38: Hernias, Abdomen, and Surgical Technology Flashcards
Which tumor is locally invasive with a high rate of recurrence and commonly presents as a painless mass in a woman with Gardner’s syndrome?
Desmoid tumor
[UpToDate: Desmoid tumors (also called aggressive fibromatosis) are benign, slowly growing fibroblastic neoplasms with no metastatic potential but a propensity for local recurrence, even after complete surgical resection. Despite being histologically benign, they are locally infiltrative and can cause death through destruction of adjacent vital structures and organs.
The risk of desmoids is increased in patients with familial adenomatous polyposis (FAP). Given the association with FAP, at some institutions, colonoscopy is recommended for all patients with desmoid tumors, particularly intraabdominal.
Treatment of desmoids can be a clinical challenge, particularly in patients with FAP who tend to develop intraabdominal desmoids at sites of prior surgery. Because of their locally aggressive behavior and tendency to relapse with more aggressive disease, multimodality treatment is often required for these benign lesions and is best delivered within the context of a multidisciplinary team specializing in sarcoma treatment.
Extraabdominal and abdominal desmoids tend to occur in women during or following pregnancy. If a woman had a desmoid arise during a prior pregnancy and the desmoid was resected, the recurrence risk during future pregnancies is low. If woman had an existing desmoid (pregnancy-associated or predating any pregnancy) that was managed with watchful waiting, that desmoid can grow during a subsequent pregnancy, but not always. The risk to the pregnancy is very low, and the course of the pregnancy may be relatively normal.]
What are the following characteristics of inguinal hernia repair?
- Most common early complication following inguinal hernia repair
- Wound infection rate
- Recurrence rate
- Most common early complication following inguinal hernia repair: Urinary retention
- Wound infection rate: 1%
- Recurrence rate: 2%
What are the following characteristics of a femoral hernia?
- Risk of incarceration
- More common in males or females
- Herniation medial or lateral to the femoral vein
- Location of characteristic bulge
- Repair technique
- Risk of incarceration: High
- More common in males or females: Males
- Herniation medial or lateral to the femoral vein: Medial
- Location of characteristic bulge: Anterior-medial thigh below the inguinal ligament
- Repair technique: McVay (Cooper’s ligament) repair
What are the boundaries of the femoral canal?
- Posterior: Cooper’s ligament
- Anterior: Inguinal ligament
- Lateral: Femoral vein
- Medial: Lacunar ligament
Which muscle/facia forms each the following structures?
- Shelving edge of inguinal ligament
- Cremasteric muscles
- Floor of inguinal canal
- Conjoined tendon
- Shelving edge of inguinal ligament: External oblique fascia
- Cremasteric muscles: Internal oblique muscle
- Floor of inguinal canal: Transversalis muscle and conjoined tendon
- Conjoined tendon: Aponeurosis of internal oblique and transversalis muscles
Which disease of the abdomen can occur with hypersensitivity to methysergide (drug formerly used for prophylaxis of cluster/migraine headaches) and can cause symptoms from trapped ureters and lymphatic obstruction?
Retroperitoneal fibrosis
[UpToDate: Retroperitoneal fibrosis is a rare disease presenting insidiously, often making the diagnosis difficult. Retroperitoneal fibrosis is most often idiopathic, but drugs, infections and malignancies, prior surgeries, radiation therapy for malignancy, smoking, and asbestos exposure have been implicated.
Idiopathic retroperitoneal fibrosis is an immune-mediated disease, which can either be isolated, associated with other autoimmune diseases, or arise in the context of immunoglobulin G4-related disease (IgG4-RD).
The pathogenesis of idiopathic retroperitoneal fibrosis is unclear. The two leading theories are that the disease is either an exaggerated local inflammatory reaction to aortic atherosclerosis or a manifestation of systemic autoimmune disease.
