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Intuitive CAST > Hernia - Inguinal & ventral > Flashcards

Hernia - Inguinal & ventral Flashcards

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1
Q

What is a hernia - where do they typically occur

A

Abnormal protrusion of an organ or tissue through a defect in its surrounding walls - anterior abdominal wall

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2
Q

What is a ventral hernia

A

Protrusion through the anterior abdominal wall fascia. Occur only at sites which aponeurosis and fascia are not covered by striated muscle.

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3
Q

What are the 4 pairs of muscles that make up the abdominal wall?

A

External oblique
Internal oblique
Tranversus abdominus
Recuts abdominus

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4
Q

What is aponeurosis

A

A type of deep fascia in the form of a sheet of pearly-white fibrous tissue

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5
Q

where are the external oblique muscles located? How do the fibers travel

A

Deep to the skin and subcutaneous fat. The fibers extend inferiorly and medially (sliding one’s hands into pants pockets)

The first and most superficial muscle of the lateral abd. wall.

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6
Q

Linea Alba

A

midline fibrous band joining both sides of the abd. wall

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7
Q

Anterior rectus sheath - where is it located and what does it enclose?

A

Medial extension of the external oblique aponeurosis. Encloses the rectus abdominis muscles.

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8
Q

Aponeurosis of the external obliques

A
  • Inserts on the linea semilunaris
  • contributes to the anterior rectus sheath
  • inserts on the linea alba
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9
Q

Where are the internal oblique locted

A

deep to the external oblique

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10
Q

How do the fibers travel - internal oblique

A

Extend superiorly and medially - opposite the external oblique

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11
Q

Aponeurosis of the internal oblique

A

-inserts on the linea semilunaris
- contributes to the anterior and posterior recuts sheath
- inserts on the linea alba

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12
Q

Transversus abdominus

A

deepest lateral muscle layer of the abdominal wall

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13
Q

How do the fibers travel - Transversus abdominis

A

Horizontal direction
- inserts on the linea semilunaris
- contributes to the posterior recuts sheath
- inserts on the linea alba

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14
Q

Rectus Abdominus

A

Medial muscle of the anterior abdominal wall. Deep to the anterior rectus sheath, on either side of the linea alba.

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15
Q

How do the fibers of the rectus abdominus run

A

longitudinally and down the entire length of the abdominal wall from the xiphoid to pubic symphysis

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16
Q

Tendinous intersections

A

3 transverse bands of collagen fibers that seperate the rectus abdominis muscle. Resulting in the look of 6 pack abs.

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17
Q

Linea semilunaris

A

Curved tendinous line one on either side of the rectus abdominis.

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18
Q

Arcuate Line

A

demacrates lower limit of the posterior recuts sheath

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19
Q

Posterior Rectus sheath - where is it located

A

Deep to the rectus abdominis (only above the arcuate line)

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20
Q

Transversalis fascia - what is it & where is it located.

A

the connective tissue layer that underlies the abdominal wall musculature, located inferior to the arcuate line

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21
Q

Arcuate line - what is it, where is it located

A

occurs about 1/2 of the distance from the umbilicus to the pubic crest (about 3-6cm below the umbilicus)

demarcates the lower limit of the posterior layer of the rectus sheath. - The rectus sheath is absent below the arcuate line.

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22
Q

Why is the arcuate line a weak spot?

