[Music] H what's up Ninja nerds in this video today we're going to be talking about hernas these are very interesting lectures so let's get right into them so when we talk about hernias there is a bunch of different types and I think let's go first through the inguinal hernas inguinal hernas there's two different type like types all right and we usually base this on the position of where the bow herniates with respect to the inferior epigastric artery so if we look here here's a normal type of patient no underlying hernia going on whatsoever here he sees the inferior epigastric vessels if I see that the bowel kind of herniates lateral to the inferior epigastric artery through this inguinal ring down into the area of the scrotum this is indicative of an indirect inguinal hernia all right so it herniates through both of the inguinal Rings lateral to the inferior epigastric artery now the reason this would happen is someone's having a very high amount of intraabdominal pressure there's many many different reasons for this maybe it's heavy lifting maybe they're trying to move boxes whatever it may be this can create the opportunity for the bowel to herniate right through this inguinal ring another type of hernia would be a direct inguinal hernia so now with respect to the inferior epigastric vessels here it is now look over here at a direct where is it with respect to the inferior epigastric it's medial and it's actually moving through the wall herniating through the last part of the inguinal ring and out to the side here this is an example of a direct inguinal hernia again same usually cause or eyology is some massive increase in intraabdominal pressure massive coughing or sneezing or heavy lifting this is usually going to trigger this herniation the next type of hernia would be a femoral hernia these are are actually pretty bad if they do happen they have a high risk of incarceration and strangulation so this is basically when the bowel herniates through something called the femoral Canal so as you can see here this is kind of our inguinal ligament right below it you have something called the femoral triangle which consists of the femoral artery the femoral vein and usually the femoral nerve and some lymph nodes right here in this vicinity is the femoral ring what happens is parts of the actual small bowel can herniate right through that femoral canal and definitely in increase the risk of this being stuck incarcerated and strangulated the last type of hernas is called vental hernas and these are usually on the abdominal wall and they usually can herniate through a couple different parts one is they can herniate through an incision so if a patient has a prior surgical incision from some type of procedure where they had to have done in their abdomen and that herniates around or through the incision that would be an indicative of what's called an incisional hernia another one is where the bow herniates right through the umbilical ring and if it does herniate through the umbilical ring which is very common with obesity and pregnancy where they have a weak kind of linear Alba this can definitely cause it to herniate right in through the umbilical ring it would be very obvious in a visible palpable Mass often times regardless of the ety You' be able to see a visible and relatively painful mass that may be outside of the actual body for example I may be able to see an inguinal hernia here a femoral hernia here an incisional hernia or an umbilical hernia and it would be very visible type of a par now with hernas they can be visible masses but they also can cause complications and it's important to know which type of hernia you have for example when a hernia occurs especially femoral and inguinal hernas sometimes when the bowel herniates out through that defect in the inguinal wall or through the inguinal Rings or through the femoral Canal if it does it can actually become stuck in this like little defect in that wall and what happens is is it can compress this portion of the bowel and compress this portion of the bowel and then all the food and fluid and air gets stuck in this portion without an ability to exit out and this can lead to an obstruction this can cause proximal dilation distension and then distal decompression which can definitely have a very profound effect like what well it can cause small bowle obstructions which usually presents with like C features right so cramping abdominal pain abdominal distension vomiting obstipation so if a patient comes in with a visible M inal femoral most commonly and then on top of that they present with the Cal features think that they've now gone from having a hernia that was just present a visible Mass to now having it cause a closed loop obstruction you're compressing it at a proximal and distal point and there's no way for this to get out these are scary and the reason why is the closed loop obstructions they pinch the artery here and they pinch the arteries here and you pretty much get no arterial blood flow to this portion of the small bow what can result is you can develop severe bisiach Mia could be indicative by an elevated lactate level which could be seen on Labs if you draw them up but the other complication is that if this becomes es schemi and not reversed it can become infared die and become very weak and then it can perforate causing a numo perenium the other thing is if it does perforate and it causes peritonitis this literally can increase the risk of the patient becoming septic but usually this is a severe case of hernas I think a way that a patient should kind of be evaluated with a hernia is if they have a visible Mass the first thing that you should go and do is literally I'm not even kidding push on the mass and see if you can push it back into position so if it's an uino hernia see if you can push it out of the scrotum and back up into the abdomen if it's femoral push it through the femoral Canal if it's an umbilical push it back through the umbilical ring if it's an incisional push it back and through the incision if it is reducible great because that's an uncomplicated hernia and eventually if this does consistently cause problems you can surgically repair this but it's more on an elective basis it's not something that you have to take care of right away if it's not the next thing that you have to say is okay I have a complicated hernia it could be strangulated within that defect in the wall of the in the inguinal area the femoral Canal or the umbilical ring or it could be incarcerated and that's important to be able to differentiate so I think the next question that you have to ask is okay I can't reduce the hernia if I can't reduce the hernia I then want to know do they have any features of small bow obstruction or ball esmia because if it's compressing it at the two points that closed loop obstruction this can be really bad so how do I do that first I'd want to obtain abdominal x-ray if the abdominal x-ray shows me that I have these dilated bow loops and then air fluid levels now I'm concerned that this turned in from just a simple hernia to a bowel obstruction that's important to identify the next thing is also I would consider checking for bis keemia by checking a lactate level and lactate levels that they're super elevated could be indicative of some pretty bad bisiach I want to make sure that I use the best possible test and that's usually a CT of the abdomen and pelvis and that would definitely help me to identify a potential hernia that's incarcerated or strangulated the next thing I have to determine here is how do I treat these hernas and uncomplicated hernas that are easily reducible you reduce it and then you can honestly just stand by and see if they develop any further recurrences and if it gets to the point where it's causing more problems it's causing issues you can then re refer the patient for a surgical consultation and they could get some type of elective surgery usually if they're very small hernas especially in children you can do something called A Hern oropy which is basically where you just kind of surgically close the defect within wherever the wall is whether it's the inguinal Canal whether it's within the femoral Canal the umbilical area you'll close that off another option is usually if the hernas are really large or they're inguinal hernas we can do something called a hernioplasty so you'll kind of open up this area of the wall and then what you'll do is you'll push the bowel contents back into the abdomen and put a synthetic mesh in place and then help to suure that area closed and that's going to be more particularly beneficial for those patients with pretty big hernas or they have an inguinal hernia and it's just their Anatomy would benefit more from a hernioplasty I think the question to ask though is if it's not if it's not an uncomplicated type of um hernia the next one is is it incarcerated in other words it's not reducible but they don't have any true evidence of this thing being really causing Bal obstruction or ball esmia if that's the case then I should then try my best to really reduce it and I may have to give the patient some more pain medication something to chill them out relax them and then I may have to really work hard to push this back in and if I can't do that then I may need to refer them to a for surgical evaluation and they may require more of an urgent herni orphy or an urgent hernioplasty against small children Hern oropy large or inguinal hernioplasty the last one is if it's strangulated in other words it's actually causing balis keemia they have bowel obstruction you don't have time I wouldn't even try to reduce this they need to go to surgery because if the patient has ballemia or bowel obstruction they're a really high risk of perforation and sepsis I need to get them to the O I need to go ahead and I need to again maybe potentially resect out the diseased portion of the hernia and then after that maybe I do IND indon asmosis close up the area there and may depend upon me doing a hernioplasty or Hern ory afterwards but again this is how we would go about treating hernas all right my friends that covers herns I hope it made sense I hope that you guys did enjoy it and as always until next [Music] time [Music]