Symptoms may include pain over the flank, lower back, or abdomen; nonspecific systemic complaints; and lower extremity edema. Often, the diagnosis is not considered until a patient is evaluated for obstructive uropathy and renal insufficiency. Most patients have an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level.
The diagnosis of retroperitoneal fibrosis is primarily made via imaging by computed tomography (CT) scan, but should be confirmed by biopsy in patients who do not have typical findings on CT scan. We also suggest performing a biopsy on patients who have clinical or laboratory abnormalities suggesting infection or malignancy, or if local experience with retroperitoneal fibrosis is limited, or if the patient does not respond to initial therapy.
The differential diagnosis of retroperitoneal fibrosis primarily includes other causes of obstructive nephropathy and retroperitoneal masses.
Once the diagnosis of retroperitoneal fibrosis has been established, secondary causes should be excluded. A history of radiation therapy or prior surgeries such as lymphadenectomy, colectomy, or aneurysmectomy should be excluded. Exposure to ergot-derivatives, methysergide, bromocriptine, beta blockers, methyldopa, hydralazine, analgesics, and biologic agents should be excluded.
A contrast-enhanced CT or MR of the chest, abdomen, and pelvis should be obtained to evaluate for malignancies, infections, and other vascular territories involved. Among patients who have no evidence of infection or malignancy and who have a history of use of medications that have been associated with retroperitoneal fibrosis, further evaluation for secondary causes is generally not done. Among patients who have no history of radiation therapy, prior surgery, or drug exposure and no evidence of infection or malignancy by imaging, we generally perform a biopsy of the retroperitoneal mass (if one has not been done already) in order to exclude infections and malignancies and Erdheim-Chester disease.]
What is the treatment for a CO2 embolus?
- Head down
- Turn patient to the left (left side down)
- Can attempt to aspirate CO2 through central line if present
- Prolonged CPR if necessary
Which type of hernia is described below?
- Inguinal hernia inferior/medial to the epigastric vessels
- Inguinal hernia superior/lateral to the epigastric vessels
- Most common inguinal hernia
- Inguinal hernia with direct and indirect components
- Inguinal hernia inferior/medial to the epigastric vessels: Direct hernia
- Inguinal hernia superior/lateral to the epigastric vessels: Indirect hernia
- Most common inguinal hernia: Indirect hernia
- Inguinal hernia with direct and indirect components: Pantaloon hernia
Spigelian hernias occur at lateral border of the rectus muscle, near which landmark?
Linea semilunaris
[Almost always inferior to the arcuate line (semicircularis). It occurs between the muscle fibers of the internal oblique muscle and the insertion of the external oblique aponeurosis into the rectus sheath.]
[UpToDate: A Spigelian hernia occurs along the semilunar line, which is the caudal most extent of the posterior rectus sheath. This anatomic location is weak because of the absence of a posterior sheath behind the rectus muscle. Spigelian hernia is well described, but relatively rare. It is likely that these hernias will become more frequently diagnosed, as they are readily seen on computed tomography scans as well as laparoscopic views of the anterior abdominal wall.
As the hernia develops, preperitoneal fat emerges through the defect in the Spigelian fascia, bringing an extension of the peritoneum with it through the fascia. The hernia is nevertheless covered by the intact external oblique aponeurosis. For this reason, almost all Spigelian hernias are interparietal in nature, and only rarely will the hernia sac lie in the subcutaneous tissues anterior to the external oblique fascia. The hernia cannot develop medially due to resistance from the intact rectus muscle and sheath. Therefore, a large Spigelian hernia is most often found lateral and inferior to its defect in the space directly posterior to the external oblique muscle.
Accurate diagnosis of Spigelian hernias by physical examination is quite challenging. The patient most often presents with a swelling in the mid to lower abdomen, just lateral to the rectus muscle. The patient may complain of a sharp pain or tenderness at this site. The hernia is usually reducible in the supine position. The reducible mass may be palpable, even if it is below the external oblique musculature. Up to 20% of Spigelian hernias will present incarcerated.
