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Surgery > Chapter 8 > Flashcards

Chapter 8 Flashcards

1
Q

What plays a role in the development of a hernia?

A

Congenital maldevelopment of an abdominal support structure

Acquired physical stresses

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2
Q

What can increase the risk of hernia development?

A

Factors that weaken the integrity of fascial tissue and collagen strength
Factors that increase intra-abdominal pressure (morbid obesity, pregnancy, chronic pulmonary disease, constipation, urinary obstruction)

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3
Q

Reducible hernia

A

The herniated contents can return to their anatomic position spontaneously or can be returned to their anatomic position with manual manipulation

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4
Q

Incarcerated hernia

A

The herniated contents cannot be returned to their anatomic position in a nonsurgical manner and may be acute or chronic. Can cause a bowel obstruction.

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5
Q

Strangulated hernia

A

An incarcerated hernia with vascular compromise

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6
Q

Sliding hernia

A

When a portion of the hernia sac is composed of the herniating organ

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7
Q

Richter’s hernia

A

When less than the full circumference of the bowel wall is trapped in the hernia
Can present with incarceration, ischemia, and bowel perforation without obstruction

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8
Q

Littre’s hernia

A

A Richter’s hernia containing a Meckel’s diverticulum

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9
Q

What is the most common type of abdominal hernias?

A

Groin hernia

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10
Q

What comprises 2/3 of inguinal hernias?

A

Indirect

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11
Q

Indirect hernia anatomy

A

Pass lateral to the epigastric vessels, through the internal inguinal ring toward the external inguinal ring and into the scrotum

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12
Q

Direct hernia anatomy

A

Passes medially to the epigastric vessels and the internal inguinal ring directly through the floor of the inguinal canal

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13
Q

Pantaloon hernia

A

Has both indirect and direct components

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14
Q

What is the makeup of the lower abdominal wall in muscles?

A

Three layers:
External oblique
Internal oblique
Transverses abdominis

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15
Q

External oblique muscle

A

Arises from the lower eight ribs interdigiting with the serratus anterior and the latissimus dorsi laterally with its fibers running in an inferomedial direction

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16
Q

What contributes to the anterior rectus sheath before inserting into the linea alba in the midline?

A

Aponeurosis

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17
Q

What is the portion of the external oblique aponeurosis that stretches between the ASIS and the pubic tubercle that is somewhat thickened and folds back on itself?

A

Inguinal (Poupart) ligament

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18
Q

Lacunar ligament

A

The medial part of the inguinal ligament that reflects back onto the pectin pubis

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19
Q

In what direction do the internal oblique muscle fibers course?

A

Superomedial

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20
Q

Direction of the inguinal canal

A

Courses form the deep inguinal ring to the superficial inguinal ring

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21
Q

Deep inguinal ring

A

A natural defect in the transversalis fascia approximately halfway between the ASIS and the pubic tubercle through which the spermatic cord in men or the round ligament in women exits the abdominal cavity and enters the inguinal canal

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22
Q

Superficial inguinal ring

A

A triangular opening in the aponeurosis of the external oblique muscle just superior to the medial part of the inguinal ligament

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23
Q

Pathway of the spermatic cord

A

Passes through deep inguinal ring and consists of vas deferens, testicular artery, pampiniform venous plexus, and processus vaginalis

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24
Q

Hesselbach’s triangle boundaries

A

Inferior epigastric artery on lateral border
Inguinal ligament on inferior side
Rectus sheath on medial border

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25
Q

What is a thickening of the endoabdominal fascia where the transversalis fascia and the iliopsoas fascia meet?

A

Iliopubic tract

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26
Q

Femoral canal

A

A potential space deep to the inguinal ligament

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27
Q

Anatomy of the iliopubic tract

A

Courses fraom the ASIS to the superior pubic ramus and pubic tubercle
Located deep to and slightly superior to the inguinal ligament, forming the inferior margin of the deep inguinal ring
Medially, forms the anterior and medial walls of the femoral canal.

