General Surgery - Hernias Flashcards
(122 cards)
1
Q
What is a hernia?
A
(L. rupture) Protrusion of a peritoneal sac through a musculoaponeurotic barrier (e.g. abdominal wall), a fascial defect
2
Q
What is the incidence of hernias?
A
5-10% lifetime
50% indirect inguinal
25% direct inguinal
~5% are femoral
3
Q
What are the precipitating factors of hernias?
A
Increased intra-abdominal pressure: straining at defecation or urination (rectal cancer, colon cancer, prostatic enlargement, constipation), obesity, pregnancy, ascites, valsavagenic (coughing) COPD, an abnormal congenital anatomic route (ie patent processus vaginalis)
4
Q
Why should hernias be repaired?
A
To avoid complications of incarceration/strangulation, bowel necrosis, SBO (small bowel obstruction), pain
5
Q
What is more dangerous: a small or large hernia defect?
A
Small defect! a tight defect is more likely to strangulate if incarcerated
6
Q
Define Reducible
A
Ability to return the displaced organ or tissue/hernia contents to their usual anatomic site
7
Q
Define Incarcerated
A
Swollen or fixed within the hernia sac (incarcerated = imprisoned), may cause intestinal obstruction (ie an irreducible hernia)
8
Q
Define strangulated
A
Incarcerated hernia with resulting ischemia, will result in signs and symptoms of ischemia and intestinal obstruction or bowel necrosis (think: strangulated = choked)
9
Q
Define complete
A
Hernia sac and its contents protrude all the way through the defect
10
Q
Define incomplete
A
Defect present without sac or contents protruding completely through it
11
Q
What is reducing a hernia “en masse”?
A
reducing the hernia contents and hernia sac
12
Q
Define a Sliding hernia
A
Hernia sac partially formed by the wall of a viscus (ie, bladder/cecum)
13
Q
Define Littre’s hernia
A
Hernia involving a Meckel’s diverticulum
(think alphabetically: Littre’s Meckel’s = LM)
14
Q
Define Spigelian hernia
A
Hernia through the linea semilunaris (or spigelian fascia), also known as spontaneous lateral ventral hernia
(Think S: Spigelian = Semilunaris)
15
Q
Define internal hernia
A
Hernia into or involving intra-abdominal structure
16
Q
Define Petersen’s hernia
A
Seen after bariatric gastric bypass - internal herniation of small bowel through the mesenteric defect from the Roux limb
17
Q
Define Obturator hernia
A
Hernia through obturator canal
females > males
18
Q
Define lumbar hernia
A
Petit’s hernia or Grynfeltt’s hernia (next cards)
19
Q
Define Petit’s hernia (a lumbar hernia)
A
RARE hernia through Petit’s triangle (aka inferior lumbar triangle)
Think: PETITe = small = inferior
20
Q
Grynfeltt’s hernia (a lumbar hernia)
A
Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle)
21
Q
Define Pantaloon hernia
A
Hernia sac exists as BOTH A DIRECT AND INDIRECT hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring (two sacs separated by the inferior epigastric vessels [the pant crotch] like a pair of pantaloon pants)
22
Q
Define incisional hernia
A
Hernia through an incisional site; most common cause is a wound infection
23
Q
Ventral hernia
A
Incisional hernia in the ventral abdominal wall
24
Q
Define Parastomal hernia
A
Hernia adjacent to an ostomy (e.g. colostomy)
25
Define Sciatic hernia
Hernia through the sciatic foramen
26
Define Richter's hernia
Incarcerated or strangulated hernia involving only ONE SIDEWALL OF THE BOWEL, which can spontaneously reduce, resulting in gangrenous bowel and perforation within the abdomen without signs of obstruction
27
Define Epigastric hernia
Hernia through the linea alba above the umbilicus
28
Define Umbilical hernia
Hernia through the umbilical ring, in adults associated with ascites, pregnancy, and obesity
29
Define Intraparietal hernia
Hernia in which abdominal contents migrate between the layers of the abdominal wall
30
Define Femoral hernia
Hernia medial to femoral vessels (under inguinal ligament)
31
Define Hesselbach's hernia
Hernia under inguinal ligament LATERAL to femoral vessels
32
Define Bochdalek's hernia
Hernia through the posterior diaphragm, usually on the left
Think: Boch da lek = back to the left, on the diaphragm
33
Define Morgagni's hernia
Anterior parasternal diaphragmatic hernia
34
Define Properitoneal hernia
Intraparietal hernia between the peritoneum and transversalis fascia
35
Define Cooper's hernia
Hernia through the femoral canal and tracking into the scrotum or labia majus
36
Indirect Inguinal Hernia
inguinal hernia LATERAL to Hesselbach's triangle
37
Direct Inguinal Hernia
inguinal hernia WITHIN Hesselbach's triangle
38
Hiatal hernia
Hernia through esophageal hiatus
39
Amyand's hernia
Hernia sac containing a ruptured appendix
Think A: Amyand's = Appendix
40
What are the boundaries of Hesselbach's triangle?
