004 Hernias - Introduction to Clinical Surgery Lectures

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Lecture on hernias from a series of lectures on an introduction to clinical surgery. It has been devised with medical students in mind.

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004 Hernias - Introduction to Clinical Surgery Lectures

  1. 1. Hernias Nick Harvey
  2. 2. Hernias <ul><li>What is a hernia? </li></ul><ul><ul><li>Protrusion of a viscus or part of a viscus through a defect in the wall that retains it. </li></ul></ul><ul><li>Basic Physical Signs of a Hernia </li></ul><ul><ul><li>Occur at a natural weak point </li></ul></ul><ul><ul><li>Cough impulse </li></ul></ul><ul><ul><li>Reducible </li></ul></ul>
  3. 3. Hernias: Surgical Anatomy <ul><li>Sac </li></ul><ul><ul><li>neck, body, fundus </li></ul></ul><ul><li>Contents </li></ul><ul><ul><li>Bowel </li></ul></ul><ul><ul><li>Omentum </li></ul></ul>
  4. 4. Hernias: Surgical Anatomy <ul><li>Common sites </li></ul><ul><ul><li>Inguinal (direct/indirect) </li></ul></ul><ul><ul><li>Femoral </li></ul></ul><ul><ul><li>Umbilical </li></ul></ul><ul><ul><li>Paraumbilical </li></ul></ul><ul><ul><li>Incisional </li></ul></ul><ul><ul><li>Epigastric </li></ul></ul><ul><li>Rare sites </li></ul><ul><ul><li>Spigelian </li></ul></ul><ul><ul><li>Lumbar </li></ul></ul><ul><ul><li>Obturator </li></ul></ul><ul><ul><li>Gluteal </li></ul></ul>
  5. 5. Hernias: Pathological Type <ul><li>Reducible </li></ul><ul><li>Irreducible ‘Incarcerated’ </li></ul><ul><li>Obstructed </li></ul><ul><li>Strangulated </li></ul><ul><li>Inflamed </li></ul>
  6. 6. Hernias: Special Types <ul><li>Sliding or Rolling </li></ul><ul><li>Richter’s </li></ul><ul><li>Maydl’s </li></ul>
  7. 7. Hernias: Inguinal Anatomy <ul><li>Anterior Superior Iliac Spine (ASIS) </li></ul><ul><li>Pubic Tubercle (PT) </li></ul><ul><li>Pubic Symphysis (PS) </li></ul><ul><li>Inguinal Ligament </li></ul><ul><li>Vessels (NAVY) </li></ul>
  8. 8. Hernias: Inguinal Anatomy
  9. 9. Hernias: Inguinal Anatomy
  10. 10. Hernias: Indirect Inguinal Hernia
  11. 11. Hernias: Direct Inguinal Hernia
  12. 12. Hernias: Femoral Hernia
  13. 13. Hernias: History <ul><li>Onset, Course, Duration </li></ul><ul><li>Painful or Painless? </li></ul><ul><li>Other Lumps </li></ul><ul><ul><li>Present or past? </li></ul></ul><ul><ul><li>Same type? </li></ul></ul><ul><li>Effect on General Condition </li></ul><ul><ul><li>Symptoms and signs of bowel obstruction </li></ul></ul><ul><li>Cause? </li></ul><ul><ul><li>Chronic cough, chronic constipation, symptoms of urinary obstruction </li></ul></ul><ul><li>Does the lump disappear? </li></ul>
  14. 14. Hernias: Examination <ul><li>Patient standing </li></ul><ul><li>Stand on the same side as the hernia </li></ul><ul><li>Ask the patient to cough </li></ul><ul><li>Examine as in any other swelling </li></ul><ul><li>Try to reduce the henia </li></ul><ul><ul><li>Comment in direction/contents </li></ul></ul><ul><li>Try to find the cause </li></ul><ul><ul><li>Examine abdomen, chest, DRE </li></ul></ul>
  15. 15. Hernias: Inspection <ul><li>Site </li></ul><ul><li>Size </li></ul><ul><li>Shape </li></ul><ul><li>Symmetry </li></ul><ul><li>Surface </li></ul><ul><li>Skin overlying </li></ul><ul><li>Scars </li></ul><ul><li>Special signs </li></ul><ul><ul><li>Cough impulse </li></ul></ul>
  16. 16. Hernias: Palpation <ul><li>Tenderness </li></ul><ul><li>Temperature </li></ul><ul><li>Can you get above the swelling? </li></ul><ul><li>Surface </li></ul><ul><li>Edge </li></ul><ul><li>Consistency </li></ul><ul><ul><li>Doughy or gurgly? </li></ul></ul><ul><li>Relation to Surrounding Structures </li></ul><ul><ul><li>Pubic Tubercle, Vessels </li></ul></ul><ul><li>Draining Lymph Nodes </li></ul><ul><li>Special signs </li></ul><ul><ul><li>Cough impulse </li></ul></ul><ul><ul><li>Reducibility </li></ul></ul>
  17. 17. Hernias: Relationship with pubic tubercle
  18. 18. Hernias: Special Signs <ul><li>Cough impulse </li></ul><ul><li>Reducibility? </li></ul><ul><ul><li>Comment on direction/contents </li></ul></ul><ul><li>Internal ring test </li></ul>
  19. 19. Differential Diagnosis of a Groin Lump <ul><li>Surgical sieve! </li></ul><ul><li>Inguinal hernia </li></ul><ul><li>Femoral hernia </li></ul><ul><li>Enlarged lymph nodes </li></ul><ul><li>Ectopic testis </li></ul><ul><li>Femoral aneurysm </li></ul><ul><li>Sapheno-varix </li></ul>
  20. 20. Hernias: Diagnosis <ul><li>Anatomical </li></ul><ul><ul><li>Side, inguinal, femoral umbilical… </li></ul></ul><ul><li>Pathological </li></ul><ul><ul><li>Reducible, irreducible, obstructed, strangulated, inflamed. </li></ul></ul><ul><li>Recurrent or not? </li></ul>

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