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1. What is the definition of a hernia?
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Correct answer:
A hernia is the protrusion of an organ or part of an organ through a defect in the wall of the cavity containing it into an abnormal position. The term is usually used with reference to the abdomen.
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2. What type of peritoneum do hernias usually involve?
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Correct answer:
Most hernias occur as a diverticulum of the peritoneal cavity and therefore have a sac of parietal peritoneum.
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3. What are the five common varieties of hernia in order from commonest to least common?
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(1) Inguinal.
(2) Femoral.
(3) Umbilical and paraumbilical.
(4) Incisional.
(5) Ventral and epigastric.
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4. What is the aetiology behind the formation of a hernia?
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Correct answer:
Hernias occur at sites of weakness in the abdominal wall. The weakness may be congenital, e.g. persistence of the processus vaginalis of testicular descent giving rise to a congenital inguinal hernia, or failure of complete closure of the umbilical scar. It may occur at the site of penetration of sutures through the abdominal wall, e.g. the femoral canal, or the layers of the abdominal wall may be weakened following a surgical incision (incisional hernia), either by poor healing as a result of infection, haematoma formation or poor technique or by damage to nerves that results in paralysis of the abdominal muscles. Hernias should also be thought of as portents of other diseases or conditions, as they are often associated with pathological increases in intra-abdominal pressure by conditions such as:
(1) chronic cough, secondary to chronic bronchitis;
(2) constipation, perhaps due to colonic carcinoma;
(3) urinary obstruction, due to prostatic disease;
(4) pregnancy;
(5) abdominal distension with ascites;
(6) weak abdominal muscles, e.g. in gross obesity or muscle wasting in cachexia.
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5. Which six pathological processes can cause an increase in intra-abdominal pressure and give rise to a hernia?
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Correct answer:
(1) Chronic cough, secondary to chronic bronchitis.
(2) Constipation, perhaps due to colonic carcinoma.
(3) Urinary obstruction, due to prostatic disease.
(4) Pregnancy.
(5) Abdominal distension with ascites.
(6) Weak abdominal muscles, e.g. in gross obesity or muscle wasting in cachexia.
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6. What are the three varieties of hernia at any site?
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Correct answer:
(1) Reducible. (2) Irreducible. (3) Strangulated.
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7. What is a reducible hernia?
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Correct answer:
The contents of a reducible hernia can be replaced completely into the peritoneal cavity.
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8. What is an irreducible hernia?
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Correct answer:
A hernia becomes irreducible usually because of adhesions of its contents to the inner wall of the sac, or sometimes as a result of adhesions of its contents to each other to form a mass greater in size than the neck of the sac. Occasionally, inspissated faeces within the loops of bowel in the hernia prevent reduction.
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9. What is a strangulated hernia?
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Correct answer:
When strangulation occurs, the contents of the hernia are constricted by the neck of the sac to such a degree that their circulation is cut off. Unless relieved, gangrene is inevitable and, if gut is involved, perforation of the gangrenous loop will eventually occur.
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10. What are the clinical features of a reducible hernia?
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Correct answer:
A reducible hernia simply presents as a lump that may disappear on lying down and that is usually not painful, although it may be accompanied by some discomfort. Examination reveals a reducible lump with a cough impulse.
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11. What are the clinical features of an irreducible hernia?
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Correct answer:
If the hernia will not reduce but is painless and there are no other symptoms, irreducibility is diagnosed. The absence of a cough impulse alone does not indicate strangulation, because in an irreducible femoral hernia, for example, the neck is often plugged by omentum, which prevents the cough impulse from being felt.
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12. What are the clinical features of a strangulated hernia?
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Correct answer:
If strangulation supervenes, the patient complains of severe pain in the hernia of sudden onset and also of central abdominal colicky pain. The other symptoms of intestinal obstruction – vomiting, distension and absolute constipation – soon appear. Examination reveals a tender, tense hernia that cannot be reduced and has no cough impulse. The overlying skin becomes inflamed and oedematous and there are signs of intestinal obstruction with distension, abdominal tenderness and noisy bowel sounds. These features are much less marked when omentum rather than intestine is contained within the sac. The three common types of hernia to strangulate are, in order of frequency, femoral, indirect inguinal and umbilical.
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13. Which are the three most common types of hernia to strangulate, in order of frequency from most common to least?
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Correct answer:
(1) Femoral. (2) Indirect inguinal. (3) Umbilical.