1. Inferior epigastric vessels
2. Inguinal ligament (Poupart's)
3. Lateral border of the rectus sheath
Floor consists of internal oblique and the transversus abdominis muscle
41
What are the layers of the abdominal wall?
Skin
Subcutaneous fat
Scarpa's fascia
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia
Preperitoneal fat
Peritoneum
\*\*\*All three muscle layer aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line
42
What is the differential diagnosis for a mass in a healed C-section incision?
Hernia
ENDOMETRIOMA
43
What is the differential diagnosis of a groin mass?
Lymphadenopathy, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC (epidermal inclusion cyst), undescended testicle, testicle torsion
44
What is a Direct Inguinal Hernia?
Hernia within the floor of Hesselbach's triangle, ie the hernia sac does not traverse the internal ring
Think **directly** through the abdominal wall
45
What causes a Direct Inguinal Hernia?
Acquired defect from mechanical breakdown over the years
46
Incidence of a Direct inguinal Hernia?
~1% of all men, frequently increases with advanced age
47
What nerve runs with the spermatic cord in the inguinal canal?
Ilioinguinal nerve
48
What is an Indirect Inguinal Hernia?
Hernia through the internal ring of the inguinal canal, traveling down toward the external ring, it may enter the scrotum upon exiting the external ring (ie, if complete), think of the hernia sac traveling **indirectly** through the abdominal wall from the internal ring to the external ring
49
Cause of indirect inguinal hernia?
Patent processus vaginalis (ie congenital)
50
Incidence of indirect inguinal hernia?
~5% of all men, most common hernia in both men AND women
51
How is an inguinal hernia diagnosed?
Relies mainly on history and physical exam with index finger invaginated into the external ring and palpation of hernia; examine the patient standing up if diagnosis is not obvious
Note: if swelling occurs below the inguinal ligament, it is possibly a femoral hernia
52
What is the differential diagnosis of an inguinal hernia?
Lymphadenopathy, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess
53
What is the risk of strangulation of inguinal hernias?
Higher with indirect than direct inguinal hernia, but highest in femoral hernias
54
What is the treatment of inguinal hernia?
Emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present; otherwise, elective herniorrhaphy is indicated to prevent the chance of incarceration/strangulation
55
Bassini procedure
**Sutures** approximate reflection of inguinal ligament (Poupart's) to the transversus abdominis aponeurosis/conjoint tendon
56
McVay procedure
**Cooper's** ligament sutured to transversus abdominis aponeurosis/conjoint tendon
57
Lichtenstein procedure
"tension-free repair" using mesh
58
Shouldice procedure
Imbrication of the floor of the inguinal canal (aka "Canadian repair")
59
Plug and patch
Placing a plug of mesh in hernia defect then overlaying a patch of mesh over inguinal floor (requires few if any sutures in mesh!)
