Hernias

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Nadine Z. Villarin

Mass in Femoral Triangle:

Obturator Hernia Pathophysiology:

A peritoneal sac protrudes through the obturator foramen of the pelvis, causing a fullness or mass in the femoral triangle. a rare type of abdominal wall hernia in which abdominal content protrudes through the obturator foramen.

The fullness is not sharply defined because the sac is covered by the pectineus muscle. Because of differences in anatomy, it is much more common in women than in men, especially multiparous and women over age 60 who have recently lost a lot of weight.
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There are three stages of formation of an obturator hernia: [1] entry of preperitoneal connective tissue and fat into the pelvic orifice of the obturator canal. [2] dimpling of peritoneum over the obturator canal leading to formation of an empty peritoneal sac. [3] entrance of an organ that eventually fails to reduce spontaneously

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The right obturator hernia is the dimpled area that, at the time of laparoscopy, did not contain any bowel.

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On the affected side, the thigh is usually held in semiflexion and all hip motion is painful. Pain extends down the medial thigh to the knee and is increased by hip extension, abduction, and external rotation. Palpation through the rectum or vagina may reveal a soft, tender mass in the region of the obturator foramen. Richter type - When only a portion of the circumference of the bowel is strangulated so there is no obstruction and the presenting pain may occur late after perforation or sepsis has occurred. In almost half the cases of strangulation, the genicular branch of the obturator nerve is compressed, producing pain down the medial aspect of the thigh to the knee (Romberg-Howship sign).
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Mass Above the Inguinal Ligament: Spigelian Hernia
Pathophysiology:
A peritoneal sac with considerable extraperitoneal fat perforates the linea semilunaris to lie within the abdominal wall. it is covered only by skin, subcutaneous fat, and the aponeurosis of the external abdominal oblique muscle.

They commonly occur at a level referred as ‘spigelian hernia belt’ which is a transverse band between the level of umbilicus (navel) and the line joining both anterior superior iliac spines

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This type of hernia is usually asymptomatic until it strangulates. It produces a tender mass within the abdominal wall approximately 3 to 5 cm above the inguinal ligament. The symptoms may vary from well-localised constant abdominal pain with or without palpable lump to vague inconstant ache. This should be inspected and palpated while the patient stands. Clinically it is difficult to feel a definite bulge or a hernial defect as they are typically submuscular. Therefore, imaging studies are frequently necessary to make or confirm the diagnosis. They often develop complications like incarceration due to delay in diagnosis.
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