abdominal wall and hernia Flashcards
hernia
protrusion of all or part of a structure through the tissues that normally contain it
what nerve is most frequently injured during an open inguinal hernia repair
ilioinguinal nerve
injury to genitofemoral nerves can leave permanent
numbness to the groin, scrotum and anterior thigh
layers of the abdominal wall
skin, subcutaneous tissue, ext oblique, int oblique, transversus muscle, transversalis fascia, peritoneum
most widely used abdominal incision
midline vertical incision; through the line alba; no vasculature; choice in trauma or lack of preop dx
incision of choice for pecs surgery
transverse incision; made along Langer’s lines= better cosmetic scars; postop coughing/exercise close incision rather than open it
what are retroperitoneal incisions used for
access to aorta and vessels, kidneys, and anterior spine
what incision is most prone to herniation or disruption
paramedian incision
what incision is used for obstetric, gyn, and urologic procedures
pfannenstiel incision
incision for appendix
McBurney*, rocky davis
what is there a risk of if hernia originates through a relatively small aperture
incarceration since can’t be reduced back into abd cavity
mc cause bowel obstruction in ppl who have not had previous abdominal surgery
incarcerated hernia
strangulation
vascular compromise of an incarcerated organ; result is bowel necrosis which can lead to perforation
when should strangulation be suspected
erythema of overlying skin, tachycardia, fever, elev wbc
bowel, omentum, or another intra-abdominal organ protrudes through the internal inguinal ring descending within the continuous peritoneal coverage of a patent processus vaginalis, which is anteromedial to the spermatic cord
indirect inguinal hernia
hernia lateral to epigastric vessels
indirect inguinal hernia
what is necessary for an indirect hernia to dev
patency of the processes vaginalis
causes of indirect inguinal hernias
lifting, coughing, constipation
workup of man >50 presenting w new hernia
rectal exam w palpation of prostate, hemoccult , routine screening colonoscopy
mc hernias in both sexes and all ages
indirect hernias
which side to indirect hernias occur more on
right because of delayed descent of that testicle
hernia bulges directly through the posterior inguinal wall
direct inguinal hernia
bulge medial to inferior epigastric vessels and are not assoc w patent processus vaginalis
direct hernia
portion of the posterior inguinal wall through which a direct hernia occurs
Hesselbach’s triangle: linea semilunaris muscle medially, inferior epigastric vessels superolaterally, and inguinal ligament inferiorly
occur over time as a result of pressure and tension on fascial layers; acquired
direct hernia
hernia more common in older men
direct hernia
predisposition for femoral hernia
short medial attachment of transverses abominis muscle onto Coopers ligament which results in enlarged femoral ring
femoral canal
lacunar ligament medially and femoral vein laterally
femoral triangle
inguinal ligament superiorly, adductor longus muscle medially, and sartorius muscle laterally
hernia much lower in groin and very susceptible to incarceration and strangulation
femoral
occur in pts who have experienced wl as they age
femoral
manual attempt at reduction of groin hernia
pt in Trendelenburg position, pain meds, steady pressure applied to incarcerated hernia, pressure applied in cephalic, lateral, and slightly dorsal direction along course of spermatic cord through the inguinal canal
what should be done after reduction of incarcerated hernia
repair or at minimum admitted to hospital for observation for 12-24 hrs and offered elective repair before discharge
surgical repair of hernias
(1) reduce any protruding abdominal viscus or organ to the abdominal cavity; (2) create a new, tension-free inguinal floor; (3) recreate a snug abdominal (internal) ring. Additionally, for indirect hernias, obliteration of the processus vaginalis (hernia sac) by either reduction back into the abdominal cavity or ligation at a point high against the abdominal wall prevents recurrence; for femoral hernias, the femoral space must also be obliterated or covered with tissue or mesh (plug technique)
key principle of femoral hernia repair
close the femoral canal, which can be achieved by the McVay repair and suturing to the Cooper ligament from an inguinal approach, or by a hernia plug when approaching the hernia inferiorly from a thigh incision.
Lichtenstein (tension free) repair (open)
placing a piece of mesh w a slit in it to accommodate spermatic cord that is sewn to inguinal ligament starting 2cm medial to pubic tubercle; 2 interrupted sutures to tack mesh superiorly and super laterally; interrupted suture to recreate abdominal ring; 6cm of mesh tucked underneath external oblique fascia
Mesh-plug repair (open)
plug is placed in defect and sewn in place
prolene hernia system (PHS, open)
preperitoneal space is accessed and dissected out exposing the myopectineal orifice, the mesh consist of two leaflets of polypropylene, with a connector in between. The lower leaflet is deployed in the preperitoneal space, with the onlay portion covering the entire inguinal floor.
stoppa or preperitoneal repair (open)
large piece of mesh in pre peritoneal space through a transverse incision above the groin
kugel repair (open)
piece of mesh that has been reinforced around the edges so that it will open and stay open once in place; pre peritoneal space
totally extra peritoneal repair (TEP) (lap)
don’t enter peritoneal cavity; use balloon to inflate space, reduce it and use mesh
transabdominal preperitoneal repair (TAPP) (lap)
repair is similar to the TEP except that the access to the preperitoneal space is gained by incising the peritoneum after placing a laparoscope into the peritoneal space. The peritoneum is reflected down and the hernia sac is reduced. The mesh is placed and tacked in the same locations, and then the peritoneum is brought back up over the mesh to minimize contact of the intestines with the tacks and mesh material.