60
High ligation procedure
Ligation and transection of indirect hernia sac without repair of inguinal floor (used only in CHILDREN)
61
TAPP procedure
TransAbdominal PrePeritoneal inguinal hernia repair
62
TEPA procedure
Totally ExtraPeritoneal Approach
63
What are the indications for laparoscopic inguinal hernia repair?
1. Bilateral inguinal hernias
2. Recurring hernia
3. Need to resume full activity as soon as possible
64
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is the first identifiable subcutaneous named layer?
Scarpa's fascia (thin in adults)
65
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is the name of the subcutaneous vein that is ligated?
Superficial epigastric vein
66
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What happens if you cut the ilioinguinal nerve?
Numbness of inner thigh or lateral scrotum; usually goes away in 6 months
67
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
From what abdominal muscle layer is the cremaster muscle derived?
Internal oblique muscle
68
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
From what abdominal muscle layer is the inguinal ligament (aka Poupart's ligament) derived?
External oblique muscle aponeurosis
69
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
To what does the inguinal (Poupart's) ligament attach?
Anterior superior iliac spine to the pubic tubercle
70
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
Which nerve travels on the spermatic cord?
Ilioinguinal nerve
71
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
Why do some surgeons deliberately cut the ilioinguinal nerve?
First they obtain preoperative consent and cut so as to remove the risk of entrapment and postoperative pain
72
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is in the spermatic cord (6)?
1. Cremasteric muscle fibers
2. Vas deferens
3. Testicular artery
4. Testicular pampiniform venous plexus
5. _+_ hernia sac
6. Genital branch of the genitofemoral nerve
73
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is the hernia sac made of?
Peritoneum (direct) or a patent processus vaginalis (indirect)
74
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What attaches the testicle to the scrotum?
Gubernaculum
75
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is the most common organ in an inguinal hernia sac in men?
Small intestine
76
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is the most common organ in an inguinal hernia sac in women?
Ovary/fallopian tube
77
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What lies in the inguinal canal in the female instead of the VAS?
Round ligament
78
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
Where in the inguinal canal does the hernia sac lie in relation to the other structures?
Anteromedially
79
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is a "cord lipoma'?
Preperitoneal fat on the cord structures (pushed in by the hernia sac); not a real lipoma; remove surgically if feasible
80
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is a small outpouching of testicular tissue off of the testicle?
Testicular appendage (aka the appendix testes); remove with electrocautery
81
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?
Remove the suture as soon as possible and apply pressure (ie do NOT tie the suture down!)
82
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What nerve is found on top of the spermatic cord?
Ilioinguinal nerve
83
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What nerve travels within the spermatic cord?
Genital branch of the genitofemoral nerve
84
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What are the borders of Hesselbach's triangle?
1. Epigastric vessels
2. Inguinal ligament
3. Lateral border of the rectus
85
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What type of hernia goes through Hesselbach's triangle?
Direct hernia due to a weak abdominal floor
86
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is a "relaxing incision"?
Incision(s) in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal ligament without tension
87
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What is the conjoint tendon?
Aponeurotic attachments of the "conjoining" of the internal oblique and transversus abdominis to the pubic tubercle
88
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
Define inguinal anatomy
1. Inguinal ligament (Poupart's ligament)
2. Transversus aponeurosis
3. Conjoint tendon
89
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
How tight should the new internal inguinal ring be?
Should allow entrance of the tip of a Kelly clamp but not a finger (the new external inguinal ring should not be tight and should allow entrance of a finger)
90
CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS
What percentage of the strength of an inguinal floor repair does the external oblique aponeurosis represent?
ZERO
91
What is a Femoral Hernia?
Hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels
Think: **FM** radio, Femoral hernia = Medial
92
What are the boundaries of the femoral canal?
1. Cooper's ligament posteriorly
2. Inguinal ligament anteriorly
3. Femoral vein laterally
4. Lacunar ligament medially
93
What factors are associated with femoral hernias?
