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Hernia

Hernia. Tintinalli’s Ch 87. Definition. Protrusion of any body part from its natural cavity. Protrusion may be internal or external. pathophysiology. Hernias occur at weak points in the abdominal wall created during embryological development Areas where extraperitoneal structures penetrate

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Hernia

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  1. Hernia Tintinalli’s Ch 87

  2. Definition • Protrusion of any body part from its natural cavity. • Protrusion may be internal or external

  3. pathophysiology • Hernias occur at weak points in the abdominal wall created during embryological development • Areas where extraperitoneal structures penetrate • Inguinal, obturator (rare), and femoris canalis • Sciatic foramen • Umbilical area

  4. pathophysiology • Areas without strong multilayer support • Linea alba • Semilunar line • incisional

  5. Risk factors • Premature infants • Indirect inguinal • Umbilical • Fm Hx of undescended testis and GU abnormality • Inguinal hernias • Conditions that increase intra-abdominal pressure • Ascites, peritoneal dialysis, pregnancy, obesity

  6. Pathophysiology • Indirect inguinal hernia • – All are caused by a ersistent processus Vaginalis • Passage of testis enlarges inguinal canal and predisposes males to inguinal hernia • More common on right in males as the right testis descends later • Frequently incarcerate and strangulate in 1st year and in females • Peaks at age 1 and 40 Route of an indirect hernia. Note that the hernia sac passes outside of the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.

  7. Direct Inguinal Hernia • Protrusion directly through the transversalis fascia and the external inguinal ring, medial to the inferior epigastric vessels • Acquired defects • Do not involve passage through the inguinal canal • Predominately adults • Rarely • incarcerate/strangulate Route of a direct hernia. The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.

  8. Femoral Hernia • Protrusion below the inguinal ligament and adjacent to the femoral vessels in the femoral canal • More common in women • Less common than • inguinal • More likely to incarcerate/strangulate Route of a femoral hernia. The hernia sac follows the potential space along the femoral vessels. It may be palpable near the femoral ring or in the medial thigh.

  9. Umbilical Hernia • Congenital • Occur commonly • especially in children of African descent • Result from incomplete development or weakness of the fibromuscular umbilical ring • Rarely incarcerate • Usually seal over time • Acquired • More common in women • Associated with obesity and pregnancy • Frequently incarcerate

  10. Epigastic hernia • Herniation through the linea alba of the rectus sheath above the umbilicus

  11. Spigelian Hernia • Herniation at site of semilunar line just lateral to the rectus muscle • Frequently intraparietal making Dx difficult • Rare

  12. Incisional hernia • Frequent complication of abdominal surgery –up to 20% in laparotomy • Increased in obese and post op wound infections • Incarceration is common with strangulation more likely in smaller sized hernias • Elective repair is encouraged especially insmaller hernias that have history of becoming incarcerated • Reoccurrence rates high

  13. Diagnosis • Physical exam • Males--external ring easily located • Females—failure to palpate hernia sac at external ring does not rule out hernia due to small size of ring and difficulty palpating

  14. Diagnosis • Abd XR • Useful if obstruction suspected • CT/US • Also helpful for suspected obstruction • Useful for spigelian detection • Lab studies • Helpful when incarceration has occurred • WBC and Lactic elevated, Electrolytes abnormal

  15. Diagnosis • Consider DDx (especially in groin hernias) • Direct inguinal hernia • Indirect inguinal hernia • Femoral hernia • Lymph nodes • Hydrocele • Spermatic cord tumor • Testicular tumor • Testicular torsion • Undescended (or retracted) testis • Epididymitis • Groin cellulitis • Femoral thrombophlebitis • Femoral artery aneurysm

  16. Treatment • Asymptomatic or reducible hernias • Elective surgical repair • Incarcerated • Reduction should be performed only if recent onset • Trendelenburg position • Pain meds if needed • Gentle compression • May use sandbag

  17. Treatment cont. • Incarcerated • If not reducible  surgery • If strangulation or shock suspected • Broad spectrum abx • Fluid resuscitation

  18. Disposition • Any acutely incarcerated unreducible hernia, regardless of type or patient age, requires surgical evaluation • Adults with reducible hernias • Dc for elective repair • Avoid heavy lifting • Return to ED if reoccurrence

  19. Disposition • Infants with inguinal hernia • High risk of incarceration within 1st year of life • Surgical consult before discharge • Children with umbilical hernia • Rarely incarcerate • Spontaneous closure in 80% by age 4 • If hernia <2cm – discharge with follow up • If hernia >2cm or if child >4 years old – surgical consult

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