General Surgery
Abdominal Wall, Hernia and Oesophagus
MBBS surgery notes on abdominal wall hernias and the oesophagus: inguinal and femoral hernias, reflux, achalasia and oesophageal cancer, mapped to NMC codes SU28.1 to SU28.6.
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Abdominal Wall, Hernia and Oesophagus
MBBS surgery notes on abdominal wall hernias and the oesophagus: inguinal and femoral hernias, reflux, achalasia and oesophageal cancer, mapped to NMC codes SU28.1 to SU28.6.
This chapter covers hernias of the abdominal wall and the surgical diseases of the oesophagus. It explains the anatomy and complications of hernias and the presentation of reflux, achalasia and oesophageal cancer.
High-yield: Abdominal Wall, Hernia and Oesophagus
- A hernia is the protrusion of a viscus or part of it through a weakness in its containing wall.
- An inguinal hernia is the commonest hernia and is more common in men.
- An indirect inguinal hernia passes through the deep inguinal ring lateral to the inferior epigastric vessels, while a direct hernia bulges medial to them.
- A femoral hernia passes below the inguinal ligament, is commoner in women and has a high risk of strangulation.
- A reducible hernia returns into the abdomen, an irreducible one does not, and an obstructed or strangulated hernia is a surgical emergency.
- Strangulation means the blood supply is compromised, giving a tense, tender, irreducible lump with signs of bowel obstruction.
- Mesh repair, such as the Lichtenstein technique, gives a low recurrence rate for inguinal hernia.
- Gastro-oesophageal reflux disease causes heartburn and regurgitation and may lead to oesophagitis and stricture.
- Barrett oesophagus is metaplasia of the lower oesophageal lining to columnar epithelium and is a premalignant condition.
- A hiatus hernia is protrusion of the stomach through the diaphragmatic hiatus, and the sliding type is the commonest.
- Achalasia is failure of the lower oesophageal sphincter to relax, causing progressive dysphagia to solids and liquids and a bird-beak appearance on barium swallow.
- Oesophageal cancer presents with progressive dysphagia, first to solids then to liquids, with weight loss.
- Squamous cell carcinoma affects the upper and middle oesophagus, while adenocarcinoma affects the lower oesophagus and arises in Barrett mucosa.
- A corrosive injury of the oesophagus from acid or alkali ingestion can cause an early perforation and a later stricture.
- A pharyngeal pouch, or Zenker diverticulum, causes dysphagia, regurgitation of undigested food and halitosis.
Inguinal versus femoral hernia
- **Indirect inguinal:** Through the deep ring lateral to the inferior epigastric vessels; commonest; can descend into the scrotum.
- **Direct inguinal:** Bulges medial to the inferior epigastric vessels through the posterior wall; rarely into the scrotum.
- **Femoral:** Below the inguinal ligament; commoner in women; high risk of strangulation.
- **Strangulation:** Tense, tender, irreducible lump with obstruction; a surgical emergency.
NMC competencies in this chapter
- **SU28.1:** Abdominal wall hernias: types and anatomy
- **SU28.2:** Complications and management of hernias
- **SU28.3:** Gastro-oesophageal reflux and hiatus hernia
- **SU28.4:** Motility disorders and achalasia of the oesophagus
- **SU28.5:** Oesophageal cancer
- **SU28.6:** Corrosive injury and other oesophageal conditions
Frequently Asked Questions
How are indirect and direct inguinal hernias distinguished?
An indirect hernia passes through the deep inguinal ring lateral to the inferior epigastric vessels and may reach the scrotum, while a direct hernia bulges medial to those vessels through the posterior wall.
Why are femoral hernias dangerous?
They pass through the narrow, rigid femoral canal, so they are prone to obstruction and strangulation and usually need repair even when small; they are commoner in women.
What is Barrett oesophagus?
Metaplastic change of the lower oesophageal squamous lining to columnar epithelium from chronic reflux. It is premalignant and predisposes to oesophageal adenocarcinoma.
How does achalasia present?
With progressive dysphagia to both solids and liquids due to failure of the lower oesophageal sphincter to relax, giving a bird-beak narrowing on barium swallow.
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