SR 36 - Hernias Flashcards Preview

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Flashcards in SR 36 - Hernias Deck (103):
1

What is a hernia?

Protrusion of a peritoneal sac through a musculoponeurotic barrier
A fascial defect

2

What are precipitating factors for hernias?

Increased intra-abdominal pressure (straining at defication or urination, obseity, pregnancy, ascities, valsavagenic (coughing), COPD)
Abdomonal congeintal anatomic route (i.e. patent processus vaginalis)

3

Complications if hernia cannot be repaired?

Incarceration
Strangulation
Bowel necrosis
SBO
Pain

4

Define reducible (hernia)

Ability to return the displaced organ or tissue/hernia contents to their usual antomical site

5

Define incarcerated (hernia)

Swollen or fixed within the hernia sac
An irreducible hernia
May cause intestinal obstruction

6

Define strangulated (hernia)

Incarcerated hernia with resulting ischemia
Symptoms of ischemia and intestinal obstruction or bowel necrosis

7

Define a complete hernia

Hernia sac and its contents protrude all the way through the defect

8

Define an incomplete hernia

Defect present withou sac or contents protruding completely through it

9

Sliding hernia

Hernia sac paritally formed by the wal of a viscus

10

Littre's hernia

Inovles Meckel's diverticulum

11

Spigelian hernia

Through linea semilunaris (aka spigelian fascia)
Spontaneous lateral ventral hernia

12

Internal hernia

Hernia into or involving intra-abdominal structures

13

Petersen's hernia

After bariatric gastric bypass
Internal herniation of small bowel through the mesenteric defect from the Roux limb

14

Obturator hernia

Hernia through the obturator canal
More comon in females

15

Lumbar hernia

Petit's hernia or Grynfeltt's hernia

16

Petit's hernia

Hernia through petit's triangle - AKA inferior lumbar triangle

17

Grynfeltt's hernia

Hernia through Grynfeltt-Lasshaft triangle (superior lumbar triangle)

18

Pantaloon hernia

Hernia sac exists as both a driect and indirect hernia straddling the inferior epigastric vessel

19

Incisional hernia

Hernia through an incisional site
Most common cause is a wound infection

20

Ventral hernia

Incisional hernia in the ventral abdominal wall

21

Parastomal hernia

Hernia adjacent to an ostomy

22

Sciatic hernia

Hernia through the sciatic foramen

23

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

24

Epigastric hernia

Through the linea alba above the umbilicus

25

Umbilical hernia

Through the umbilical ring
Associated with ascites, pregnancy, obseity

26

Intraparietal hernia

Abdominal contents migrate bweteen the layers of the abdominal wall

27

Femoral hernia

Hernia medial to femoral vessels (under inguinal ligament)
Travels beneath teh inguinal ligament down teh femoral canal medial to the femoral vessels

28

Hesselbach's hernia

Hernia under inguinal ligament lateral to femoral vessels

29

Bochdalek's hernia

through posterior diaphragm, usually on the left

30

Morgagni's hernia

Anterior parasternal diaphragmatic hernia

31

Properitoneal hernia

Intraparietal hernia between the peritoneum and transversalis fascia

32

Cooper's hernia

Through the femoral canal and tracking into the scrotum or labia majorus

33

Indirect inguinal hernia

Lateral to Hesselbach's triangle
Travels through the internal ring of the inguinal canal, travling down toward the external ring

34

Direct inguinal hernia

Within Hesselbach's triangle
Travels directly though the abdominal wall (not through the internal ring)

35

Hiatal hernia

Through esophageal hiatus

36

Amyand's hernia

Hernia sac contains a ruptured appendix

37

What are the boundaris of Hesselbach's triangle?

Inferior epigastric vessels
Inguinal ligament of Poupart
lateral border of the rectus sheath
Peritoneum
Floor consists of internal oblique and transversus abdominis muscle

38

What are the layers of the abdominal wall?

Skin
SubQ fat (camper's fascia)
Scarpa's fascia (membrane)
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia
Preperitoneal fat

39

What is the DDx for a mass in a healed C-section incision?