Ultrasound is the most reliable and easiest imaging modality to assist in the diagnostic workup. Even if the hernia is fully reduced during examination and no mass is palpable, ultrasound can show a break in the echogenic shadow of the semilunar line associated with the fascial defect. Ultrasound can also identify the nonreduced hernia sac passing through the defect in the Spigelian fascia. Computed tomography scanning of the abdomen will also confirm the presence of a Spigelian hernia. The anatomy of the Spigelian hernia should make it readily apparent on laparoscopic evaluation of the anterior abdominal wall.
Given the frequency of bowel obstruction, repair is generally recommended once the hernia is diagnosed. Surgery is usually performed under general anesthesia. A transverse incision is made directly over the palpable mass or fascial defect. A hernia in the subcutaneous space will be immediately obvious, whereas an interparietal hernia will require deeper dissection. The external oblique muscle is split to identify the sac posterior to it. The sac is isolated, opened, and the contents reduced. The sac can be excised or inverted depending upon its size. The defect is closed by suturing the medial and lateral edges of the internal oblique and transversus abdominis aponeuroses, which approximates the internal oblique and transverses fascia laterally to the rectus sheath medially. Although the use of mesh plugs to close the hernia defect has been described, prosthetic mesh is not required for this repair. Laparoscopic repair has also been performed successfully, following previously described techniques for incisional hernia. Recurrence is uncommon.]
What are the #1 and #2 most common malignant retroperitoneal tumors?
- # 1 Lymphoma
- # 2 Liposarcoma
What is the treatment for retroperitoneal fibrosis?
- Steroids
- Nephrostomy if infection is present
- Surgery to free up ureters and wrap in omentum if renal function becomes compromised
[UpToDate: Retroperitoneal fibrosis is an uncommon cause of obstructive uropathy. Untreated patients may develop severe complications or progress to end-stage renal disease (ESRD). The goals of therapy are to relieve the obstruction, stop the progression of the fibrotic process, and prevent recurrence.
In patients with significant renal dysfunction due to obstruction of the urinary tract by retroperitoneal fibrosis, as with any other cause of obstructive uropathy, we recommend immediate relief of obstruction (Grade 1A). A variety of surgical interventions are available (open or laparoscopic surgical, percutaneous or endoureteral); open and laparoscopic interventions may be associated with significant risks and complications, whereas percutaneous and endoureteral techniques appear to be safer.
In patients with retroperitoneal fibrosis who have hydronephrosis but no significant impairment in renal function, we suggest initiating a trial of medical therapy without surgical intervention (Grade 2C). If a surgical procedure has been deferred, renal function should be closely followed, and sequential ultrasonography should be performed every two to four weeks to monitor for progression of obstruction. These patients should be referred for surgical decompression of the urinary tract if there is deterioration of kidney function or if there is no improvement or worsening of the hydronephrosis.
Medical therapy of retroperitoneal fibrosis depends upon the cause. Therapy for secondary retroperitoneal fibrosis is aimed at treating the underlying etiology or stopping the offending agent, although some cases of drug-induced disease respond to immunosuppressive therapy.
In patients with idiopathic retroperitoneal fibrosis, we recommend induction therapy with one month of high-dose prednisone, followed by maintenance therapy with tapering doses of prednisone (Grade 1B). If there is a contraindication to prednisone therapy, we suggest initial therapy with tamoxifen (Grade 2C).
Within a few days of beginning glucocorticoid therapy, pain and constitutional symptoms usually improve, and the erythrocyte sedimentation rate should fall dramatically. Improvement in urinary tract obstruction indicated by diuresis or by ultrasound may be observed within a few weeks, and resolution of the mass by computed tomography (CT) may begin within a few weeks of initiating medical therapy.