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28
Q

Anatomy of the femoral canal

A

Bounded laterally by the common femoral vein, superoanteriorly by the inguinal ligament, posterior by Cooper’s ligament and medially by the lacunar ligament

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29
Q

Ilioinguinal nerve

A

Arises from L1 nerve root and runs superior tot he spermatic cord through the superficial inguinal ring to innervate the scrotum or labium majus

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30
Q

Iliohypogastric nerve

A

Arises with the ilioinguinal nerve from the L1 nerve root and courses between the internal oblique and transverses abdominis where it branches into an anterior branch and a lateral branch

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31
Q

Genital branch of genitofemoral nerve

A

Arises from the L1 and L2 nerve roots and enters the inguinal canal inferior to the deep inguinal ring
Provides motor innervation for the cremaster muscle and sensory innervation to the scrotum and medial thigh

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32
Q

Hx of groin hernias

A

Pain and/or swelling in the groin
Radiation into the scrotum
Intermittent or continuous
May get worse after extended periods of standing, may improve with rest

33
Q

What also must be asked about with a groin hernia?

A 
Sx of bowel obstruction:
Nausea
Vomiting
Abdominal distention
Abdominal pain
Constipation
34
Q

What is concerning in a groin hernia for strangulation and ischemia of the hernia contents?

A

Erythema of the skin overlying the hernia

35
Q

How to examine for an inguinal hernia

A

Pt stands and in the supine? position with and without the pt performing a Valsalva maneuver (e.g., bearing down, coughing)

36
Q

How is a dx of a groin hernia made?

A

Primary by hx and PE

37
Q

What can be assessed in the superficial canal in addition to an indirect hernia?

A

The integrity of the floor of the inguinal canal

38
Q

When should women be considered for surgical exploration and hernia repair even if the exam is negative?

A

Those who report a hx of a palpable or reducible mass in the appropriate location

39
Q

What else should be included in a hernia PE?

A

Abdominal exam
Abdominal distention may suggest a bowel obstruction d/t an incarcerated hernia
Peritonitis may suggest a bowel perforation d/t a strangulated hernia

40
Q

When to get a CT or u/s for a hernia

A

Confirm the diagnosis in cases with atypical sx or inconclusive findings

41
Q

Alternate diagnoses for a groin hernia

A 
Inguinal adenopathy
Undescended testis
Spermatocele
Varicocele
Hydrocele
Lipoma
Testicular cancer
42
Q

Additional use for imaging in hernias

A

Identifying the hernia contents

43
Q

Purpose of labs for hernias

A

No labs are diagnostic of a hernia

44
Q

Tx of groin hernias

A

Although watchful waiting is a safe strategy for asymptomatic or minimally symptomatic pts, it may be preferable to offer surgical repair, esp to older pts, given that eventually these pts will require surgery

45
Q

Open general hernia repair procedure- groin

A

Supine position
Incision made approximately 2cm above and parallel to the inguinal ligament
Dissection through skin, subcutaneous fat, and Camper’s and Scarpa’s fascia to the external oblique aponeurosis
Incision made parallel with its fibers and spread to expose the inguinal canal
Ilioinguinal and iliohypogastric nerves either spared or sacrificed to prevent post-op neuralgia

46
Q

Open indirect hernia procedure after initial steps

A

Exposed and separated from the cord by dividing the cremaster muscle
Hernia contents can be replaced into the peritoneal cavity and the hernia sac can either be replaced into the peritoneal cavity as well or it can be divided and ligated at its base

47
Q

Open direct hernia procedure after initial steps

A

Without opening or excising the sac, the hernia is reduced and the posterior wall of the inguinal canal is repaired
If the sac extends into the scrotum, no attempt should be made to retrieve the sac distal to the pubic tubercle
Sac should be divided at the pubic tubercle

48
Q

What additional step needs to be done in an open direct hernia procedure?

A

The floor of the inguinal canal needs to be repaired

49
Q

What are the four methods of inguinal canal floor repair?

A

Bassini
Shouldice
McVay
Mesh repair- Lichtenstein or Rutkow

50
Q

Bassini repair

A

The aponeurosis of the transversus abdominis muscle is sewn to the shelving edge of the inguinal ligament

51
Q

Shouldice repair

A

The transversalis fascia is divided from the internal ring tot he pubic tubercle
The fascia is then imbricated onto itself and sewn to the inguinal ligament with two suture lines

52
Q

McVay or Cooper’s ligament repair

A

The floor of the inguinal canal is excised and reconstructed by sewing the conjoined tendon to the femoral sheath and inguinal ligament laterally and Cooper’s ligament medially from the pubic tubercle to the femoral vein

53
Q

Lichtenstein repair

A

The floor of the inguinal canal is reconstructed with prosthetic mesh. The mesh lies posterior to the spermatic cord and is sutured to the inguinal ligament inferiorly and transversus abdominis aponeurosis or internal oblique aponeurosis superiorly and is split laterally to create an opening for the cord to exit the deep inguinal ring

54
Q

Rutkow repair

A

A mesh plug is placed within the deep ring beside the spermatic cord to help attenuate the opening of the deep inguinal ring.