Women, pregnancy & exertion
94
What percentage of all hernias are femoral?
5%
95
What percentage of patients with a femoral hernia are female?
85%!!
96
What are the complications of a femoral hernia?
Approximately one third incarcerate (due to the narrow, unforgiving neck)
97
What is the most common hernia in women?
indirect inguinal hernia
98
What is the repair of a femoral hernia?
McVay (Cooper's ligament repair), mesh plug repair
99
HERNIA REVIEW QUESTIONS
Should elective TURP or elective herniorrhaphy be performed first?
TURP
100
HERNIA REVIEW QUESTIONS
Which type of esophageal hiatal hernia is associated with GE reflux?
Sliding esophageal hiatal hernia
101
HERNIA REVIEW QUESTIONS
Classically, how can incarcerated hernia be reduced in the ER?
1. Apply ice to incarcerated hernia
2. Sedate
3. Use the Trendelenburg position for inguinal hernias
4. Apply steady gentle manual pressure
5. Admit and observe for signs of necrotic bowel after reduction
6. Perform surgical herniorrhaphy ASAP
102
What is appropriate if you cannot reduce an incarcerated hernia with steady, gentle compression?
Go directly to the OR for repair
103
What is the major difference in repairing a pediatric indirect inguinal hernia and an adult inguinal hernia?
In babies and children it is rarely necessary to repair the inguinal floor; repair with "high ligation" of the hernia sac
104
What is the Howship-Romberg sign?
Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia
105
What is the "sillk glove" sign?
Inguinal hernia sac in an infant/toddler feels like a finger of a silk glove when rolled under the examining finger
106
What must you do before leaving the OR after an inguinal hernia repair?
Pull the testical back down to the scrotum
107
ESOPHAGEAL HIATAL HERNIAS
Define type I & type II hiatal hernias
Type I = sliding
Type II = paraesophageal
108
What is a Sliding Esophageal Hiatal Hernia?
Both the stomach and GE junction herniate into the thorax via the esophageal hiatus, also known as type I hiatal hernia
109
Incidence of Sliding Esophageal Hiatal Hernia?
\>90% of all hiatal hernias
110
Symptoms of sliding esophageal hiatal hernia?
Most patients are asymptomatic, but the condition can cause **reflux**, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration
111
How is sliding esophageal hiatal hernia diagnosed?
UGI series, manometry, esophagogastroduodenoscopy (EGD), with biopsy for esophagitis
112
Complications of sliding esophageal hiatal hernia?
reflux -\> esophagitis -\> Barrett's esophagus -\> cancer & stricture formation; aspiration pneumonia; it can also result in UGI bleeding from esophageal ulcerations
113
Treatment of sliding esophageal hiatal hernia?
85% of cases treated medically with antacids, H2 blockers/PPIs, head elevation after meals, small meals, and no food prior to sleeping
15% of cases require surgery for persistent symptoms despite adequate medical treatment
114
What is the surgical treatment for sliding esophageal hiatal hernia?
Laparoscopic Nissen fundoplication (LAP NISSEN) involves wrapping the fundus around the LES and suturing it in place
115
What is a Paraesophageal hiatal hernia?
Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the gastroesophageal junction; aka type II hiatal hernia
116
Incidence of paraesophageal hiatal hernias?
\<5% of all hiatal hernias (rare)
117
Symptoms of paraesophageal hiatal hernia?
Derived from mechanical obstruction; dysphagia, stasis gastric ulcer, and strangulation; many cases are asymptomatic and not associated with reflux because of a relatively normal position of the GE junction
118
Complications of paraesophageal hiatal hernia?
Hemorrhage, incarceration, obstruction, and strangulation
119
Treatment of paraesophageal hiatal hernia?
Surgical, because of frequency and severity of potential complications
120
What is a type III hiatal hernia?
Combined type I and type II
121
What is a type IV hiatal hernia?
Organ (eg colon or spleen) +/- stomach in the chest cavity
122
