Fiser Chapter 38 HERNIAS, ABDOMEN, AND SURGICAL TECHNOLOGY

Question 1

What does the external oblique fascia form in inguinal canal?

Answer 1

Inguinal ligament (shelving edge) at inferior portion of inguinal canal

Question 2

What does the internal oblique form in the inguinal canal?

Answer 2

Cremasteric muscles

Question 3

What does the transversalis muscle and fascia form in the inguinal canal?

Answer 3

Conjoined tendon and inguinal floor (respectively)

Question 4

Lacunar ligament

Answer 4

Where the inguinal ligament splays out to insert in the pubis

Question 5

Cooper’s ligament (pectineal ligament)

Answer 5

Posterior to femoral vessels, lies against bone

Question 6

What is the vas deferens in inguinal canal?

Answer 6

Runs medial to cord structures

Question 7

Hesselbach’s triangle

Answer 7

Recus muscle lateral border, inguinal ligament, inferior epigastrics

Direct hernias are in the triangle, indirect hernias are lateral to epigastric vessels

Question 8

Etiology of indirect hernia

Answer 8

Persistent patent processor vaginalis; most common

Question 9

Direct hernias

Answer 9

Lower risk of incarceration, rare in females, higher recurrence than indirect

Question 10

Pantaloon hernia

Answer 10

Both direct and indirect components

Question 11

Risk factors for inguinal hernia in adults

Answer 11

Age

Obesity

Heavy lifting

COPD (coughing)

Chronic constipation

Straining (BPH)

Ascites

Pregnancy

Peritoneal dialysis

Question 12

Incarcerated hernia

Answer 12

Can lead to bowel strangulation and should be repaired emergently

Question 13

Sliding hernias

Answer 13

Retroperitoneal organ in hernia sac (ovaries, fallopian tubes, cecum, sigmoid bladder)

Question 14

Tx of female with ovary in inguinal canal

Answer 14

Ligate the round ligament, return ovary to peritoneum, biopsy if looks abnormal

Question 15

Infants and children with inguinal hernia

Answer 15

Open sac and then perform high ligation (almost always indirect)

Question 16

Lichtenstein inguinal hernia repair

Answer 16

Mesh (less tension, decreases recurrence)

Question 17

Bassini inguinal hernia repair

Answer 17

Approximate conjoined tendon and transversalis fascia to the free shelving edge of the inguinal ligament

Question 18

Cooper’s (pectineal) ligament inguinal hernia repair

Answer 18

Approximate conjoined tendon and transversalis fascia to Cooper’s ligament

• Needs relaxing incision in external oblique fascia
• Can use for femoral hernia repair

Question 19

Indication for laparoscopic inguinal hernia repair

Answer 19

Bilateral or recurrence

Question 20

Most common early complication following inguinal hernia repair

Answer 20

-Urinary retention

• Recurrent 2%
• Wound infection 1%
• Testicular atrophy (d/t dissection of distal component of sac causing vessel disruption, spermatic cord vein thrombosis, usually with indirect hernias)
• Pain (ilioinguinal nerve compression, tx is local infiltration)
• Nerve injury to ilioinguinal or genitofemoral

Question 21

Postop inguinal hernia repair, patient has loss of cremasteric reflex, numbness on ipsilateral penis, scrotum, and thigh

Answer 21

Ilioinguinal nerve injury, usual at external ring, runs on top of cord

Question 22

Postop laparoscopic inguinal hernia repair, patient has loss of cremastric reflex, scrotum numbness, and upper lateral thigh numbness

Answer 22

-Genitofemoral nerve injury

Question 23

Femoral hernia characteristics

Answer 23

Bulge on anterior-medial thigh, below inguinal ligament; usually repair through inguinal approach with Cooper’s ligament repair

Most common in females over males (but indirect inguinal hernia still most common in females)

Hernia passes under inguinal ligament, medial to femoral vein, lateral to lymphatics (in empty space)

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

Question 24

Femoral canal boundaries

Answer 24

Cooper’s (pectineal) ligament posteriorly

Inguinal ligament anteriosuperiorly

Femoral vein laterally

Lacunar ligament medially

Contains lymph node of Cloquet

Question 25

Umbilical hernia characteristics

Answer 25

Increased in African Americans Delay repair until 5yo, often close on own Risk of incarceration in adults, not kids

Question 26

Spigelian hernia characteristics

Answer 26

Lateral border of rectus muscle, adjacent to linea semilunaris; almost always inferior to semicircularis Occurs between muscle fibers of internal oblique muscle and insertion of external oblique aponeurosis into rectus sheath

Question 27

Old woman with previous pregnancies, presents with tender medial thigh mass and SBO, has inner thigh pain with internal rotation (Hoship-Romberg sign)

Answer 27

Obturator hernia (anterior pelvis) Tx: operative reduction, may need mesh; check other side for similar defect

