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Surgery.(General 1).Hernia > 6. Treatment of Oblique and Direct inguinal hernia > Flashcards

6. Treatment of Oblique and Direct inguinal hernia Flashcards

1
Q

Treatment of Oblique inguinal hernia

A
  1. Truss

2. Surgical treatment

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2
Q

Disadvantage of Truss in Treatment of Oblique inguinal hernia

A

Predispose to:

  • Strangulation
  • Hydrocele of hernial sac
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3
Q

Surgical treatment in Treatment of Oblique inguinal hernia

A
  • The only curative treatment
  • Modalities
  • Surgical details
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4
Q

Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Herniotomy
  • Herniorrhaphy
  • Hernioplasty
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5
Q

Herniotomy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Principle

* Indication

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6
Q

Principle of Herniotomy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A

Excision of the hernial sac up to the neck.

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7
Q

Indication of Herniotomy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A

This is sufficient in children with congenital hernia when the musculature is good & the only problem is performed sac

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8
Q

Principle of Herniorrhaphy in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A

Repair of the defect by sutures with herniotomy (better) or without herniotomy.

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9
Q

Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Alternative name
  • Principle
  • Advantages
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10
Q

Alternative name of Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A

Lichntenstein repair ليخنشتاين

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11
Q

Principle of Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A

Repair with mesh

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12
Q

Advantages of Hernioplasty in Modalities of Surgical treatment in Treatment of Oblique inguinal hernia

A

Tension free repair )> no recurrence

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13
Q

Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Preoperative preparation :

* Operative

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14
Q

Preoperative preparation in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Treat first any predisposing factor as COPD, BPH

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15
Q

Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Anesthesia
  • Position
  • Sterilization
  • Incision
  • Steps
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16
Q

Anesthesia in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

General / spinal or epidural / local anesthesia

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17
Q

Position in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Supine.

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18
Q

Sterilization in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Betadine from umbilicus to mid-thigh.

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19
Q

Incision in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

1 inch above & parallel to the medial 2/3 of the inguinal ligament

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20
Q

Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  1. Divide skin, S.C tissue & Scarpa’s fascia.
  2. Divide the external oblique aponeurosis in the direction of its fibers
  3. Reflect the ext oblique aponeurosis upwards & downwards.
  4. Identify the ilioinguinal nerve & reflect it over the aponeurosis
  5. The cord is delivered & lifted over a gauze tape.
  6. Divide the cremasteric muscle & internal spermatic fascia
  7. Manipulation of the sac
  8. Herniotomy alone is enough in congenital hernia in infants and children
  9. Herniorrhaphy

or

  1. Hernioplasty
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21
Q

The direction of its fibers in Division of the external oblique aponeurosis in the direction of its fibers in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

from the external ring extending laterally till the internal ring

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22
Q

Reflection of the external oblique aponeurosis upwards in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

to expose the conjoint tendon

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23
Q

Reflection of the external oblique aponeurosis downwards in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

to expose the superior surface of the inguinal ligament.

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24
Q

Identification of the ilioinguinal nerve & its reflection over the aponeurosis in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

as injury of the ilioinguinal nerve at this level causes hypoesthesia in the scrotum only without any paralysis.

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25
Q

Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  1. Identification of The sac
  2. Identification of The neck
  3. Dissection of the sac by sharp & blunt dissection until its neck
  4. Twisting of the sac and its transfixation
  5. Excision of the redundant sac
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26
Q

Identification of The sac in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The sac is known by:

  • Pearly white in colour.
  • Antero-lateral to the vas.
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27
Q

Identification of The neck in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The neck is known by:

  • Lateral to the inferior epigastric vessels
  • The narrowest Part of the sac.
  • Extra-peritoneal fat around it
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28
Q

Twisting of the sac and its transfixation in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • if the sac is not the Processus vaginalis

* if the sac is the Processus vaginalis

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29
Q

if the sac is not the Processus vaginalis in Twisting of the sac and its transfixation in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Transfixation at the deep ring

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30
Q

if the sac is the Processus vaginalis in Twisting of the sac and its transfixation in Manipulation of the sac in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Transfixation of the proximal part

* Eversion of the distal part as in hydrocele.

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31
Q

Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Indication

* Principle

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32
Q

Indication of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Done in adults with good musculature

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33
Q

Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Herniotomy

* Repair of the weak posterior wall of the inguinal canal.

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34
Q

Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Type of sutures used
  • Modalities
  • Note on the modalities
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35
Q

Type of sutures used in Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

interrupted non- absorbable prolene sutures

36
Q

Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  1. Shouldice Repair
  2. Marcy repair
  3. Bassini repair
  4. Lytle repair
37
Q

Shouldice Repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Repair is done by double breasting of the fascia transversalis

38
Q

double breasting of the fascia transversalis in Shouldice Repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  1. The fascia transversalis is opened in the length of the floor of inguinal canal from the pubic tubercle to the internal ring; this creates 2 flaps.
  2. The lower flap is sutured to the undersurface of the upper flap.
  3. The upper flap is sutured to the shelving edge of the inguinal ligament
  4. Finally the fascial part of the conjoint tendon is sutured to the inguinal ligament.
39
Q

the shelving edge of the inguinal ligament in double breasting of the fascia transversalis in Shouldice Repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

It’s the natural extension of the fascia transversalis below

40
Q

Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The transversus abdominis aponeurotic arch is sutured inferiorly to the iliopubic tract

41
Q

The iliopubic tract in Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Alternative name

* Definition

42
Q

Alternative name for The iliopubic tract in Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Thomson’s ligament

43
Q

Definition of The iliopubic tract in Marcy repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The thickened lower part of fascia transversalis.

