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1

forms the inguinal ligament (shelving edge) at inferior portion of the inguinal canal

External abdominal oblique fascia

2

forms cremasteric muscles

internal abdominal oblique

3

along with the conjoined tendon, forms inguinal canal floor

transversalis muscle

4

composed of the aponeurosis of the internal abdominal oblique and transversalis muscles

conjoined tendon

5

from external abdominal oblique fascia, runs from ASIS to the pubis; anterior to the femoral vessels

inguinal ligament (Poupart's ligament)

6

where the inguinal ligament splays out to insert in the pubis

lacunar ligament

7

pectineal ligament; posterior to the femoral vessels; lies against bone

Cooper's ligament

8

runs medial to cord structures

vas deferens

9

what composes hesselbach's triangle?

rectus muscle, inferior inguinal ligament, and inferior epigastrics

10

hernia: inferior/medial to the epigastric vessels

direct hernias

11

hernia: superior/lateral to the epigastric vessels

indirect hernias

12

hernia: most common, from persistently patent processus vaginalis

indirect hernia

13

hernia: lower risk of incarceration; rare in females, higher recurrence than indirect

direct hernias

14

hernia: direct and indirect components

pantaloon hernia

15

risk factors for inguinal hernia in adults

age, obesity, heavy lifting, COPD (coughing), chronic constipation, straining (BPH), ascites, pregnancy, peritoneal dialysis

16

can lead to bowel strangulation; should be repaired emergently

incarcerated hernia

17

retroperitoneal organ that makes up part of the hernia sac

sliding hernia

18

female: component of sliding hernia

ovaries or fallopian tubes most common

19

males: component of sliding hernia

cecum or sigmoid most common

20

aside from ovarian/fallopian tubes or cecum/sigmoid, what else can be involved in a sliding hernia?

bladder can also be involved

21

management: females with ovary in canal

- ligate the round ligament
- return ovary to peritoneum
- perform biopsy if looks abnormal

22

management: hernias in infants and children

- just perform high ligation (nearly always indirect)
- open sac prior to ligation

23

what is a lichtenstein repair?

hernia repair with mesh; recurrence decreases with use of mesh (decreases tension)

24

hernia: approximation of the conjoined tendon and transversalis fascia (superior) to the free edge of the inguinal ligament (shelving edge, inferior)

bassini repair

25

hernia: approximation of the conjoined tendon and transversalis fascia (superior) to Cooper's ligament (pectineal ligament, inferior)

Cooper's ligament repair

26

incision necessary in cooper's ligament repair

needs a relaxing incision in the external abdominal oblique fascia

27

when can you use cooper's ligament repair?

can use this for femoral hernia repair

28

indications for laparoscopic hernia repair

indicated for bilateral or recurrent inguinal hernia

29

most commonly early complication following hernia repair

urinary retention

30

hernia repair: wound infection rate

1%

31

hernia repair: recurrence rate

2%

32

usually secondary to dissection of the distal component of the hernia sac causing vessel disruption
- thrombosis of spermatic cord veins
- usually occurs with indirect hernias

testicular atrophy

33

what veins are affected in testicular atrophy?

spermatic cord veins

34

when does testicular atrophy usually occur?

usually occurs with indirect hernias

35

what is the usual cause of pain after hernia?

usually compression of ilioinguinal nerve

36

tx: compression of ilioguinal nerve causing pain after hernia

local infiltration can be diagnostic and therapeutic

37

loss of cremasteric reflex; numbness on ipsilateral penis, scrotum, and thigh

ilioinguinal nerve injury

38

where is ilioinguinal nerve usually injured?

nerve is usually injured at the external ring; nerve runs on top of cord

39

when is genitofemoral nerve usually injured in hernia repair?

usually injured with laparoscopic hernia repair

40

genitofemoral nerve:
- cremaster (motor) and scrotum (sensory)

genital branch of the genitofemoral nerve

41

genitofemoral nerve:
- upper lateral thigh (sensory)

femoral branch of the genitofemoral nerve

42

management: cord lipoma

should be removed

43

most common in males, although incidence is increased in females compared to inguinal hernias

femoral hernias

44

femoral canal boundaries

- posterior: cooper's ligament
- anterior: inguinal ligament
- lateral: femoral vein
- medial: Poupart's ligament

45

where is a femoral hernia?

medial to the femoral vein and lateral to the lymphatics (in empty space)
- hernia passes under the inguinal ligament

46

femoral hernia: risk of incarceration

high risk of incarceration -> may need to divide the inguinal ligament to reduce the bowel

47

characteristic presentation of femoral hernia

characteristic bulge on the anterior-medial thigh below the ligament

48

how is femoral hernia usually repaired?

hernia is usually repaired through an inguinal approach with cooper's ligament repair

49

- increased incidence in African americans; often close on their own
- delay repair until 5 years
- risk of incarceration in adults, not children

umbilical hernia

50

- lateral border of rectus muscle, adjacent to the linea semilunaris
- almost always inferior to the semicircularis

spigelian hernia

51

where does spigelian hernia occur?

occurs between the muscle fibers of the internal abdominal oblique muscle and insertion of the external abdominal oblique aponeurosis into the rectus sheath

52

- can present as tender medial thigh mass or as small bowel obstruction
- elderly women, previous pregnancy, bowel gas below superior pubic ramus

obturator hernia (anterior pelvis)

53

inner thigh pain with internal rotation

howship-romberg sign (obturator hernia)

54

tx: obturator hernia

operative reduction, may need mesh; check other side for similar defect

55

herniation through the greater sciatic foramen; high rate of strangulation

sciatic hernia (posterior pelvis)

56

hernia: most likely to recur; inadequate closure is the most common cause

incisional hernia

57

rectus sheath: anterior vs posterior

- anterior: complete
- posterior: absent below semicircularis (below umbilicus)

58

how does the posterior aponeurosis of the internal abdominal oblique descend below the umbilicus?

the posterior aponeurosis of the internal abdominal oblique and transversalis aponeurosis move anterior below the umbilicus.

