Abdominal Wall Flashcards
Def hernia
Protrusion of an organ through a defect in the wall of the cavity containing it, into an abnormal position
Reducible hernia
The contents of the hernia can be completely replaced into the cavity
Irreducible hernia
Contents of the hernia can’t be completely replaced into the cavity
Obstructed hernia
Bowel contents can’t pass through the hernaited bowel
Strangulated hernia
There is ischaemia of contents of hernia (b/c constructed vv return) - which unless relived –> gangrene + perforation
Incarcerated hernia
Contents of hernia sac = stuck inside by adhesions
Mx hernia if irreversible
Elective surgery - Lichenstein repair mesh technique being gold standard
Mx of hernia if strangulated/obstructed
Emergency Hartmanns procedure
Mx congenital inguinal hernia in infants
Herniotomy + ligation processus vaginalis at 1y
What is the inguinal canal formed from?
Relocation of testes during foetal development
what does the inguinal contain?
3aa
3nn
3 other
3aa contained in the inguinal canal
testicular/ovarian aa
aa to vas deferens
cremasteric aa
3 nn contained in the inguinal canal
genital branch genitofemoral
ilioinguinal
sympathetic nn
what are the 3 other structures contained in the inguinal canal
vas deferens/ round ligament uterus
pampiniform plexus
testicular lymphatics
what are the 3fascial coverings related to the mm layers of the abdomen
Internal spermatic fascia
Cremasteric fascia
External spermatic fascia
Where is the deep inguinal ring located
1cm superior to mid point of inguinal ligament
WHere is the midpoint of the inguinal ligament
Halfway between ASIS to PT
where is the mid inguinal point
Halfway between ASIS to PS
Where is the superficial inguinal ring located
1cm superior.+ lat to PT
what are the 4 boundaries of the inguinal ligament
Superior wall M
Anterior wall A
Inferior wall L
Posterior wall T
superior wall inguinal ligament (2Mms)
Int oblique
Transversus abdominalis
anterior wall inguinal ligament (2 aponeurosis)
Aponeurosis of: int oblique + ext oblique
Inferior wall inguinal ligament (2 ligaments)
lacunar ligament
inguinal ligament
posterior wall inguinal ligament (2 Ts)
Transversalis fascia
Conjoint tendon
What % of inguinal hernias are indirect
66%
What is the hernia covered by in indirect inguinal hernia
processus vaginalis
all 3 fascia coverigns
Where does indirect inguinal hernia exit
exits superficial ring inside cord . can pass into scrotum
Why are indirect inguinal hernias more likely to strangulate
B/c superficial ring is not dilated
Direct inguinal hernia
Contents pass through weakness in anterior abdo wall in inguinal triangle
Cause direct inguinal hernia (4)
chronic cough
straining at micturition/defacation
heavy lifting
smoking
coverings direct inguinal hernia
peritoneium + transveralis fascia
Exit direct inguinal hernia
Exits superficial ring lateral to the cord
Ix if you cannot feeel the inguinal hernia
USS
How is absolute differentiation between the 2 rtypes of inguinal hernia achieved
in theatre
indirect passes lateral to inf epigastric aa
direct passes medial to inf epigastric aa
Physical findings inguinal hernia
Ask pt to cough /
Scrotal continuation
Increased bowel sounds
features of incarcerated inguinal hernia (4)
Constipation
Distention
Vomiting
Pain
Which sex is femoral hernia more common in
F
borders of the femoral triangle
SUP: inguinal ligament
LAT: med border of sartorius
MED: lat border of adductor longus
What does the femoral triangle contain
NAVY (lat to med)
Femoral nn
Femoral aa
Femoral vv
What is the femoral sheath
inferior prolongation of transversalis/iliapsoas fascia that passes deep to inguinal ligament to allow passage of female aa/vv into triangle
Where is the femoral canal
At medial extremity of femoral sheath
where does bowel exit the abdominal cavity in a femoral hernia
femoral ring
Why is there a high risk of strangulation/obstruction in femoral hernia
Femoral canal is v small w/ strong borders
What is a Richter’s hernia
Hernia involving only 1 sidewall of bowel + not bowel lumen
Where is a Richter’s hernia particularly likely
Femoral sac
Sx femoral hernia
globular lump below + lat to PT
What % femoral hernia present as an emergency
50%
If a femoral hernia is hard and tender - what has likely happened
Strangulation.obstruction
DDx lump in groin (6)
Inguinal hernia Lipoma Femoral aa aneurysm Saphenous ovarix Psoas abscess LN
what are true umbilical hernias due to
incomplete closure of umbilical cicatrix
Which babies are more at risk of true umbilical hernias? (3)
Black
Male
Premature
Sx true umbilical hernia
Usually asymp
What % umbilical hernia retract by age 2
90%
what is a paraumbilical hernia
Acquired hernia that occurs just above/below umbilicus
Cause paraumbilical hernia
raised IAP
Who is paraambulical hernia more common in
Obese, middle aged, multiparous F
PS paraumbilical hernia
localised dragging pain
Enlarged hernia over time
Tender
Mx paraumbilical hernia
Early operative
Excision of sac + stitching of rectus sheath = Mayo’s operation
What % of hernias are incisional
10%
Pre-op RF incisional hernias (7)
Old age Poor nutrition Sepsis Uraemia jaundice obesity steroids
Operative RF incisional hernia (3)
Veritcal incisions
KNots that are too loose/tight
Presence of drains
Postop RF incisional hernia (4)
Post op ileus
Coughing
Obesity
Wound infections
Sx incisional hernia
Bulge in scar
Local discomfort
Which type of incision most commonly leads to incisional hernia
midline laparotomy scars
Def epigastric hernia
1 or > protrusions through linea alba above umbilicus usually containing only extraperitoneal fat
What % epigastric hernia are asymp
75%
When is pain of an epigastric hernia worst
On physical exertion
After meals
What is divarification of rectus mm
when the rectus mm do not meet at the midline of linea alba - hence split apart when pt flexes abdo mm
Who gets divarification of rectus mm
Obese men
Parous F
People w/ chronically raised IAP