Hernia
Endometrioma

40

DDx for a groin mass?

LAD, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm (pulsating), EIC (epidermal inclusion cyst), undescended testicle, sarcoma, hernias, testicle torsion

41

What is the cause of a direct inguinal hernia?

Acquired defect from mechanical breakdown over the years

42

What nerve runs with the spermatic cord in the inguinal canal?

Ilioinguinal nerve

43

What is the cause of indirect inguinal hernia?

Patent processus vaginalis

44

How is an inguinal hernia diagnosed?

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

45

DDx of an inguinal hernia?

LAD, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess

46

What is the risk of strangulation with inguinal hernias?

Higher with indirect than direct inguinal hernia
But highest in femoral hernias

47

What is the treatment for inguinal hernias?

Emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present
Uncomplicated hernias can have elective herniorrhaphy to prevent the change of incarceration/strangulation

48

Inguinal hernia repair - describe the procedure:
Bassini

Sutures approximate relfection of inguinal ligament to the transversus abdominis aponeurosis/conjoint tendon

49

Inguinal hernia repair - describe the procedure:
McVay

Cooper's ligament sutured to transversus abdominis aponeurosis/conjoint tendon

50

Inguinal hernia repair - describe the procedure:
Lichtenstein

Tension free repair using mesh

51

Inguinal hernia repair - describe the procedure:
Shouldice

AKA Canadian repair
Imbrication of the floor of the inguinal canal

52

Inguinal hernia repair - describe the procedure:
Plug and patch

Place a plug of mesh in hernia defect adn then overlay a patch of mess over inginal floor (few if any stitches)

53

Inguinal hernia repair - describe the procedure:
High ligation

Used in children only
Ligation and transection of indirect ehrnia sac without repair of inguinal floor

54

Inguinal hernia repair - describe the procedure:
TAPP procedure

Transabdominal preperitoneal inguinal hernal repair

55

Inguinal hernia repair - describe the procedure:
TEPA procedure

Totally extraperitoneal appraoch

56

What are teh indication for laparoscopic inguinal hernia repair?

- Bilateral inguinal hernias
- Recurring hernia
- Need to resume full activity as soon as possible

57

Surgical inguinal hernia repair:
What is the first identifiable subcutaneous named layer?

Scarpa's fascia

58

Surgical inguinal hernia repair:
What is the name of the subcutaneous vein that is ligated?

Superficial epigastric vein

59

Surgical inguinal hernia repair:
What happens if you cut the ilioinguinal nerve?

Numbness of inner thigh or lateral scrotum
Goes way in 6 months

60

Surgical inguinal hernia repair:
From what abdominal muscle layer if the cremaster muscle derived?

Internal oblique muscle

61

Surgical inguinal hernia repair:
From what abdominal muscle layer is the inguinal ligament derived?

External oblique msucle aponeurosis

62

Surgical inguinal hernia repair:
To what does the inguinal ligament attach?

Anterior superior iliac spine to the pubic tubercle

63

Surgical inguinal hernia repair:
Which nerve travels on the spermatic cord?

Ilioinguinal nerve

64

Surgical inguinal hernia repair:
Why do some surgeons deliberatly cut the ilioinguinal nerve?

With preoperative consent, they cut it to remove the risk of entrapment and postoperative pain

65

What is in the spermatic cord?

Cremasteric muscle fibers
Vas deferens
Testicular artery
Testicular pampiniform venous plexus
+/- Hernia sac
Genital branch of the genitofemoral nerve

66

What is the inguinal hernia sac made of?

Peritoneum (direct)
Patent processus vaginalis (indirect)

67

What attaches the testicle to the scrotum?

Gubernaculum

68

What is the most common organ in an inguinal hernia sac in men?

Small intestine

69

What is the most common organ in an inguinal hernia sac in women?

Ovary/fallopian tube

70

What lies in the inguinal canal in the female instead of the VAS?

Round ligament

71

Where in the inguinal canal does the hernia sac lie in relation to the other structures?