44
Q

Bassini repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Principle

* Disadvantages

45
Q

Principle of Bassini repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The inguinal ligament is sutured to the conjoint tendon & arched fibres of internal oblique and transversus abdominis muscle

46
Q

Disadvantages of Bassini repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

i. Tension atrophy of conjoint tendon
ii. Interferes with the normal shutter mechanism.
iii. Union & healing is unlikely to occur between the fleshy fibers of the conjoint tendon & the fibrous tissue of the inguinal ligament in the lateral part of the repair.

47
Q

Principle of Lytle repair in Modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Narrowing of the internal ring.

48
Q

Note on the modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

It is recommended to do Tanner’s slide release incision

49
Q

Tanner’s slide release incision in Note on the modalities of Repair in Principle of Herniorrhaphy in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • a relaxing incision in the anterior rectus sheath

* to avoid sutures under tension which may disrupt.

50
Q

Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Alternative name
  • Indications
  • Advantages
  • Mechanism of action
  • Types
  • Types of mesh used
  • Recent trends
51
Q

Alternative name of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Lichtenstein repair

52
Q

Indications of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Done in patients with weak musculoaponeurotic boundaries or wide defect.

53
Q

Advantages of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Most surgeons prefer it now as
  • it is tension free
  • recurrence is rare.
54
Q

Mechanism of action of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The interstices of the mesh will be impregnated with a dense sheet of fibrous tissue.

55
Q

Types of Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

(A) Onlay hernioplasty :

(B) Inlay hernioplasty

56
Q

Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Site of mesh used
  • Fixation of the mesh
  • Gilbert hernioplasty
57
Q

Site of mesh used in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

On the fascia transversalis

58
Q

Fixation of the mesh in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Superior

* Inferior

59
Q

Superior Fixation of the mesh in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

It is sutured to the transversus abdominis aponeurotic arch

60
Q

Inferior Fixation of the mesh in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

It is sutured to the iliopubic tract and inguinal ligament .

61
Q

Gilbert hernioplasty in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Some surgeons recommend application of a mesh plug in the internal ring with lateralization of the cord .

62
Q

lateralization of the cord in Gilbert hernioplasty in Onlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

As the hernia normally descends downwards forwards and medially

So lateralization of the cord is recommended to prevent the descent of hernia

63
Q

Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Alternative names
  • Site of mesh used
  • Approach
64
Q

Alternative names for Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Preperitoneal Hernioplasty

* Stoppa repair

65
Q

Site of mesh used in Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The mesh is placed in the space of Bogros

66
Q

Space of Bogros in Site of mesh used in Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

between the fascia transversalis and the peritoneum

67
Q

Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

a) Open surgery “stoppa repair”

b) Laparoscopic hernioplasty

68
Q

Techniques of Laparoscopic hernioplasty in Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Done by 2 techniques

  • TAPP : Trans-abdominal pre-peritoneal repair.
  • TEP : Totally extra peritoneal repair
69
Q

Trans-abdominal pre-peritoneal repair in Techniques of Laparoscopic hernioplasty in Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Laparoscope enters Abdominal cavity then finally the preperitoneal plane

70
Q

Totally extra peritoneal repair in Techniques of Laparoscopic hernioplasty in Approach of Inlay hernioplasty in Types in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Laparoscope Directly reach preperitoneal plane

71
Q

Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

1- Prolene mesh

2- Vicryl mesh

3- Vypro mesh

72
Q

Advantages of Prolene mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Strong & inert

* Most commonly used

73
Q

Most commonly used mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Prolene mesh

74
Q

Indication of Vicryl mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Used in cases of burst abdomen when there is big muscular defect.

75
Q

Vypro mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Composition

* Advantages

76
Q

Composition of Vypro mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

composed of Vicryl + Prolene

77
Q

Advantages of Vypro mesh in Types of mesh used in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Easily handled and sutured.

* Vicryl will be absorbed within 3 months leaving prolene only

78
Q

Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

Prolene hernia system (PHS)

79
Q

Prolene hernia system (PHS) in Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A
  • Components

* Mechanism of action

80
Q

Components of Prolene hernia system (PHS) in Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

This system consists of an anterior oval prolene mesh connected to a circular posterior prolene mesh.

81
Q

Mechanism of action of Prolene hernia system (PHS) in Recent trends in Hernioplasty in Steps in Operative in Surgical details of Surgical treatment in Treatment of Oblique inguinal hernia

A

The anterior component is inserted on the fascia transversalis & the posterior component is laid pre-peritoneal.

82
Q

Treatment of Direct inguinal hernia

A
  • The only curative Treatment is surgery after correction of any predisposing factors.
  • Operations
83
Q

Operations in Treatment of Direct inguinal hernia

A

As for OIH with the following differences

1- Herniotomy MAY BE NOT NEEDED in the lateral type as the neck is wide (but herniotomy is needed in the medial type)

  1. Invagination of the sac by the repair is enough .

2- Hernioplasty: Best.

84
Q

Pantaloon hernia

A
  • Alternative names

* Definition

85
Q

Alternative names for Pantaloon hernia

A

saddle-bag hernia

86
Q

Definition of Pantaloon hernia

A

sometimes, the patient may have 2 sacs at the same time; one sac passing through the internal ring (oblique) and the other passes through the posterior wall (Direct)

with the inferior epigastric vessels between the 2 sacs

Surgery.(General 1).Hernia (13 decks)

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