After one month of therapy, we evaluate patients for resolution of symptoms and also perform CT and laboratory studies (including assessments of renal function, erythrocyte sedimentation rate, and C-reactive protein). If regression of disease is noted at one month, we continue maintenance therapy for another 6 to 18 months, depending upon the severity of disease and speed of resolution. After the first month, we repeat the evaluation every two to three months, or more frequently as dictated by symptoms. Following discontinuation of steroids (or other immunosuppressive agents), we monitor for disease relapse by obtaining a renal ultrasound, erythrocyte sedimentation rate, C-reactive protein level, and serum creatinine concentration every three to six months and a CT scan every six months for the first year. Thereafter, we evaluate patients every 6 to 12 months and perform a CT scan every one to two years.
In patients with idiopathic retroperitoneal fibrosis who fail to achieve clinical or radiologic improvement within four to six months of initiating prednisone therapy, we suggest adding therapy with methotrexate or mycophenolate mofetil (Grade 2C).
Full resolution of the associated manifestations may depend in part on the duration of entrapment. As an example, renal insufficiency may persist despite relief of obstruction if there has been permanent renal damage. In patients with idiopathic retroperitoneal fibrosis who respond to steroids, mortality is less than 10%.]
Between direct and indirect inguinal hernias, which is characterized by each of the following?
- Higher recurrence rate
- Results from a persistently patent processus vaginalis
- Lower risk of incarceration
- Rarely occurs in females
- More common
- Higher recurrence rate: Direct inguinal hernia
- Results from a persistently patent processus vaginalis: Indirect inguinal hernia
- Lower risk of incarceration: Direct inguinal hernia
- Rarely occurs in females: Direct inguinal hernia
- More common: Indirect inguinal hernia
What is it called when a the mesentery of viscera or viscera itself makes up part of the wall of the hernia sac and which organ/viscera is most common in males and females?
- A sliding hernia
- Males: Cecum or sigmoid is most common
- Females: Ovaries or fallopian tubes are most common
[Bladder can also be involved.]
[UpToDate: If all contents of the sac cannot be reduced, adhesions of viscera to the sac or a sliding component may be present.
A sliding hernia is one in which a portion of the wall of the hernia sac is composed of the mesentery of viscera or viscera itself. The visceral component can be ovary, fallopian tube, cecum, appendix, sigmoid colon, bladder, ureter, or only the preperitoneal fat associated with any of these structures. When the cecum, terminal ileum, appendix, or sigmoid colon contributes to the sac, they present laterally and posteriorly. The urinary bladder and ovary present as medial components of the sac. Ovaries frequently incarcerate without truly sliding. When a true slide is encountered, the sliding component must still be separated from the rest of the sac. When the appendix contributes as a sliding component of a hernia sac, we do not recommend removal of the appendix.
Sliding hernias are rarely direct except in the case of the urinary bladder. Direct sliding hernias require no special techniques, since the sac, including the sliding component, can be inverted behind a purse string suture.
The essence of the repair of sliding indirect inguinal hernias is the peritonealization of the sliding component. Peritonealizing the extra-peritoneal surface is not required as long as the base at the level of the internal ring is incorporated in the high ligation of the sac. Regardless of the size or source of the sliding component of the sac, the approach described below, a modification of either the Bevan or the LaRoque technique, is always applicable.
The sliding hernia sac should be opened with caution. The surface of the mesentery and enteric organ are covered with peritoneum and serosa, respectively, which will only be present inside of the hernia sac. The outer surface, having been extraperitoneal prior to herniation, has no peritoneal or serosal layer. Once the hernia sac is entered, the serosalized surface of the sliding organ will be seen. The sliding component is separated from the rest of the sac, leaving a 1 centimeter circumferential cuff of adjacent sac attached, which will be used to peritonealize the extraperitoneal surface. This peritonealization is accomplished by everting the cuff and approximating its everted margins edge-to-edge with a running suture beginning at the apex and continuing to the level of the internal ring. The sliding component is now totally peritonealized and ready to assume its intraperitoneal location. The organ is reduced through the internal ring into the abdominal cavity. On rare occasions, ligation of the deep epigastric vessels and/or enlargement of the internal ring medially by incising the conjoined tendon may be required to accommodate a bulky sliding component. Beginning at the termination of the previously completed peritonealizing suture, the remaining peritoneal defect is closed at the level of the internal ring while, at the same time, any remaining redundant sac is excised. The procedure can be completed in typical Lichtenstein fashion.]
