents of the hernia can’t be pushed back to where its supposed to be
- Incarcerated – the contents of the hernia sac are stuck inside it (e.g. by adhesions)
- Obstructed – the contents of the bowel is prevented from passing along the bowel as an obstruction has occurred as a result of the hernia
- Strangulated – ischaemia of the tissue inside the hernia occurs. This patient will become toxic and requires urgent surgery. Note that with a strangulated hernia, it is possible to push the strangulation back inside where it has come from, and thus give the appearance of a successful reduction, but in actual fact, you have not de-strangulated the hernia.
The three signs of bowel obstruction:
- Distension
- Vomiting
- Absolute constipation – (no wind or faeces)
Checking for hernias
Inguinal
These are more common in men, and are more common than femoral hernias.
To understand inguinal hernias, we have to know a little bit about the inguinal canal. We find the inguinal canal, just above the medial half of the inguinal ligament. The inguinal ligament goes from the anterior superior iliac spine, to the pubic tubercle. The inguinal canal ahs the deep inguinal ring at its lateral side, and the external inguinal ring at its medial side. The inguinal canal is the canal between these two rings. In men, the rings and the canal are larger, hence the fact that inguinal hernias are more common in men. The contents of the canal are the genitofemoral nerve, and the spermatic cord (round ligament in women).
Indirect inguinal hernias – these come through the deep inguinal ring, and if large enough, out of the superficial inguinal ring. To reduce these, you have to go from medial to lateral. You will see this above and medial to the pubic tubercle – if it is large enough to have come out of the superficial ring. These account for 80% of inguinal hernias. They can strangulate – and usually at the deep inguinal ring as this is narrow.
If the hernia is really big it can descend into the scrotum and the labia majora.
Direct inguinal hernias – these come into the inguinal canal through a defect in the posterior wall of the canal. These are easier to reduce – they should just pop straight back in! these account for 20% of inguinal hernias. They are generally easy to reduce and do not strangulate.
As this fantastic diagram demonstrates, you can see the deep inguinal ring is located ½ way along the inguinal ligament, 1 ½ cm above this midpoint. The superficial ring is just about above the pubic tubercle.
- N – Nerve
- A – artery
- V – vein
- E – empty space
- L – lymphatics
Femoral
Paraumbilical hernias
Umbilical hernias are most commonly seen in children and typically resolve by the age of 2-5 without intervention.
Epigastric hernias
Inscisional hernias
Spigelian Hernias
Investigations
- Hernias are often diagnosed on examination and further imaging is not required
- If there is doubt about the diagnosis, or, occasionally for surgical planning – then an USS may be performed – this is becoming more common as USS becomes cheaper and more widely available
Repairing an inguinal hernia
- Laparoscopic surgical techniques generally result in shorter recovery times. The rate of complications between laparoscopic and open are similar
- Laparoscopic technique is becoming more popular
- In emergency surgery for strangulated hernia, open technique is still generally preferred
Reducing a hernia
- Get a chaperone
- Wash hands
- Introduce to patient – explain what you are going to do, get consent etc.
- Get hands + gloves
- Ask the patient if they are having any pain anywhere
- Ask them to stand up and expose themselves
- Cough – whether you can see a bulge or not, ask them t cough. You might then see one even if you couldn’t see it to begin with.
- Feel – if you can see a bulge, put your hand on it, and get them to cough. You should feel it bulge when they cough.
- Still not felt anything? – then you should you feel around a bit! Remember where the deep inguinal ring is – ½ way along the inguinal ligament – just above it. Just below the inguinal ligament in this place is the femoral pulse. Identify the pubic tubercle to help you identify what type of hernia (direct, indirect, femoral). You might also want to check the scrotum for inguinal scrotal hernia.
- Try reducing the hernia – along with the info you have got from the site of the hernia, this should help you tell what type it is.
- Wash your hands and report your findings!
- Lymph nodes of greater than 1cm in this region are pathological and should not be ignored