Anteromedially

72

What is a 'cord lipoma'?

Reperitoneal fat on the cord structures (pushed in by the hernia sac)
Not a real lipoma
Remove surigcally

73

What is a small outpouching of testicular tissue off of the testicle?

Testicular appendage, AKA appendix testes
Remove with electrocautery

74

What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?

remove teh suture as soon as possible and apply pressure.
Do NOT tie the suture down

75

What nerve travels within the spermatic cord/

Genital branch of the genitofemoral nerve

76

Surgical inguinal hernia repair:
What is a 'relaxing incision'?

Incision in the rectus sheath to relax the conjoint tendon so that it can be approximated ot the reflection of the inguinal ligament without tension

77

What is the conjoint tendon?

Aponeurotic attachments of the 'conjoining' of the internal oblique and transversus abdominis to the pubic tubercle

78

Surgical inguinal hernia repair:
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 ring shoudl allow entrance of a finger)

79

What percentage of the strenght of an inginal floor repair does the external oblique aponeurosis represent?

NONE

80

What are the boundaries of teh femoral canal?

Cooper's ligament posteriorly
Inguinal ligament anteriorly
Femoral vein laterally
Lacunar ligament medially

81

What factors are you associated with femoral hernias?

Women, pregnancy, exertion

82

What are the complications of femoral hernias?

1/3 incarcerate - due to narrow neck

83

What is the most common hernia in women?

Indirect inguinal hernia

84

What is the repair of a femoral hernia?

McVay (Cooper's ligament repair)
Mesh plug repair

85

Should elective TURP or elective herniorrhaphy be performed first?

TURP

86

Why type of esophageal hiatal hernia is associated with GE reflux?

Sliding esophageal hiatal hernia

87

How can incarcerated hernias be reduced in the ER?

Apply ice to area
Sedate
Use trendelenburg position for inguinal hernias
Apply steady gental manual pressure
Admit and observe for signs of necrotic bowel after reduction
Perform surgical herniorrhaphy ASAP

88

What do you do if you cannot reuce an incarcerated hernia with steady, gentle compression?

Go to OR for repair

89

What is the Howship-Romberg sign?

Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia

90

What is the 'silk glove' sign?

Inguinal hernia sac in infant feels like a finger of a silk glove when rolled under the examining finger

91

What must yuo do before leaving the OR after an inguinal hernia repair?

Pull the testicle back down to the scrotum

92

Define Type I and Type II hiatal hernias

Type I - Sliding
Type II - paraesophageal

93

What is a sliding esophageal hiatal hernia?

Type I - sliding
Stomach and GE junction herniate into the thorax via the esophageal hiatus

94

Symptoms of a sliding esophageal hiatal hernia?

Generally asymptomatic.
But can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration

95

How is a sliding esophageal hiatal hernia diagnosed?

UGI series
Manometry
Esophagogasroduodenoscopy (EGD) with biopsy for esophagitis

96

What are complications of esophageal hiatal hernias?

Reflux --> esophagitis --> barrett's esophagus --> cancer and stricture formation
Aspiration pneumonia
UGI bleeding from esophageal ulcerations

97

Treatment for esophageal hiatal hernias?

85% treated medically - H2 blockers, PPIs, head elevation after meals, small meals, no food prior to sleeping
15% - surgery for persistent symptoms despite medical treatment

98

What is the surgical treatment for esophageal hiatal hernias?

Laproscopic Nissen Fundoplication
Wrap the fundus around the LES and suture it in place

99

What is a paraesophageal hiatal hernia?

Type II hiatal hernia
Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the GE junction

100

Symptoms of a paraesophageal hiatal hernia?

Mechanical obstruction - dysphagia, stasis gastric ulcer, strangulation
NOT associated with reflux as the GE junction is normal

101

What are the complications of a paraesophageal hiatal hernia?

Surgical, because of frequency and severity of potential consequences

102

What is a type III hiatal hernia?

Combination of type I and type II

103

What is a type of IV hiatal hernia?

Organ (i.e. colon or spleen) +/- stomach in the chest cavity