Flashcards in Hernia and Abdominal Wall Problems Deck (49)
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#1 hernia in both male AND females?
indirect inguinal
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Hernia general info
Protrusion of a viscus through an abnormal opening in the wall of a cavity in which it is contained
10% of population develops some sort in life. 3-4% current male population
50% indirect inguinal
25% direct (mostly people over 50)
15% femoral
Abdominal wall hernia is #1 condition requiring major surgery
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External hernia
Sac protrudes completely through the abdominal wall. Ex = inguinal (indirect and direct), femoral, umbilical, epigastric
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Internal hernia
sac is within the visceral cavity.
Ex = diaphragmatic (congenital or acquired), small intestine herniating in the paraduodenal pouch
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Intraparietal hernia
sac is contained within abdominal wall
Ex = spigelian hernia
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Reducible vs irreducible
Irreducible = incarcerated
Cannot be returned to abdomen
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Strangulated
vascularity of viscus is compromised
surgical emergency
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Layers of abdominal wall
skin
subq fat
camper's
Scarpa's
External oblique
Internal oblique
transversalis abdominis
transversalis fascia
peritoneal fat
peritoneum
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Inguinal canal
Length = 4cm
Anterior = ext oblique aponeurosis
Posterior = transverse abdominal muscle aponeurosis and transversalis fascia
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Spermatic cord
Begins at deep ring and contains:
Vas Deferens and its artery
1 testicular artery
2-3 veins
lymphatics
Autonomic nerves
Fat
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Genital nerve
Travels along with cremaster vessels to form neurovascular bundle
From L1 and L2
Motor and sensory
Innervates cremaster, skin of side of scrotum and labia
May sub for ilioinguinal nerve if it doesn't work
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Iliohypogastric, ilioinguinal nerves, genital branch of genitofemoral nerve
Iliohypogastric and ilioinguinal intertwine
originate from T12 and L1
Sensory to groin skin, base of penis, medial upper thigh
Genital branch of genitofemoral nerve is located on top of spermatic cord in 60% of people but can be found behind or within the cremaster muscle. Often cannot be found or is too small to be seen
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Femoral canal structures
Lateral to medial = NAVEL
Nerve
Artery
Vein
Empty space
LN
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Hesselback's triangle
lower abdominal wall
site of direct inguinal hernias
Inferior = inguinal ligament
Medial = rectus abdominis
Lateral = Inferior epigastric vessels (lateral umbilical fold)
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Triangle of Grynfeltt
"superior lumbar triangle"
Bounded by 12th rib superiorly
Internal oblique anteriorly
Floor = fibers of quadratus lumborum muscle
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Triangle of Petit
"inferior lumbar triangle"
Posterior = Lat
Anterior = ext oblique
Inferior = iliac crest
Floor = fibers from int oblique and transversus ab
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Inguinal hernia - general
Hernias arising above the abdominocrural crease
Most common site for abdominal hernias
Male:Female = 25:1
Males: Indirect > direct (2:1)
Female: Direct is rare
Incidence, strangulation, and hospitalization all increase with age
Cause 15-20% of intestinal obstructions
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Risk factors for inguinal hernia
1) Abdominal wall hernias occur in areas where aponeurosis and fascia are devoid of protecting support of striated muscle
2) They can be congenital or acquired by surgery or muscle atrophy
3) Female predisposition to femoral hernias: increased diameter of the true pelvis as compared to men, proportionally widens the femoral canal
4) Muscle deficiency of the internal oblique muscles in the groin exposes the deep ring and floor of inguinal canal, which are further weakened by intra-abdominal pressure
5) Connective tissue destruction (transverse aponeurosis and fascia): caused by physical stress 2/2 intra-abdominal pressure; smoking; aging; connective tissue disease; systemic illness; fracture of elastic fibers; alterations in structure, quantity and metabolism of collagen
6) Other: Abdominal distention, ascites with chronic increase in intra-abdominal pressure, peritoneal dialysis
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Symptoms of inguinal hernia
Asymptomatic sometimes
Symptomatic - nonspecific discomforts vary by patient
Pain: Worse at the end of the day and relieved at night when patient lies down (bc hernia reduces)
Groin hernias do NOT usually cause testicular pain. Likewise, testicular pain doesn't usually indicate the onset of a hernia
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Dx of inguinal hernia
PE
In standing position, have patient strain or cough. Hernia sac will enlarge and transmit a palpable impulse
Hydroceles can resemble an irreducible groin hernia. To distinguish, transilluminate (hernia will not light up)
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Ddx of inguinal hernia
Abdominal wall mass
Desmoids
Neoplasm
Adenopathy
Rectus sheath hematoma
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Radiology role in inguinal hernias
diagnosis is clinical
imaging only used in special cases like when obesity limits clinical exam (US/CT)
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Management of inguinal hernia
Principles of Tx:
1) Tension-free repair of hernia defect
2) Repair using fascia, aponeurosis or mesh
3) Suture material used should hold until fibrous tissue is formed over it
4) Resuscitation in case of strangulated hernia with gangrene with shock or with intestinal obstruction
Nonsurgical:
1) No role for medical management in patient who can tolerate surgery
2) Can be considered in moribound patients
3) Hernia truss is a device to keep a reducible hernia contained by external pressure
Surgical:
1) Treatment of choice
2) Herniotomy is when hernia sac is ID'd, freed, its neck ligated and the sac is reduced. May be enough in young, muscular person and in kids
3) Herniorrhaphy and hernioplasty are herniotomy along with repair of posterior wall of inguinal canal and internal ring
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Complications of surgical repair
Ischemic orchitis with testicular atrophy
Residual neuralgia
Both: more common with anterior groin hernioplasty bc of the nerves and spermatic cord dissection and mobilization
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Prognosis following surgery
Expert surgeons 1-3% in 10y follow up
Caused by excessive tension on repair, deficient tissue, inadequate hernioplasty or overlooked hernias
Decreased with relaxing incisions
More common with direct hernias
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Direct inguinal hernia
A direct hernia enters inguinal canal through its weakened posterior wall. The hernia does NOT pass through internal ring
- Lies posterior to spermatic cord
- Practically never enters scrotum
- wide neck (strangulation rare)
- almost all in men
- common in older age groups
- common in smokers due to weakened connective tissue
- predisposing factors = hard labor, cough, straining, and so on
- can lead to damage to ilioinguinal nerve
Symptoms:
- bulge in groin
- Dull dragging pain in inguinal region referred to testis
- Pain increases with hard work and straining
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Indirect inguinal hernia
Herniation through internal ring traveling to external ring. If complete, it can enter the scrotum while exiting external ring
If congenital, associated with patent processus vaginalis
B/l in 33% of cases
Most common hernia in men AND women
Occurs at all ages
More common in men
In first decade of life, the right-sided hernia is more common than left bc of late descent of R testis
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Femoral hernia def
Form of indirect hernia arising out of the femoral canal beneath the inguinal ligament (medial to femoral vessels)
Female: Male = 2:1
Males affected are in younger group
Rare in children
Uncommon - 2.5% of all groin hernias
Left side 1:2 right side 2/2 sigmoid colon tamponading the left femoral canal
Common in elderly patients
High incidence of incarceration due to narrow neck
22% strangulate after 3 months
45% after 21 months
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Anatomy of femoral hernia
Femoral canal is 1.25cm long and arises from femoral ring to the saphenous opening
Femoral sac originated from femoral canal through defect on the medial side (common) or anterior (rare) side of femoral sheath
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