Hernias

Definitions

Obstructed = Bowel contents cannot pass

Strangulated = Ischaemia occurs

Irreducible = contents cannot be pushed back into place

Incarceration = Contents of the hernial sac are stuck inside by adhesions

= The protrusion of a viscus through a defect of the walls of its containing cavity into an abnormal position

Hiatus Hernia

50% of patients have symptomatic reflux

Investigations

Rolling Hiatus Hernia

Treatment

Sliding Hiatus Hernia

80% of hiatus hernias

Acid reflux is frequent as the lower oesophageal sphincter becomes less competent

Where the gastro-oesophageal junction slides up into the chest

Where the gastro-oesophageal junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oeseophagus

Gastro-oesophageal junction remains intact so acid reflux is uncommon

20% of hiatus hernias

Barium swallow

Upper GI endoscopy visualises the mucosa

Treat reflux symptoms

Surgery if symptoms cannot be cured

Lose weight

Rolling hiatus hernia should be repaired prophylactically as it may strangulate

Inguinal Hernias

Definitions

Indirect

Direct

Predisposing Conditions

Urinary obstruction

Heavy lifting

Constipation

Ascites

Chronic cough

Past abdominal surgery

Epidemiology

M:F = 8:1

Examination

Ensure it is not a scrotal lump

Ask patient to cough - hernia will appear above and medial to the pubic tubercle

Is the lump visible?

80% of inguinal hernias

Can strangulate

Indirect hernias pass through the internal inguinal ring and if large pass out through the external inguinal ring

20% of inguinal hernias

Rarely strangulate

Direct hernias push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall

Treatment

Lose weight and stop smoking pre-op

Hernias may recur

Try to reduce these hernias to prevent strangulation and necrosis

Polyprophylene mesh reinforces posterior wall

Long standing hernias may become painful and irreducible

Femoral Hernias

Occurs more often in women, middle aged, elderly

Irreducible and strangulate

Presents as a mass in the upper medial thigh or above the inguinal ligament

Must repair with surgery

Bowel enters the femoral canal

Incisional Hernias

If obese, repair is not easy

Mesh repair: less recurrence but more infections compared to sutures

Follows breakdown of muscle closure after surgery