Question 28

Sciatic thigh hernia characteristics

Answer 28

Posterior pelvis (versus obturator hernia) Herniation through greater sciatic foramen High rate of strangulation

Question 29

Incisional hernia characteristics

Answer 29

Most likely to recur Inadequate closure most common cause

Question 30

Rectus sheath above and below arcuate line

Answer 30

Anterior present all the way down Posterior is present until arcuate line: is made of posterior aponeurosis of internal oblique and transversalis aponeurosis

Question 31

Painful abdominal wall mass after trauma, most prominent and painful with flexion of rectus muscle (Fothergill's sign)

Answer 31

Recut sheath hematoma: epigastric vessel injury Tx: Nonoperative, surgical if expanding

Question 32

Woman with Gardner's syndrome has a painless abdominal wall mass

Answer 32

Desmoid tumor, benign but locally invasive, high recurrence Tx: WLE if possible Medical tx: Sulindac and tamoxifen (If involves significant small bowel mesentery, may not be resectable)

Question 33

Retroperitoneal fibrosis

Answer 33

Can occur with hypersensitivity to methysergide (5-HT antagonist formerly used for cluster headaches) Dx: IVP most sensitive test: see constricted ureters. Symptoms usually related to trapped ureters and lymphatic obstruction Tx: Steroids, nephrostomy if infection, surgery if renal function compromised (to free ureters and wrap in omentum)

Question 34

Mesenteric tumors

Answer 34

Most are cystic Malignant (liposarcoma, leiomyosarcoma) are closer to root of mesentery; benign are more peripheral Dx: abdominal CT Tx: Resection

Question 35

Kid presents with vague abdominal and back pain, and found to have a retroperitoneal tumor

Answer 35

Malignant most common: 1. lymphoma, 2. liposarcoma Sarcomas: < 25% are resectable, 40% have local recurrence, 10% 5-year survival - Pseudocapsule but cannot shell out -> leave residual tumor - Mets go to lung

Question 36

Omental tumors

Answer 36

Most common omental solid tumor is metastatic disease Omentectomy for some (e.g. ovarian cancer) Usually asymptomatic but can undergo torsion Primary solid omental tumors are rare, 1/3 are malignant - do NOT biopsy, as can bleed - Tx: resection

Question 37

Peritoneal membrane and how peritoneal dialysis works

Answer 37

Blood absorbed through fenestrated lymphatic channels in peritoneum. Movement of fluid into peritoneal cavity can occur with hypertonic intra-peritoneal saline load (mechanism of peritoneal dialysis); can cause hypotension NH3, Ca, Fe, lead removed Most drugs NOT removed with PD.

Question 38

CO2 pneumoperitoneum, physiological effects

Answer 38

- Cardiopulmonary dysfunction with intra-abdominal pressure > 20 - Increased MAP, pulmonary artery pressure, HR, systemic vascular resistance, CVP, mean airway pressure, peak inspiratory pressure, and CO2 - Decreased pH, venous return (IVC compression), CO (and renal flow), decreased myocardial contractility (from CO2)

Question 39

Problem of hypovolemia with pneumoperitoneum

Answer 39

Lowers the pressure necessary to cause compromise of CO and venous return

Question 40

Problem of PEEP and pneumoperitoneum

Answer 40

PEEP worsens effects of pneumoperitoneum

Question 41

Sudden rise in ETCO2 and hypotension in pneumoperitoneum

Answer 41

CO2 embolus: head down, turn patient to left, try to aspirate CO2 through central line, prolonged CPR

Question 42

Harmonic scalpel

Answer 42

- Cost-effective for medium vessels (short gastrics) | - Disrupts protein H-bond, causes coagulation

Question 43

Surgical ultrasound

Answer 43

B-mode used most commonly (B - brightness; assesses relative density of structures)

Question 44

Shadowing versus enhancement in ultrasound

Answer 44

Shadowing- dark area posterior to object indicates mass Enhancement- brighter area posterior to object indicates fluid-filled cyst

Question 45

Ultrasound duplex: lower versus higher frequencies

Answer 45

Lower for deep structures Higher for superficial structures

Question 46

Argon beam

Answer 46

Energy transferred across argon gas Depth of necrosis related to power setting (2 mm); causes superficial coagulation Is non-contact: good for hemostasis of liver and spleen; smokeless

Question 47

Surgical laser

Answer 47

Return of electrons to ground state releases energy as heat -> coagulates and vaporizes Used for condylomata acuminata (wear mask)

Question 48

Nd:YAG laser

Answer 48

Good for deep tissue penetration, bronchial lesions 1-2 mm cuts, 3-10 mm vaporizes, 1-2 cm coagulates

Question 49

Gore-Tex versus Dacron

Answer 49

Gore-Tex (PTFE): No fibroblast ingrowth Dacron (polypropylene): allows fibroblast ingrowth

Question 50

Incidence of vascular or bowel injury with Veress needle or trocar

Answer 50

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