59

- most common after trauma; epigastric vessel injury
- painful abdominal wall mass
- mass more prominent and painful with flexion of the rectus muscle (Fothergill's sign)

rectus sheath hematomas

60

tx: rectus sheath hematomas

nonoperative usual, surgery if expanding

61

what vessel is injured in rectus sheath hematomas?

epigastric vessel injury

62

Fothergill's sign

rectus sheath hematomas: mass more prominent and painful with flexion of the rectus muscle.

63

- women, benign but locally invasive; increased recurrences
- gardner's syndrome
- painless mass

desmoid tumors

64

sx tx: desmoid tumor

wide local excision if possible; if involving significant small bowel mesentery, excision may not be indicated -> often not completely resectable.

65

medical tx: desmoid tumor

sulindac and tamoxifen

66

what causes retroperitoneal fibrosis?

can occur with hypersensitivity to methysergide

67

most sensitive test for retroperitoneal fibrosis

IVP most sensitive test (constricted ureters)

68

symptoms usually related to trapped ureters and lymphatic obstruction

retroperitoneal fibrosis

69

tx: retroperitoneal fibrosis

steroids, nephrostomy if infection is present, and surgery if renal function becomes compromised (Free up ureters and wrap in momentum)

70

mesenteric tumors: of the primary tumors, most are...

of the primary tumors, most are cystic

71

mesenteric tumors: location of malignant tumors

closer to the root of the mesentery

72

mesenteric tumors: location of benign tumors

more peripheral

73

MCC malignant mesenteric tumors

#1 liposarcoma
leiomyosarcoma

74

dx / tx mesenteric tumors

dx: abdominal ct
tx: resection

75

- 15% in children, others in 5th - 6th decade
- malignant > benign
- symptoms: vague abdominal and back pain

retroperitoneal tumors

76

most common malignant retroperitoneal tumor

#1 lymphoma
#2 liposarcoma

77

- would leave residual tumor
- mets go to lung

retroperitoneal sarcomas

78

MC omental solid tumor

metastatic disease

79

management: mets to omentum

omentectomy for metastatic cancer has a role for some cancers (e.g. ovarian CA)

80

omentum: usually asymptomatic, can undergo torsion

omental cysts

81

omentum:
- rare, 1/3 are malignant
- NO Biopsy: can bleed
- tx: resection

primary solid omental tumors

82

how is blood absorbed in the peritoneum?

blood is absorbed through fenestrated lymphatic channels in the peritoneum

83

drugs removed with peritoneal dialysis

most drugs are removed with peritoneal dialysis

84

elements removed with peritoneal dialysis

NH3, Ca, Fe, and lead

85

how does fluid move into the peritoneal cavity?

movement of fluid into the peritoneal cavity can occur with hypertonic intra-peritoneal saline load (mechanism of peritoneal dialysis); can cause hypotension

86

CO2 pneumoperitoneum causing cardiopulmonary dysfunction

can occur with intra-abdominal pressure > 20

87

what parameters does CO2 pneumoperitoneum increase?

MAP, PAP, HR, SVR, CVP, mean airway pressure, PIP, CO2

88

what parameters does CO2 pneumoperitoneum decrease?

pH, venous return (IVC compression), CO, renal flow secondary to decreased CO

89

what lowers pressure necessary to cause compromise in CO2 pneumoperitoneum?

hypovolemia

90

what worsens effects of pneumoperitoneum?

PEEP

91

how does CO2 affect myocardial contractility?

CO2 can cause some decrease in myocardial contractility

92

tx: CO2 embolus

head down, turn patient to the left (sudden rise in ETCO2 and hypotension); can try to aspirate CO2 thru central line; prolonged CPR

93

- cost-effective for medium vessels (short gastric)
- disrupts protein H-bonds, causes coagulation

Harmonic scalpel

94

most commonly used mode on ultrasound

b-mode (b= brightness; assess relative density of structures)

95

US - dark area posterior to object indicates mass

shadowing

96

US - brighter area posterior to object indicates fluid-filled cyst

enhancement

97

US - Duplex:
- Lower frequencies: show?
- higher frequencies: show?

lower: deep structures
higher: superficial structures

98

energy transferred against argon gas

Argon beam

99

argon beam: determines depth of necrosis

depth of necrosis related to power setting (2mm); causes superficial coagulation

100

what is good for hemostasis of the liver and spleen?

argon beam: is non-contact: good for hemostasis of the liver and spleen; smokeless

101

return of electrons to ground state releases energy as heat -> coagulates and vaporizers

laser

102

tx: condylomata accuminata

laser (wear mask)

103

good for deep tissue penetration; good for bronchial lesions

Nd:YAG laser

1-2mm cuts, 3-10 mm vaporizes, and 1-2 cm coagulates

104

cannot get fibroblast ingrowth

Gore-Tex (PTFE)

105

allows fibroblast ingrowth

Dacron (polypropylene)

106

incidence of vascular or bowel injury with Veress needle or trocar

0.1%