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Abdominal Hernias (examination (patient should be both supine and standing…
Abdominal Hernias
examination
patient should be both supine and standing to examine.
fingertip placed in scrotal sac and advanced upward to the inguinal canal. if superolateral to inferomedial and strikes the dstal tip of the finger then likely indirect
if the hernia strike the pad of the finger from deep to superficial, more likely direct
a bulge felt below the inguinal ligament is likely femoral
cough may be required to expose the hernia.cough is repeated whilst invaginates the scrotum and feels for an impulse
Definition
An abnormal protrusion of a cavity's contents through a weakness in the wall, taking with it all the linings of the cavity
Occur at sites where the abdominal wall is weakened. Such as surgical incision sites, inguinal and femoral canals, umbilicus, obturator canal or oesophageal hiatus
Most commonly contains fat (omentum) and or small bowel
Consists of a fundus, body and neck. The mouth of the hernia is an orifice in the abdominal wall through which the hernia passes.
Groin hernias.
Account for 75% of abdominal wall hernias 85% male.
Inguinal hernia
- protrusion of abdominal or pelvic contents through a dilated internal inguinal ring or attenuated inguinal floor into the inguinal canal male to female ratio 7:1
Indirect
60%- Caused by a defect in the abdominal wall. Can be congenital or acquired. Most hernias in females are indirect. Strangulation more common if compared with direct potrude at the deep inguinal ring exiting the superficial inguinal ring.. Lateral to the inferior epigastric artery.
Direct
25%Always acquired. Unusual before age 25. Caused by aging/strain/stress weakening the abdominal wall. Present in the Hesselbach triangle (bordered by the rectus abdominus, inguinal ligament and inferior epigastric vessels) potrudes media to the inferior epigastric artery. passess through the superficial inguinal ring
Femoral hernias 15%
A protrusion of a peritoneal sac through the femoral ring into the femoral canal, posterior and inferior to the inguinal ligament.
Forms a bulge in the upper inner aspect of the thigh. A lump may be the presenting symptom. Groin pain related to exercise is also common
Likely to obstruct & strangulate, therefore surgical intervention is indicated
Approximately 40% present as emergencies
groin repair procedure is associated with low health gain
50% no health benefit. 30% will suffer some degree of chronic pain. 1-2% wil suffer debilitating symptoms resulting in being unable to work or unable to fulfil ADLs
Ventral Hernias
Occur through areas of weakness in anterior abdominal wall.
Epigastric hernia
- protrude through the linea alba above level of the umbilicus
Para- umbilical hernia
- occur due to weakening of tissues around umbilicus.
Most often affects obese, multiparous women
Often irreducible because of adhesions. Skin may become reddened, excoriated and ulcerated. Rarely an intestinal fistula may develop
Risk of obstruction and strangulation is high
Umbilical hernia
occur in 1 in 5 infants and usualy spontaneously resolve. Not normally treated surgically until after 3 years.
Incisional hernia
- at incision site after surgery
Occur after approx. 5% of abdominal operations.
Predisposing factors: vertical incisions, poor surgical technique, wound infection, obesity, chest infection
Internal Hernias
- Protrusion of a viscus, most commonly small bowel, through a peritoneal or mesenteric aperture
Uncommon. More likely to occur after surgery, particularly after Roux-en-Y gastric bypass surgery.
Types: Paraduodenal (approx. 50%), transmesenteric, pericaecal, inter-sigmoid, supra or perivesical, foramen of Winslow, Omental
Requires CT for diagnosis
Hiatus hernia
- Herniation of the stomach through the oesophageal hiatus in the diaphragm
Types Sliding (90%), Rolling (10%)
Possible symptoms: Heartburn/reflux, oesophagititis, epigastric pain, palpitations and hiccups.
Management: Treatment is as for GORD. If obstructive symptoms such as vomiting and regurgitation or SOB - consider for surgery. If obstruction suspected, NG tube should be placed to decompress to prevent strangulation. Emergency surgery required if conservative therapy fails or gastric necrosis is suspected.
Most are treated as elective cases. unless incarcerated or strangulated
incarcerated.
Strangulated
Symptoms of incarcerated hernia
possibility of stangulation if pain and tenderness persist following reduction
pain out of proportion to external findings
Painful enlargement of a previous hernia. Inabiltity to reduce either spontaneously or manually. Nausea, vomiting. Possible symptoms of bowel obstruction
peritoneal signs and intestinal obstruction
ADMIT
asymtptomatic.
swelling or fullnes at hernia site. Aching sensation. no true pain or tenderness on examination. Enlargement with increasing abdominal pain on standing
Garden, JO., Bradbury, AW., Forsyth, JLR., Parks, RW., (2012). Principles and Practices of Surgery. 6th Ed. Edinburgh. Elsevier
Blachar, A., Federle, MP., (2002), Internal hernia: An Increasingly Common Cause of Small Bowel Obstruction. Seminars in Ultrasound, CT and MRI. [online] 23(2). pp 174-183. [Viewed 30 March 2019]. Available from:
https://doi.org/10.1016/S0887-2171(02)90003-X
Medscape. Abdominal hernias Treatment and Management.
https://emedicine.medscape.com/article/189563
. Accessed 01/04/2019
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References