Inguinal Hernia Flashcards
(17 cards)
The incidence of inguinal hernias in men has bimodal distribution, which peaks
Before the first year of life and after age 40
- Approximately 75% of abdominal wall hernias occur in the groin
- lifetimr risk of inguinla hernia is 27% in men and 3% in women
- Of inguinal hernia repairs,90% are performed in men and 10% in women
- Approximately 70% of femoral hernia repairs are performed in women
- the most common subtype of groin hernia in men and women is the indirect inguinal hernia
The two types of collagen to exist in a decreasd ratio of the skin of inguinal hernia patients are
Type I and III
- Type III does not contribute to wound tensile strength as significant as type I collagen
- Connective tissue disorders
According to the Nyhus classification system that categorizes hernia defects by location, size and type, Type IIIC represents
Femoral hernia
- Type I - Indirect hernia; internal abdominal ring normal; typically in infants, children, small adults
- Type II - Indirect hernia; internal ring enlarged without impingement on the foot of the inguinal canal; does not extend to the scrotum
- Type IIIA - Direct hernia; size is not taken into account
- Type IIIB - Indirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are usually placed in this category because they have are commonly associated with extension to the direct space; also includes pantaloon hernias
- Type IIIC - Femoral hernia
- Type IV - Recurrent hernia; modifiers A-D, which correspond to indirect, direct, femoral, and mixed respectively
Taxis
Shoul be used for incarcerated hernias without sequelae or strangulation
- Incarceration occurs when hernia contents fail to reduce
- analgesics and light sedatives are administered, and the patient is placed in the trendelenburg position
- Indication for emergent inguinal hernia reair is impending compromise of intestinal contents
- Stangulation of hernia
- fever, leukocytosis, and hemodynamic isntability
- hernia bulge is usually warm and tender
- erythematous or discolored skin
- taxis should not be attempted
Ahernia sac that extends into the scrotum may ____-
Require division within the inguinal canal
- extensive dissection and reduction risks injury to the pampiniform plexus resulting in testicular atrophy and orchitis
- In cases where the viability of sac contents is in question, the sac should be incised and hernia, contents should be evaluated for signs of ischemia
The technique indicated for femoral hernias in cases where prosthetic material is contraindicated
The mcvay repair
- addresses both inguinal and femoral ring defects
- once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space
- The upper flap is mobilized
- Cooper ligament is bluntly dissected
- a 2 -4cm relaxing incision is made in the anterior rectus sheath vertically from the pubic tubercle
- The superior tranersalis flap is then fastened to the cooper ligament
- Transversalis then sutured to the inguinal ligament
General anesthesia induction resulting in reduction of an incarcerated or strangulated inguinal hernia during laparoscopic repair
Required abdominal exploration for nonviable tissue
- Laparascopic inguinal hernia repairs
- posterior approach
- Transabdominal preperitoneal (TAPP), totally extraperitoneal repair (TEP), Intraperitoneal onlay mesh (IPOM)
- general anesthesia
Medical issues associated with hernia
- Malnutrition
- immunosuppression
- diabetes
- steroid use
- smoking
alcohol use is not associated with recurrence
When a recurrent hernia is discovered and warrants reoperation, an approach through a virgin plane facilitates its dissection and exposure
Nociceptive pain
Results of ligamentous or muscular trauma and inflammation
- Nociceptive pain - most common
- Neuropathic pain
- result of direct nerve damage or entrapment.
- localized, sharp, burning or tearing sensation
- pharmacologic and to local steroid or anesthetic injections when indicated
- Visceral pain
- pain conveyed through afferent autonomic pain fibers
- poorly localized and may occur during ejaculation as a result of sympathetic plexus injury
The triangle of Pain is bordered by
Iliopubic tract, gonadal vessels, reflected peritoneum
-
Triangle of doom
- medially by the vas deferens and laterally by the vessels of the spermatic cord
- external iliac vessels, deep circumflex iliac vein, femoral nerve and genital branch of the genitofemoral nerve
-
Triangle of pain
- Iliopubic tract, gonadal vessels, reflected peritoneum
- lateral femoral cutaneous femoral branch of the genitofemoral and femoral nerves
-
Circle of death
- vascular continuation formed by the common iliac, internal iliacm obturator, inferior epigastric, and external iliac vessels
The msot common cause of urinary retention after hernia repair is
General anesthesia
- Other risk factors
- pain, narcotic analgesia, and perioperative bladder distention
- Initial treatment
- decompression of th ebladder with short term catheterization
- requires overnight admission and trial of normal voiding before discharge
The outcome found more commonly with TAPP repair compared with TEP repair is
Risk of intraabdominal injuries
- TAPP should only be attempted by surgeons with sufficient experience
The ratio of inguinal hernias to femoral hernias
5:1
The high incidence of inguinal hernias in preterm babies is most often due to _________-
failure of the peritoneum to close
Injury to the lateral femoral cutaneous nerve results in
Meralgia paresthetical
- treatment includes rest, ice, NSAIDs, physical therapy, and possible local corticosteroid and anesthetic injection
- Osteitis pubis
- inflmaation of the pubic symphysis and usually presents as medial groind or symphyseal plain that is reproduced by thigh adduction
The hernia repair method associated with the lowest recurrence rate is the
Lichtensein tension free repair
-
Shouldice operation
- most commonly performed technique
- most frequently executed at specialized center
- longer operative duration, and longer hospital stay
- most effective if tissue based repair when mesh is unavailable or contraindicated
-
Lichtensein tension-free repair
- shorter and faster return to usual activities
- recurrence rate is 0.2%
-
Stoppa technique
- Longer operative duration
- nonexpert surgeons rapidly achieve similar outcomes to their extpert counterparts
A sliding hernia
Can involve the baldder