55
Q

What can be used to repair femoral hernias?

A

Infrainguinal approach

Posterior/preperitoneal approach

56
Q

How should groin hernias that are strangulated with a high suspicion for ischemic bowel or bowel perforation be approached?

A

Lower midline incision

57
Q

What are the three different methods of laparoscopic repair?

A 
Transabdominal preperitoneal (TAPP)
Total extraperitoneal (TEP)
Intraperitoneal onlay mesh (IPOM)
58
Q

TAPP repair

A

Peritoneal cavity entered in the standard fashion
Peritoneum on the posterior surface of the anterior abdominal wall is incised transversely above the level of the hernia and then reflected inferiorly
Indirect hernias are mobilized and dissected away from the cord structures
Direct hernias are isolated from the transversalis fascia
Mesh patch is placed

59
Q

What must be done after placement of mesh in TAPP repair?

A

Must resecure the peritoneal flap to the abdominal wall

60
Q

TEP repair

A

Periumbilical incision
Anterior rectus sheath is incised on the side opposite the hernia
Dissecting balloon is placed into the preperitoneal space
5-mm trocars are placed either in the midline or laterally.
Remainder is same as TAPP repair

61
Q

IPOM repair

A

Similar to TAPP repair, but no peritoneal flap raised

62
Q

Why has IPOM repair been largely abandoned in inguinal hernia repair?

A

There is risk of bowel herniation under the mesh

63
Q

Complications of groin hernia repair

A

If hernia contains ischemic bowel requiring bowel resection, risk of infection is increased
Testicular atrophy
Neuralgia
Recurrence

64
Q

When do clinical manifestations of primary arterial ischemia to the testicle present?
What establishes the diagnosis?

A

2-5 days following the repair
Doppler flow studies or a nuclear medicine flow scan
Care is supportive pain management

65
Q

When is orchiectomy indicated for primary arterial ischemia of the testicle?

A

Intractable pain or lack of blood flow to the testicle

66
Q

Presentation of neuralgia

A

Variable pain that may present as burning pain at the incision with intermittent shooting pain that radiates into the scrotum with or without skin hypersensitivity

67
Q

Management of neuralgia

A 
Analgesics
Antidepressants
Anxiolytics
Transcutaneous electrical stimulation
Steroid injections
Ilioinguinal and iliohypogastric nerve blocks or paravertebral block at L1 and L2 can be diagnostic and therapeutic
68
Q

Who absolutely must undergo an open repair?

A

Pts at high risk for for general anesthesia

69
Q

Risks of laparoscopic repair

A

Injury to surrounding structures during port placement
Port site hernia
Gas embolism
Bowel obstruction secondary to adhesions in the TAPP and iPOM reapirs that enter the peritoneum
Nerve injuries

70
Q

Origin of umbilical hernias

A

Commonly congenital in origin but may be acquired in adults

71
Q

When to surgically repair umbilical hernias in the pediatric population

A

Defer until at least the age of 2 unless there is abdominal pain referable to the hernia, incarceration, skin maceration, or a very large hernia

72
Q

What are a population that is particularly at risk for developing hernias and are at a higher risk for incarceration and strangulation as well as a higher risk of perioperative morbidity and mortality?

A

Cirrhotic pts with ascites

73
Q

Adult umbilical hernia repair

A

Periumbilical curvilinear incision
ID the hernia sac, fascial defect and intact surrounding fascia
Hernia and its contents are reduced or excised
Fascial edges are reapproximated primarily for small defects or brought together using a piece of mesh to reinforce the repair and relieve tension on the fascia

74
Q

What are epigastric hernias possibly due to?

A

Congenital variation sin the decussation patterns of the linea alba

75
Q

Who more commonly gets epigastric hernias?

A

Men

76
Q

MC location of epigastric hernias?

A

Slightly off the midline

77
Q

Spigelian hernias

A

Hernias of the lateral abdominal wall

78
Q

When are spigelian hernias indicated for repair?

A

Whenever they are identified because of the high likelihood of incarceration or strangulation

Surgery (30 decks)

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