What is the incidence of vascular or bowel injury with Veress needle or trocar insertion?
0.1%
At what insufflation pressure is there a risk of cardiopulmonary dysfunction?
> 20 mmHg
[Hypovolemia lowers the pressure necessary to cause compromise. PEEP worsens the effects of pneumoperitoneum.]
Which ligaments are described below?
- Ligament found where the inguinal ligament splays out to insert into the pubis
- Ligament that runs on the pectineal line of the pubic bone, posterior to the femoral vessels
- Ligament found where the inguinal ligament splays out to insert into the pubis: Lacunar ligament
- Ligament that runs on the pectineal line of the pubic bone, posterior to the femoral vessels: Coopers ligament (pectineal ligament)
What is a McVay (Cooper’s ligament) repair for an inguinal hernia?
Non-mesh repair utilizing approximation of the conjoint tendon and transversalis fascia superiorly to Cooper’s ligament (pectineal ligament) inferiorly
[Needs a relaxing incision in the external abdominal oblique fascia. Can use this for a femoral hernia repair.]
[UpToDate: The McVay repair can be used for the repair of inguinal or femoral hernias.
The McVay repair is somewhat more technically challenging than the Bassini repair and involves incising the transversalis fascia in the region of Hesselbach’s triangle to enter the preperitoneal space to expose the pectineal ligament (Cooper’s ligament). The conjoined tendon is then sutured to Cooper’s ligament from the pubic tubercle laterally as far as the vicinity of the femoral sheath as it crosses Cooper’s ligament. At that point, a transition stitch is placed incorporating the conjoined tendon, Cooper’s ligament, the femoral sheath at the medial aspect of the femoral vein, and the inguinal ligament (occasionally the femoral sheath cannot be identified and can be excluded).
The remainder of the inguinal floor is repaired by approximating the conjoined tendon to the inguinal ligament extending laterally to the area of the internal ring. This repair generates considerable tension, and requires a relaxing incision. To do this, the anterior rectus sheath behind the external oblique aponeurosis should be exposed from the pubic tubercle cephalad for several centimeters and it is then incised from the pubic tubercle extending cephalad for approximately 6 centimeters along the fusion of the external oblique aponeurosis with the sheath’s other components. This type of relaxing incision can also be used with other non-mesh repairs.]
Where in relation to the cord structures does the vas deferens run?
Medial to the cord structures
What my need to be divided to reduce bowel from a femoral hernia?
The inguinal ligament
[Femoral hernias have a high risk of incarceration.]
What signs and symptoms may manifest with the following nerve injuries during an inguinal hernia repair?
- Ilioinguinal nerve
- Genitofemoral nerve
- Ilioinguinal nerve: Loss of cremasteric reflex, numbness on ipsilateral penis/scrotum/thigh (Usually injured at the external ring)
- Genitofemoral nerve: Impaired motor function of cremaster muscle and imparied sensation to the scrotum (genital branch), Impaired sensation to upper lateral thigh (femoral branch)
[UpToDate: Postsurgical pain lasting more than eight weeks is mostly, but not entirely, neuropathic in character. Neuropathic pain is due to injury to a nerve or to the elements responsible for nerve transmission. The nerves most commonly implicated in post-herniorrhaphy neuralgia are the ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves. Nerve injury can be primary or secondary to an adjacent inflammatory process such as a close association of the nerve with hernia mesh.
Risk factors for chronic groin pain following hernia repair include younger age, female gender, postoperative complications (eg, hematoma, infection), recurrent hernia repair, open repair techniques, history of preoperative pain, and an interval of less than three years from a previous surgery.