A

the absence of the posterior recuts sheath below the arcuate line

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23
Q

Where do the Inferior epigastric vessels enter the rectus abdominis

A

At the level of the arcuate line

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24
Q
A
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25
What is a TAPP hernia repair
Transabdominal Pre-peritoneal
26
What is a TAR hernia repair
Transversus Abdominus Release
27
What is the peritoneum, what and where is it located
Serous membrane that forms the lining of the abdominal cavity. Deep to the tranversalis fascia
28
What is the omentum - & where is it located
Large flat adipose tissue layer sitting on the surface of the intra-peritoneal organs. Deep to the peritoneum
29
What/where is the falciform ligament
Attached to the anterior side of the liver. Separates the right & left lobes of the liver. Anchors the liver to the abdomen
30
What is a common reason the falciform ligament is taken down?
to ensure the mesh lays flat during an intraperitoneal only mesh ventral hernia (IPOM)
31
What is an IPOM hernia repair
Intraperitoneal onlay mesh (IPOM)
32
How may the falciform ligament be used in a hernia repair
used as a natural patch for holes in the facial layer
33
When is a hernia classified as reducible
if the contents can be pushed back into the abdminal cavity with light manual pressure. May or may not present with pain Does not need immediate attention may progress if untreated
34
What is an incarcerated/irreducible hernia
Its contents get trapped and cannot move back into the abdominal cavity. Tissue trapped within the hernia sac still receives blood supply May progress if untreated patients should seek medical attention w/increased swelling, soreness, and pain
35
Strangulated Hernia
The blood supply to the herniated tissue has been cut off. The tissue can release toxins and infection into the bloodstream, Medical emergencies Any hernia can become strangulated May require bowel resection
36
symptoms of strangulated hernia's
severe abd. pain profuse sweating increased swelling w/ tight glistening red skin severe nausea and vomitting change in bowel habits - inablility to pass gas or a bowel movement decrease in or absence of urine output high fever - 101 or higher
37
Hernia mass contents
Covering tissue (skin, subcutaneous tissues) peritoneal sac, and any contained viscera
38
Fascial defect of the hernia
where the hernia protrudes from - a break in the fascia
39
neck of the hernia
innermost musculoaponeurotic layer
40
Causes of hernia - ventral
weakness at incision site of a previous surgery Weakness in an abdominal wall area present at birth Weakness in abd. wall caused by conditions that put strain or weakens tissue
41
activites that can increase pressure on abd. wall
Straining on the toilet persistent cough being overweight or obese pregnancy abd. fluid lifting heavy items physical exertion
42
activities that can weaken tissue
peritoneal dialysis poor nutrition smoking diabetes
43
Diagnosis of hernia
Review med. history Physical exam - determine stage ultrasound - view contents CT scan - view contents MRI - view contents Blood work - infection or shock
44
Why do an ultrasound or blood test
to study the contents of the hernia or check for infection or shock
45
Types of Hernias - Ventral
Umbilical Epigastric Incisional Spigelian
46
Umbilical hernia
Occurs at the umbilicus. More common in women and in patients with intra-abdominal pressure. More common in patients who have only a single layer of midline aponeurotic crossing
47
Epigastric Hernia
located between the xiphoid process and the umbilicus - usually w/in 5-6cm of the umbilicus More common w/single aponeurotic decussation ~ 3-5% Often small and produce pain beyond their size
48
Incisional Hernia
occur at the healing site. These can be the most frustrating and difficult to treat. They enlarge over time, leading to pain, bowel obstruction, incarceration, and strangulation. Obesity, advanced age, malnutrition, pregnancy, and conditions that increase intra-abdominal pressure.
49
Spigelian Hernia
Occurs through the linea semilunaris. Almost all occur at or below the arcuate line. Most are small and develop during the 4th-7th decade of life. It is repaired because it often has a narrow neck
50
Another name for inguinal ligament
Poupart's ligament
51
Pubic Tubercle
a common landmark for medical dissection during an inguinal hernia repair. It also serves as a common location for fixation of mesh with suture or a tack
52
Inguinal ligament (Poupart's ligament)
spans from the ASIS to pubic tubercle. The medial half of the inguinal ligament is curled inwardly, forming a trough
53
what is another name for Cooper's ligament
Pectineal ligament
54
Cooper's ligament
fibrous extension of the inguinal ligament. Travels posteriorly along the superior edge of the suprapubic ramus
55
What is coopers ligament used for in a hernia repair
useful to anchor suture to
56
Inguinal canal
a passage through the lower abdominal wall and is about 4cm long. There are 2, 1 on each side of the lower abd.
57
Inguinal canal boundaries
Posterior wall: transversalis fascia Inferior boundary: inguinal ligament Superior boundary: Transversus Abd. & internal oblique Anterior wall: External oblique
58
