PANCE Blueprint GI and Nutrition (9%)

Hernias (ReelDx)


VIDEO-CASE-PRESENTATION-REEL-DX

Inguinal hernia

Patient will present as → a 50-year-old man presents with a lump in his groin for 2 weeks. He states he was lifting an air conditioner and he felt a pop in his groin and began to notice an outpouching in his lower abdomen that has become mildly tender over the last week. Resting and lying flat appears to help, and standing and lifting aggravates it. He denies any fevers, nausea, vomiting, or changes in bowel habits. Patient denies any previous abdominal surgeries or procedures. Upon examination, you identify a soft, reducible mass in the lower abdomen and hernia examination reveals a mass pushing against the side of your finger. You order an ultrasound of the lower abdomen and find the intestinal sac has traversed through a weakened area of the abdominal wall and through Hesselbach's Triangle. 

A hernia is a protrusion of an organ or structure through the wall that normally contains it.

  • Hiatal (diaphragmatic): Involves protrusion of the stomach through the diaphragm via the esophageal hiatus.  It can cause symptoms of GERD; acid reduction may suffice, although surgical repair can be used for more serious cases.
  • Ventral: Often from previous abdominal surgery, obesity.  Abdominal mass noted at site of previous incision.
  • Umbilical hernia: Very common, generally is congenital and appears at birth.  Many umbilical hernias resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life.

Umbilical Hernia

Inguinal hernias:

  • Indirect Inguinal Hernia (Most Common): Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.
    • Remember: Indirect goes through the Internal Inguinal Ring (an “I” for an “I”)
  • Direct Inguinal Hernia: Passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum

Hernias of various types can entrap the intestines and cause an intestinal blockage – this is called an “incarcerated hernia” and is a medical emergency.

  • Strangulated hernia: A hernia becomes strangulated when the blood supply of its contents is seriously impaired.
  • Obstructed hernia: This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel. 
  • Incarcerated hernia: A hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.

History and physical exam, including attempt to reduce the mass

  • Ultrasound - especially in a male child where other scrotal masses (hydrocele, varicocele) are considered

If the patient is otherwise well, refer non-urgently to surgery for definitive surgical repair

  • If concerned for hernia incarceration or strangulation, refer immediately to surgery.
location of hernias

Location of common hernias

IM_NUR_TypesofHernias_v1.2_ A hernia occurs when contents of the abdomen, usually a portion of the intestine, protrudes through an area of weakened muscle or tissue. Types of hernias include: hiatal, inguinal, femoral, umbilical, and incisional. If a hernia becomes strangulated, emergency surgery must be performed to restore blood flow and to prevent bowel necrosis.

 

Question 1
What type of hernia involves passage of intestine through the external inguinal ring at Hesselbach triangle and rarely enters the scrotum
A
Indirect inguinal hernia
Hint:
Indirect Inguinal Hernia (Most Common): Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.
B
Direct inguinal hernia
C
Ventral hernia
Hint:
Ventral: Often from previous abdominal surgery, obesity. Abdominal mass noted at site of previous incision.
D
Hiatal hernia
Hint:
Hiatal (diaphragmatic): Involves protrusion of the stomach through the diaphragm via the esophageal hiatus. It can cause symptoms of GERD; acid reduction may suffice, although surgical repair can be used for more serious cases.
Question 1 Explanation: 
Direct Inguinal Hernias involve passage of intestine through the external inguinal ring at Hesselbach triangle and rarely enters the scrotum.
Question 2
What type of hernia involves passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one?
A
Direct inguinal hernia
Hint:
Passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum
B
Indirect inguinal hernia
C
Umbilical hernia
Hint:
Very common, generally is congenital and appears at birth. Many umbilical hernias resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life
D
Ventral hernia
Hint:
Often from previous abdominal surgery, obesity. Abdominal mass noted at site of previous incision.
Question 2 Explanation: 
Indirect Inguinal Hernia (Most Common) is described as passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one. Remember: Indirect goes through the Internal Inguinal Ring (an “I” for an “I”)
Question 3
Which of the following concerning femoral hernias is not true?
A
They are more common in women.
Hint:
See B for explanation
B
Has a low incidence of strangulation.
C
Cannot be controlled with a TRUSS.
Hint:
See B for explanation
D
accounts for about of 5% hernias in men.
Hint:
See B for explanation
Question 3 Explanation: 
Femoral hernias have a high incidence of strangulation mainly because of the narrowness of the neck of the sac and the rigidity of the femoral ring.
Question 4
An otherwise-healthy 7-month old female infant was brought to the clinic by her mother on account of a 3-month history of umbilical swelling which is usually more apparent when she cries. On examination, the swelling was reducible and a defect was felt through the umbilicus. The appropriate management option is
A
Umbilical herniorrhaphy.
Hint:
Surgical treatment for complicated umbilical hernia before age 4-5years and complicated and uncomplicated hernia at age 4-5 years.
B
Conservative treatment.
C
Mayo's overlapping operation.
Hint:
Done to treat paraumbilical hernia.
D
None of the above.
Hint:
See B for answer
Question 4 Explanation: 
In most cases (85%) the hernial defect in the linea alba closes spontaneously by age 4 – 5 years. The patient should therefore be left alone without any form of treatment except in the event of strangulation or incarceration.
Question 5
Which of the following is not a risk factor for abdominal hernias?
A
Chronic cough
Hint:
See D for explanation
B
Obesity
Hint:
See D for explanation
C
Heavy lifting
Hint:
See D for explanation
D
Diarrhea
Question 5 Explanation: 
Diarrhea is not a risk factor for abdominal hernias, but chronic constipation is. Any condition that increases intra-abdominal pressure may contribute to the formation of abdominal hernia. All other options are correct.
Question 6
A hernia whose blood supply has been cut off is called
A
Obstructed hernia
Hint:
This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel.
B
Strangulated hernia
C
Incarcerated hernia
Hint:
A hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.
D
None of the above
Question 6 Explanation: 
A hernia becomes strangulated when the blood supply of its contents is seriously impaired.
Question 7
The initial management of a patient with strangulated inguinal hernia includes all of the following except
A
Placing of intravenous line for rehydration and electrolyte correction.
Hint:
See D for explanation
B
Passage of nasogastric tube for decompression.
Hint:
See D for explanation
C
Administration of oxygen
Hint:
See D for explanation
D
Surgery
Question 7 Explanation: 
Surgery, when indicated for acute intestinal obstruction is done after the patient has been adequately resuscitated. All other options are resuscitative measures.
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