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General Surgery > Inguinal Hernia > Flashcards

Inguinal Hernia Flashcards

(51 cards)

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1
Q

Littre’s hernia

A

Meckel’s diverticulum in hernia sac

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2
Q

Amyand’s hernia

A
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3
Q

Richter’s hernia

A

Antimesenteric border of intestine protrudes through

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4
Q

Pantoloon Hernia

A

A “saddlebag” hernia is any combination of two hernia sacs of the femoral and inguinal region. Often indirect + direct hernia

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5
Q

Romberg Hernia

A

A Pantoloon hernia that is specifically direct + indirect hernia

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6
Q

Maydl’s hernia

A

two small loops of bowel within single hernia sac in a “W” manner

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7
Q

Boundaries of the Hasselbach Triangle

A

Lateral border of rectus muscle

Inferior epigastric artery

inguinal ligament

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8
Q

Surgical importance of the Hasselbach triangle

A

Potentially weak area due to the fact that the triangle is not reinforced by the conjoint tendon

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9
Q

What is a hernia?

A

A hernia is an abnormal protrusion of a viscus through its normal covering

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10
Q

What are the borders of the inguinal canal?

A

Inferior: inguinal ligament

Anterior: external oblique aponeurosis with lateral third of the internal oblique

Posterior: transversalis fascia and conjoint tendon

Superior: internal oblique and tranversalis abdominis

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11
Q

Risk factors for inguinal hernia

A

Gender

Advancing age

Obesity

COPD

Chronic constipation

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12
Q

Types of inguinal hernia

A

Direct : herniation through the Hasselbach Triangle

Indirect: protrusion of abdominal contents through the deep inguinal ring

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13
Q

Where is the deep inguinal ring

A

2cm above the mid-point of the inguinal ligament

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14
Q

Where is the superficial inguinal ring?

A

Triangular aperture of the EOA 1cm above the pubic tubercle

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15
Q

Where is the superficial inguinal ring?

A

Triangular aperture of the EOA 1cm above the pubic tubercle

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16
Q

Nyphus Type 1

A

Indirect hernia with normal internal ring

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17
Q

Nyphus Type II

A

Indirect hernia with enlarged internal ring

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18
Q

Nyphus Type IIIa

A

Direct hernia with weakened posterior wall

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19
Q

Nyphus Type IIIb

A

Indirect hernia with enlarged ring and weekend posterior wall

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20
Q

Nyhus Type IIIc

A

Femoral hernia

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21
Q

Nyhus Type IV (a,b,c,d)

Study These Flashcards
A

Recurrent hernia

a) Direct
b) Indirect
c) Femoral
d) Combination

22
Q

Evidence in asymptomatic inguinal hernia

Study These Flashcards
A

Two RCTs (Fitzgibbon JAMA 2006, O’Dwyer Ann Surg 2006)

FU study by Fitzgibbon (Ann Surg 2013), men over 65

Conclusions

  • Repair does not affect rate of long term chronic pain but beneficial to improving overall health
  • Watchful waiting is reasonable and safe, but symptoms likely to progress and will eventually need surgery
23
Q

What are the surgical options of inguinal hernia repair?

Study These Flashcards
A
  • OPEN
    • Anterior approach
      • Non-Mesh
        • Bassini
        • Shouldice
        • McVay
      • Mesh
        • Lichenstein
        • Preperitoneal (Rives/Stoppa)
    • Posterior approach
      • Nyhus
  • LAPAROSCOPIC
    • Total ExtraPeritoneal (TEP)
    • TransAbdominal PrePeritoneal (TAPP)
24
Q

Describe an ideal mesh

Study These Flashcards
A

Lightweight <80g/m2

Large pore (> 1mm)

Macroporous

Able to cope with transient increase in pressure (>200mmHg during coughing)