Superficial ring
lies at the pubic tubercle
59
Deep ring
at the midpoint of the inguinal ligament
60
What does the inguinal canal contain in males
Spermatic cord: Vas deferens and testicular vessels
61
Vas Deference
the duct that transports sperm from the epididymis to ampulla for ejaculation
62
What does the inguinal canal contain in women
Round ligament
63
Round ligament
supports the uterus within the pelvic cavity and travels through the inguinal canal to the labia majora
64
Indirect hernia
Occurs when abdominal contents protrude through the deep ring of the inguinal canal Lateral to the inferior epigastric vessels
65
Spermatic cord
passes through the inguinal canal and connects to the testicles. Carries sperm from the testicles to the penis
66
Inguinal region
Aka the groin - located on the lower portion of the anterior abd. wall It falls between the anterior superior iliac spine and the pubic tubercle
67
ASIS
Anterior superior Iliac spine
68
3 umbilical folds
Median umbilical fold Medial umbilical folds lateral umbilical folds
69
Where are the umbilical folds located and how are they used?
On the posterior surface of the anterior abd. wall They are used as surgical landmarks
70
What does the median umbilical fold contain?
the Urachus: an embryonic remnant of the allantoic duct
71
What do the medial umbilical folds contain
remnant of the umbilical artery. They also suspend the bladder with the urachus
72
what do the lateral umbilicus folds contain
inferior epigastric vessels
73
Vessels of the inguinal region
Inferior epigastric vessels testicular vessels external iliac vessels
74
Hesselbach's triangle
an area of potential weakness in the anterior abd. wall. A hernia through hesselbach's triangle is referred to as a direct hernia
75
Boarders of hesselbach's triangle
Lateral border of the rectus abdominis inferior epigastric vessels Inguinal ligament
76
Triangle of doom
an area that contains the external iliac vessels
77
Boarders of the triangle of doom
Deep ring Vas deferens testicular vessels
78
Triangle of Pain
an area with a high concentration of nerves
79
Borders of the triangle of pain
Deep ring inguinal ligament testicular vessels
80
What are the nerves that are contained within the triangle of pain
Lateral femoral cutaneous nerve genitofemoral nerve femoral nerve
81
Lateral femoral cutaneous nerve
provides sensory innervation to the anterior skin of the thigh
82
Genitofemoral nerve
provides sensory and motor innervation to the scrotum and cremaster muscles in males, as well as labia majora and mons pubis in females
83
femoral nerve
provides motor and sensory innervation to the anterior compartment of the thighs as well as sensory branches to the hip joint
84
Signs and symptoms of an inguinal hernia
bulge in the groin area discomfort or pain in the groin with increased pain during activity weakness, heaviness, burning, or aching in the groin swollen or an enlarged scrotum in men or boys
85
how to distinguish between a direct and indirect hernia
based off of the inferior epigastric vessels Direct - medial indirect - lateral
86
Indirect hernia
caused by a defect in the abd. wall that is congenital (present at birth) More common than direct Lateral to the inferior epigastric vessels failure of embryonic closure abd. contents protrude through the deep inguinal ring
87
Direct hernia - caused by?
caused by a weakness in the muscles of the abd. wall that develops over time or are due to straining or heavy lifting
88
Direct hernia
Medial to the inferior epigastric vessels abdominal contents protrude through a weak spot in the transversalis fascia Less common than indirect hernia
89
Causes of a hernia - inguinal
Faliure of abd. wall closure during embryonic development. - More common in males weakness in abd. wall caused by strain
90
incidence of hernia in men vs women
men are 25x more likely to have an inguinal hernia indirect hernias are at a ratio of 2:1
91
Robotic inguinal hernia repair
TAPP (Transabdominal preperitoneal) is the simplest and most common robotic repair TAPP is a 3 are procedure
92
TAPP patient positioning and prep
Supine Tuck arms and pad pressure points and bony prominences secure patient to table insufflate up to 12mmHg 15 degrees trend set table to lowest limit
93
TAPP port placement - LEFT
94
TAPP Inguinal repair instruments
95
TAPP advanced instrumentation
Force bipolar - dual grip technology - bipolar functionality
96
TAPP Procedure steps
1. lysis of adhesions 2. Creation of the peritoneal flap and mesh pocket dissection 3. Mesh fixation 4. closure of the peritoneum 5. bilateral hernia repair
97
Lysis of Adhesions
For pelvic access - take-down abdominal adhesions. Reduce Hernia contents if possible.
98
Creating of the peritoneal flap and mesh pocket dissection
measure and mark a point superior to the hernia defect using two lengths of the cadiere forceps to approx. a 4-5cm distance. Incise peritoneum to create flap perform: medial, lateral, and central dissection
99
Mesh fixation
Insert the mesh secure the mesh with interrupted sutures consider placing one suture into coopers ligament avoid nerves and vasculature self fixing mesh my be used
100
Closure of the peritoneum
close the peritoneum using a running stitch of barbed,self-locking suture
101

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