Fiser Chapter 38 HERNIAS, ABDOMEN, AND SURGICAL TECHNOLOGY Flashcards Preview

ABSITE > Fiser Chapter 38 HERNIAS, ABDOMEN, AND SURGICAL TECHNOLOGY > Flashcards

Flashcards in Fiser Chapter 38 HERNIAS, ABDOMEN, AND SURGICAL TECHNOLOGY Deck (50):
1

What does the external oblique fascia form in inguinal canal?

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

2

What does the internal oblique form in the inguinal canal?

Cremasteric muscles

3

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

Conjoined tendon and inguinal floor (respectively)

4

Lacunar ligament

Where the inguinal ligament splays out to insert in the pubis

5

Cooper's ligament (pectineal ligament)

Posterior to femoral vessels, lies against bone

6

What is the vas deferens in inguinal canal?

Runs medial to cord structures

7

Hesselbach's triangle

Recus muscle lateral border, inguinal ligament, inferior epigastrics

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

8

Etiology of indirect hernia

Persistent patent processor vaginalis; most common

9

Direct hernias

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

10

Pantaloon hernia

Both direct and indirect components

11

Risk factors for inguinal hernia in adults

Age

Obesity

Heavy lifting

COPD (coughing)

Chronic constipation

Straining (BPH)

Ascites

Pregnancy

Peritoneal dialysis

12

Incarcerated hernia

Can lead to bowel strangulation and should be repaired emergently

13

Sliding hernias

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

14

Tx of female with ovary in inguinal canal

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

15

Infants and children with inguinal hernia

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

16

Lichtenstein inguinal hernia repair

Mesh (less tension, decreases recurrence)

17

Bassini inguinal hernia repair

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

18

Cooper's (pectineal) ligament inguinal hernia repair

Approximate conjoined tendon and transversalis fascia to Cooper's ligament

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

19

Indication for laparoscopic inguinal hernia repair

Bilateral or recurrence

20

Most common early complication following inguinal hernia repair

-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

21

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

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

22

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

-Genitofemoral nerve injury

23

Femoral hernia characteristics

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

24

Femoral canal boundaries

Cooper's (pectineal) ligament posteriorly

Inguinal ligament anteriosuperiorly

Femoral vein laterally

Lacunar ligament medially

Contains lymph node of Cloquet

25

Umbilical hernia characteristics

Increased in African Americans

Delay repair until 5yo, often close on own

Risk of incarceration in adults, not kids

26

Spigelian hernia characteristics

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

27

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

Obturator hernia (anterior pelvis)

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

28

Sciatic thigh hernia characteristics

Posterior pelvis (versus obturator hernia)

Herniation through greater sciatic foramen

High rate of strangulation

29

Incisional hernia characteristics

Most likely to recur

Inadequate closure most common cause

30

Rectus sheath above and below arcuate line

Anterior present all the way down

Posterior is present until arcuate line: is made of posterior aponeurosis of internal oblique and transversalis aponeurosis

31

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

Recut sheath hematoma: epigastric vessel injury

Tx: Nonoperative, surgical if expanding

32

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

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)

33

Retroperitoneal fibrosis

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)

34

Mesenteric tumors

Most are cystic

Malignant (liposarcoma, leiomyosarcoma) are closer to root of mesentery; benign are more peripheral

Dx: abdominal CT

Tx: Resection

35

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

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

36

Omental tumors

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

37

Peritoneal membrane and how peritoneal dialysis works

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.

38

CO2 pneumoperitoneum, physiological effects

-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)

39

Problem of hypovolemia with pneumoperitoneum

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

40

Problem of PEEP and pneumoperitoneum

PEEP worsens effects of pneumoperitoneum

41

Sudden rise in ETCO2 and hypotension in pneumoperitoneum

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

42

Harmonic scalpel

-Cost-effective for medium vessels (short gastrics)

-Disrupts protein H-bond, causes coagulation

43

Surgical ultrasound

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

44

Shadowing versus enhancement in ultrasound

Shadowing- dark area posterior to object indicates mass

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

45

Ultrasound duplex: lower versus higher frequencies

Lower for deep structures

Higher for superficial structures

46

Argon beam

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

47

Surgical laser

Return of electrons to ground state releases energy as heat -> coagulates and vaporizes

Used for condylomata acuminata (wear mask)

48

Nd:YAG laser

Good for deep tissue penetration, bronchial lesions

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

49

Gore-Tex versus Dacron

Gore-Tex (PTFE): No fibroblast ingrowth

Dacron (polypropylene): allows fibroblast ingrowth

50

Incidence of vascular or bowel injury with Veress needle or trocar

0.1 %