Escolar Documentos
Profissional Documentos
Cultura Documentos
Definitions
Hernia A general term referring to a protrusion of a tissue through the wall of the cavity in which it is normally contained Incarceration the contents of the hernia cannot be returned to the cavity from which they came Strangulation The blood supply to the herniated tissue is disrupted causing ischemia and tissue death
Groin Hernias
96% Inguinal 9:1 M:F 4% Femoral 4:1 F:M Lifetime risk approximately 25% in males and <5% in females 700,000 repairs each year
Case 1
14 y/o male with no significant PMHx presents to the ED with scrotal swelling that he noticed after helping his father carry a couch. He has never noticed this swelling before, but it now causes him some discomfort when he stands from a sitting position. The patient states that it seems to mainly be on the right side of the scrotum. He denies severe pain, N/V, fevers, and says that the bulge does not seem to go away when he is supine.
Differential Diagnosis
Acute Conditions Testicluar Torsion Epididymitis Nonacute Conditions Hydrocele Varicocele Spermatocele Epdidiymal Cyst Testicular Tumor
http://feedbus.com/wikis/wikipedia.php?title=Inferior_epigastric_artery
Testicular Descent
Ventromedial aspect of urogenital ridge Descend through coelomic cavity pulled by gubernaculum testis Processus vaginalis forms at internal ring and precedes testicles into scrotum Processus Vaginalis obliterates
http://caltest.vet.upenn.edu/repropath/MReview/normdiag/picture.htm#Testicular%20Descent
Hernial sac formed by processus vaginalis Hernia is w/in the coverings of the spermatic cord
http://www.aafp.org/afp/990101ap/143.html
PE
Reducible versus non-reducible Can be mildly tender to exquisitely tender (strangulated)
Hernia Complications
Incarceration
14 to 31% of inguinal hernias, usually in infants < 1y/o Swelling due to decreased venous and arterial flow Outright pain, irritability and crying in children Bowel obstruction (N/V/colicky abdominal pain/distention) Tender, edematous, erythematous
Strangulation
Severe pain secondary to bowel ischemia Bowel obstruction Swelling, erythema, tenderness, peritoneal signs, fever, N/V Study of 439 patients showed probability of strangulation was 2.8% at three months, 4.5% at two years for groin hernias
Sx
Similar to Indirect hernias without extension of the hernia into the scrotum
PE
Symptoms similar to indirect inguinal hernias Often more easily reducible than indirect hernias
Hernia Track
Bulges through Hesselbachs Triangle in hernial sac formed by transversalis fascia Traverses the medial portion of the inguinal canal Emerges around conjoint tendon to reach the superficial inguinal ring Gains an outer covering of http://www.hernia.net.au/hernia_inguinal.html external spermatic fascia
Incarceration/Strangulation
Only true indications for repair Emergent reduction Bowel can be saved in most patients if operation occurs within four to six hours
Tx Contd
Operative Repair
Only definitive repair Recurrence in .5 to 15% depending on type of repair Open Repair versus Laparoscopic repair
Lap with less post op pain and faster return to work Increase risk of complications with longer surgery, higher risk of nerve, vascular, bowel, and bladder injury
Case 2
57 y/o G5P5 female with PMHx of HTN presents to clinic with a two hour history of a nonreducible bulge on her upper thigh. She reports severe pain, some fevers, N/V. She reports that she has had this same bulge intermittently for about a month. However, it has never hurt like it does at the time of presentation. Physical exam shows an exquisitely tender, erythematous bulge on the upper anterior thigh below the inguinal ligament. It is non-reducible.
Femoral Hernia
40% present with emergencies (incarceration/strangulation) Most commonly in females, especially older women
Less bulky musculature Weakness of pelvic floor muscles 2/2 childbirth Pelvic floor muscle atrophy 2/2 age Prior inguinal hernia repair is a RF
http://herniaplasty.med.nyu.edu/strangulatedhernia.html
Hernia Track
Hernia protrudes through medial aspect of femoral canal/sheath Below the inguinal ligament medial to the femoral vein Below and lateral to the pubic tubercle through the femoral ring Becomes more pronounced when it passes through the saphenous opening
http://www.aafp.org/afp/990101ap/143.html
Incisional Hernia
Due to failure of fascial tissues to heal and close Promoted by inhibition of wound healing 10-15% of abdominal incisions Highest incidence with midline incisions
Incisional Hernia
Sx
Bulge of abdominal wall deep to skin scar Cosmetic concern versus discomfort Worsened with coughing or straining Incarceration
<1cm, >7-8 cm unlikely to incarcerate
Tx
Most should be repaired (unlike groin hernias) Suture versus mesh repair
Suture repair in one European study showed 60% recurrence with mesh recurrence at 30%
Umbilical Hernia
Congenital
Opening in linea alba when umbilical scar fails to heal at birth More common in AA children Most close in first 12-18 months of life Repair rarely recommended prior to 3 y/o
Acquired
3:1 F:M Men more likely have incarceration Associated with increased intra-abdominal pressure
Obesity Ascites Abdominal distention Pregnancy
http://medicine.ucsd.edu/clinicalimg/abdomen-incarcerated-umbo.html
Spigelian
Lateral ventral hernia
Hernias
Junction of vertical semilunar line and horizontal semicircular line (arcuate line)
PE
Difficult to diagnose Below EAO U/S or CT can aid in diagnosis
http://herniaplasty.med.nyu.edu/spigelianhernia.html
Richters
or strangulates
Littres
Any groin hernia that involves a Meckels Diverticulum Usually incarcerated or strangulated
Armands
Any hernia that contains the appendix Can cause symptoms of Appendicitis
Pantaloon Hernia
Simultaneous Direct and Indirect Inguinal Hernias Two bulges straddle the inferior epigastric vessels
Incarceration with frank pain or strangulation are operative emergencies and bowel can be saved if done within 4-6 hours
An attempt at reduction should be made with a hernia, but operative reduction is the only definitive treatment Femoral hernias have a high rate of incarceration and should be repaired, but other inguinal hernias may be watched if asymptomatic With abdominal incisions, try not to put excessive tension or damage the suture in any way as it can promote incisional hernias