Laparoscopic meshes should not cause abdominal adhesions

25
Causes of inguinodynia
* Neuropathic * local nerve injury * Non-neuropathic * fibrosis of ilioinguinal, iliohypogastric and genital branch of genitofemoral nerve
26
Risk factors for inguinodynia
Young age Preoperative pain Pain in other sites
27
Evidence for use of mesh for repair
Meta-analysis by EU Hernia Trialist Collaboration (Ann Surg 2002) * Less recurrence * Technically easier and results reproducible
28
Indication for laparoscopic approach
29
Describe Shouldice repair
**Four layered** open repair without mesh * **Transverse fascia** incised from internal ring to pubic tubercles creating upper and lower flaps * Flaps are overlapped with double breasted approach with two layers of sutures * Conjoint tendon sutured to the inguinal ligament in two layers
30
Describe the Bassini Repair
Open repair, non-mesh technique * Incision of transversals fascia from deep ring to pubic tubercle * Three layer reconstruction approach (transversals fascia, transverses abdomens, internal oblique ms)
31
Stoppa repair
**Open** repair of **preperitoneal** approach with **mesh** * Lower midline or transverse incision * Enter preperitoneal space * Large mesh placement from one ASIS to the other, below the pubic symphysis and above the umbilicus
32
Space of Rietzius
Extraperitoneal retropubic space between pubis and bladder Boundaries: * Anterior: Transversalis fascia * Posterior: Umbilicovesical fascia * Superior: umbilicus * Inferior: pubovesical fascia
33
Space of Bogros
Lateral extension of space fo Rietzius to the level of ASIS * Boundaries * Anterior: transversals fascia * Medial: Adherent zone of umbilicovesical fascia transversals fascia and peritoneum * Lateral: iliacus muscle and pelvic wall * Inferior: psoas, external iliac vessel, femoral nerve
34
Iliopubic tract
Thickened inferior margin of transversals fascia, runs deep to the inguinal ligament, from pubic symphysis to ASIS
35
Myopectineal orifice
Where all groin hernias originate from * Boundaries: * Superior: arching fibers of transverses abdominis * Inferior: ilium covered by pectineal ligament * Medial: rectus muscle * Lateral: fascia covering iliopsoas muscle
36
Triangle of doom
Contains the external iliac vessels * Boundaries: * Medial: vas deferens * Lateral: gonadal vessels * Inferior: peritoneal edge * Apex: deep ring
37
Triangle of Pain
* Boundaries: * Medial: testicular/gonadal vessels * Lateral: iliopubic tract * Inferior: peritoneal edge
38
Nerves crossing the triangle of pain
Femoral nerve Lateral femoral cutaneous nerve of thigh Femoral branch of genitofemoral nerve
39
Corona Mortis
Arterial ring formed by the anastomosis of an aberrant artery from the epigastric artery with the oburator artery It passes over the pubic tubercle, infers-medial to deep ring 20-30% of patients
40
Mesh coverage requirements for open repair
* Extending 5-6cm lateral to deep ring * 2cm medial to pubic tubercle * Superiorly attached high up under the superior leaf of EOA * Inferiorly reaching or overlap inguinal ligament
41
Mesh coverage requirements for laparoscopic repair
* Inferiorly below pubis and pectineal ligament * Large enough to cover all three potential hernia site, 3cm overlapping * Crosses over the midline medially * Peritoneum and any lipoma of cord must be well behind the inferior edge
42
Complications of hernia repair
* Early * Seroma * Hematoma * Wound infection * AROU * Bladder injury * Ischemic orchitis, testicular atrophy, damage to vas * Damage to intestines * Late * Chronic pain * Recurrence
43
Spermatic cord rule of three
* Contents * Vas deferens * Lymphatic * Obliterated processus vaginalis * 3 Nerves: * Genital branch of genitofemoral nerve * Cremasteric nerve * Autonomic/ Sympathetic * 3 Arteries * Testicular artery * Artery to the Vas * Cremasteric artery * 3 Veins * Pampiniform plexus * Vein from vas * Cremasteric vein * 3 Fascial coverings ( external spermatic, cremasteric, internal spermatic)
44
Signs of poor bowel viability
* Gangrenous change * Loss of normal sheen * Absent of peristalsis * Malodorous * Bloody fluid in sac * Loss of pulsation in mesentery
45
Femoral triangle
* Inguinal hernia * Adductor longus * Sartorius
46
Contents of the femoral triangle
* N:Femoral nerve *outside femoral sheath* * A: Femoral artery *inside femoral sheath* * V: Femoral vein *inside femoral sheath* * E: empty space * L: lymphatics *contains deep inguinal node*
47
Boundaries of the femoral canal
* Anterior: Inguinal ligament * Medial: Lacunar ligament * Posterior: Pectineal ligament * Lateral: femoral vein
48
Surgical approaches for femoral hernia repair
* Low approach: Lockwood * Trans-inguinal: Lothieson * High: McEvedy
49
Lockwood repair
* Low repair * Incision 1 cm below and parallel to inguinal ligament * Suture pectina fascia to inguinal ligament * Avoid injury/compression to femoral vein
50
Lothieson approach
* incision similar to inguinal hernia * Divide the transversalis fascia to reach pre-peritoneal plane * Identify and reduce hernia sac * Close the femoral ring by suture or mesh plug * Reconstruct inguinal canal
51
Surgical technique to minimise incision hernia
* Slowly absorbable or non absorbable suture * Place stitches * in aponeurosis only * 5-8mm from wound edge * 4-5mm apart * Suture length to wound length ratio lower than 4

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