A diagnosis of post-herniorrhaphy neuralgia is suspected in patients with persistent groin pain beyond six to eight weeks following inguinal hernia repair despite standard pain management. The clinical triad of burning near an incision or region of dissection radiating along a specific nerve distribution, evidence of impaired sensory perception in the distribution of that nerve, and pain that is relieved by peripheral nerve block strongly support a diagnosis of post-herniorrhaphy neuralgia. Imaging studies (computed tomography or magnetic resonance) are used primarily to exclude nonneuropathic hernia-related pathologies or other non-hernia-related diseases in the differential diagnosis.
In patients with post-herniorrhaphy neuralgia, we manage the pain with multimodal analgesia including a nerve block.
Response to a nerve block, even a transient one, indicates that the pain is likely neuropathic in origin. If a specific groin nerve block (eg, ilioinguinal or iliohypogastric) is reproducibly effective, but the effect is transient, then that nerve can be sacrificed to achieve permanent pain relief. Nerve sacrifice can be attempted first by percutaneous nerve ablation.
For patients who have failed nonsurgical management (including percutaneous nerve ablation), we suggest triple neurectomy rather than excision of fewer nerves, neurolysis (freeing the nerve), or simple nerve division (Grade 2C). Triple neurectomy, which is the combined resection of the ilioinguinal, iliohypogastric, and genitofemoral nerves, permanently relieves chronic groin pain in the majority of patients (up to 95%), but with a loss of inguinal sensation. An open, laparoscopic, or combined approach can be used.
Patients who have persistent or recurrent pain after surgical neurectomy with mesh removal are difficult to manage. Nerve stimulation is an experimental treatment that may be effective for some patients; the rest are managed medically.]
What is the Howship-Romberg sign, what diagnosis does its presence suggest, and what is the treatment?
- Pain with internal rotation at the hip
- Concerning for an obturatory hernia
- Treat with operative reduction and mesh repair (check other side for similar defect)
[More common in elderly women with a previous pregnancy.]
Which type of hernia can present as a tender medial thigh mass with inner thigh pain with internal rotation of the hip?
Obturator hernia
[Pain with internal rotation at the hip is the Howship-Romberg sign.]
[UpToDate: Obturator hernias are a rare type of abdominal wall hernia in which the abdominal contents protrude through the obturator foramen. Weakening of the obturator membrane may result in enlargement of the canal with a defect that is usually anterior and medial to the obturator neurovascular bundle. Factors that increase intra-abdominal pressure are implicated as risk factors. They are more commonly right sided, but can be bilateral. These are much more common in women, usually in the setting of profound weight loss. A pilot tag or properitoneal fat precedes the development of a hernia sac. The hernia sac usually contains small bowel, but may contain large bowel, omentum, fallopian tube, or appendix. In >90% of cases, the diagnosis is made intraoperatively during exploration for bowel obstruction. It can also present as obturator neuralgia (groin pain radiating medially to the knee) due to compression of the obturator nerve, palpable proximal thigh mass (between pectineus and adductor longus muscles), or ecchymosis of the thigh if bowel necrosis has occurred. Obturator hernias may be initially confused as femoral hernias, but can also occur in conjunction with femoral hernia. Nonstrangulated obturator hernias can be repaired using mesh via a posterior preperitoneal approach (open or laparoscopic), which provides direct access to the hernia. Reduction of the hernia may require incision of the obturator membrane. When strangulation is suspected, an abdominal approach is used.]
What is the difference between the abdominal wall above vs below the arcuate line?
- Above arcuate line: Anterior and posterior rectus sheath
- Below arcuate line: Anterior rectus sheath only
[The posterior aponeurosis of the internal abdominal oblique and transversalis aponeurosis move anterior below the umbilicus.]
What are the borders of Hesselbach’s triangle?
- Rectus muscle
- Inferior inguinal ligament
- Inferior epigastrics
