Hernias: Adnan Akram

Hernias

Adnan Akram Riga 2009

Definations As defined in 1804 by Astley Cooper, " a hernia as a protrusion of any viscus from its proper cavity " The protruded parts are generally contained in a sac-like structure, formed by the membrane with which the cavity is naturally lined Protrusion of an organ beyond its normal confines is termed as hernia.

Etiology Any condition that increases the pressure in the intraabdominal cavity may contribute to the formation of a hernia

• • • • • • • • •

Marked obesity Heavy lifting Coughing Straining with defecation or urination Ascites Peritoneal dialysis Ventriculoperitoneal shunt Chronic obstructive pulmonary disease (COPD) Family history of hernias

Types of Hernias (location) 1. Inguinal hernia 2. Femoral hernia 3. Umbilical hernia 4. Incisional hernia  

Inguinal Hernia An inguinal hernia follows the tract through the inguinal canal. This results from a persistent process vaginalis. Contents of this hernia then follow the tract of the testicle down into the scrotal sac. Every year in UK, 70,000 surgical operations are required to repair inguinal hernias

Femoral Hernia The femoral hernia follows the tract below the inguinal ligament through the femoral canal. The canal lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament. Because femoral hernias protrude through such a small defined space, they frequently become incarcerated or strangulated. These are less common than inguinal hernias, occurring in 16 out of every 100,000 people in England. Around three quarters of cases of femoral hernias occur in women.

Femoral Hernia

Umbilical Hernia The umbilical hernia occurs through the umbilical fibromuscular ring, which usually obliterates by 2 years of age. They are congenital in origin and are repaired if they persist in children older than age 2-4 years. These are very common in young children, with as many as one in six children being affected.

Incisional Hernia occurs in 2-10% of all abdominal operations secondary to breakdown of the fascial closure of prior surgery. Even after repair, recurrence rates approach 20-45%.

Mortality/Morbidity Morbidity is secondary to missing the diagnosis of the hernia or complications associated with management of the disease. • A hernia can lead to an obstructed bowel. • The hernia also can lead to strangulated bowel with a compromised blood supply. Reduced strangulated bowel leads to persistent ischemia/necrosis with no clinical improvement. Surgical intervention is required to prevent further complications such as perforation and sepsis. • Ensuing surgery to repair the hernia or its complications may leave the patient at risk for infection, future hernias, or intra-abdominal adhesions.

Clinical Patients with hernias present to the emergency department (ED) secondary to a complication associated with the hernia. • • • •

Presents as a swelling or fullness at the hernia site Aching sensation (radiates into the area of the hernia) No true pain or tenderness upon examination Enlarges with increasing intra-abdominal pressure and/or standing • Nausea, vomiting, and symptoms of bowel obstruction (possible)

DD Epididymitis Hidradenitis Suppurativa Hydrocele Lymphogranuloma Venereum Testicular Torsion

Diagnostics Complete blood count • Results from CBC are nonspecific. • Leukocytosis with left shift may occur with strangulation. Urinalysis: This test assists with narrowing the differential diagnosis of genitourinary causes of groin pain in the setting of associated hernias.

Investigations Imaging Studies • Ultrasonography can be used in differentiating masses in the groin or abdominal wall or in differentiating testicular sources of swelling. • CT scanning or ultrasonography may be necessary in the following cases: o To diagnose a spigelian or obturator hernia o Inability to obtain a good examination because of body habitus

Treatment Analgesic (IM Morphine)

Antibiotic Cefoxitin (Mefoxin) Pediatric 80 mg/kg/d IV divided into 4 equal doses q6h

Surgery OpenSurgery Laparoscopic (keyhole) surgery

Hydrocele A hydrocele is a collection of fluid within the processus vaginalis (PV) that produces swelling in the inguinal region or scrotum.

Etiology • • • • • • • • • • •

Ambiguous genitalia Liver disease with ascites Abdominal wall defects Continuous ambulatory peritoneal dialysis Prematurity Low birth weight Family history of hernia or hydrocele Hydrops Meconium peritonitis Cystic fibrosis Connective tissue disease

Reactive Hydrocele A reactive hydrocele can result from the following factors: • • • •

Trauma Torsion Infection (eg, epididymo-orchitis) Abdominal or retroperitoneal operations that impair lymphatic drainage

Physical signs A bulge in the groin or scrotal enlargement is the classic presentation of hernia or communicating hydrocele. Pain is generally not a prominent feature but may occur if a hydrocele expands quickly; tension in the wall may cause milder pain. Severe pain raises concern about a strangulated hernia. Very rarely, a hydrocele may become infected and cause pain.

DD Abdominal Trauma Cryptorchidism Testicular Torsion Varicocele in Adolescents

Diagnostics Laboratory Studies • Laboratory evaluation is generally not essential to the evaluation of hydroceles and hernias. • Leukocytosis may be a sign of a strangulated hernia. • Leukocytosis with a higher percentage of neutrophils suggests an infectious and/or inflammatory process (eg, epididymo-orchitis). Imaging StudiesUS abdominal plain films

Treatment Surgery Laparoscopy

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