areas to avoid tacking mesh for groin hernias
laterally (cutaneous nerve of thigh and femoral branch of genitofemoral nerve) and triangle of doom (vas deferens medially, spermatic vessels laterally and iliac vessels inferiorly)
marcy repair
popular in very small or early indirect hernias. Because these hernias represent only a dilation of the abdominal ring, the Marcy repair simply snugs up that aperture by sewing the transversus aponeurosis on the lateral side of the ring to the transversus aponeurosis on the medial side of the ring until that layer is snug around the cord.
bassini repair
more superficial repair in which margins of transversus and internal oblique muscles are anchored inferiorly to the inguinal ligament with nonabsorbable interrupted suture. It was the most widely used traditional method for repair of hernias, and associated with a 10% recurrence rate.
mcvay (coopers ligament) repair
anatomic repair, like the Marcy operation, that is used for larger indirect hernias and direct hernias and femoral hernias. The principle of this repair is that when the posterior inguinal wall is destroyed by the hernia, the surgical repair of that wall should be as close as possible to the original anatomy. The strong transversus aponeurosis is sewn to Cooper’s ligament, along that tendon’s natural insertions and the anterior femoral sheath.
halsted repair
similar to a McVay repair except that the external oblique fascia is closed underneath the spermatic cord. It is important to know this when reoperating on these patients from an anterior approach. The cord will be in the subcutaneous tissue, literally unprotected by the external oblique fascia.
shouldice repair
incorporates a series of four running suture lines that approximate and imbricate the transversus aponeurosis to several lateral structures. In a sense, this procedure combines a deep repair similar to McVay’s with a superficial repair similar to Bassini’s. The Shouldice Clinic in Canada specializes in this repair. Their results in terms of recurrence and chronic pain are as good as or better than results from open mesh and laparoscopic repairs reported in multicenter trials.
mesh vs nonmesh
mesh- reduction in risk of recurrence, quicker return to work, lower rates of persisting pain
lap vs open
lap- less pain and faster return to work, simultaneous repairs, reduce difficulty of operating through scar but operation times were longer and higher risk of serious complications (visceral or vascular injury), requires general anesthesia
current recommendations for inguinal hernia repair following findings of cochrane review
in adult men, hernias should be repaired with mesh, whether the approach is laparoscopic or open, although open repair appears to be associated with a lower recurrence rate and fewer life-threatening complications.
groin hernia repairs in women
recurrance rate lowest w lap repair
groin hernia repairs in kids
with inguinal hernias, the hernia is repaired by high ligation (elimination) of the sac without muscle/fascia repair. A laparoscopic exploration of the contralateral groin to exclude a bilateral hernia can be performed through the ipsilateral hernia sac using a needlescope. Hernia repairs in children should have a very low recurrence rate.
firm swelling in the region of the hernia within 2-3days after the procedure
seroma or hematoma; reassurance that swelling will resolve in few weeks; warm pts of possibility
complications of hernia repair
seroma, hematoma, infx, ischemic orchitis, injury ot vas derens impairs fertility, nerve injury leading to numbness or neuralgia
leading causes of recurrent hernia
failure to dx multiple hernias at initial operation, failure to close enlarged internal ring, excessive tension on repair
most frequent cause of recurrence of direct hernia
postop hematoma or undue tension may cause mesh to become dislodged from pubic tubercle medially
preferred surgical approach to a recurrent hernia
lap posterior repair (TAPP or TEP)
mc hernia but least significance and threat
umbilical hernia
abd wall hernias that are more severe, affect only newborns and very uncommon
omphalocele and gastroschisis
tx umbilical hernia
children and in adults with defects
incisional (ventral) hernias causes
deep wound infx*, poor surgical technique, poor wound healing due to cirrhosis, malnutrition, malig, immunosup, steroid dependence; obesity, COPD, constipation
tx incisional hernias
small (sutures) but most require repair w mesh; component separation using autogenous tissues (
pantaloon hernia
simultaneous occurrence of a direct and an indirect hernia. The pantaloon hernia causes two bulges that would be seen intraoperatively, straddling the inferior epigastric vessels
sliding hernia
any hernia in which a portion of the wall of the protruding peritoneal sac is made up of some intra-abdominal organ (usually sigmoid on the left, cecum on the right). As the sac expands, the organ is drawn out, into the hernia.
how to differentiate sliding hernia from inguinal hernias
through the presence of an incompletely reducible hernia or the finding of colon in the scrotum on barium enema is most suggestive
richter’s hernia
name given to a hernia at any site through which only a portion of the circumference of small bowel incarcerates or strangulates. Because the entire lumen is not compromised, symptoms of bowel obstruction can be partial or absent.
spigelian hernia
rare herniations through the semilunar line, which is the lateral margin of the rectus muscle, at or just below the junction with the semicircular line of Douglas. Unlike groin hernias, these hernias lie cephalad to the inferior epigastric vessels. The tight aponeurotic defect predisposes them to incarceration. The patient should be offered surgical repair, typically via the open approach; the placement of mesh is typically not required.
grynfelt’s hernia
wide-mouthed hernia that protrudes through the superior lumbar triangle, which is bounded by the sacrospinalis muscle, the internal oblique muscle, and the inferior margin of the 12th rib. Diagnosis is hampered by the protrusion of these hernias under the latissimus dorsi muscle.
petit’s hernia
protrudes through the inferior lumbar triangle, which is bounded by the lateral margin of the latissimus dorsi, the medial margin of the external oblique, and the iliac crest. Like the superior lumbar hernia, these hernias are broad, bulging hernias that usually do not incarcerate.
Littre’s hernia
Any groin hernia that contains a Meckel’s diverticulum is Littre’s hernia. This type of hernia is usually incarcerated or strangulated at presentation, and may require a laparotomy for intestinal resection.
Amyand’s hernia
Any groin hernia that contains the appendix is an Amyand’s hernia. If appendicitis develops it can present a confusing clinical picture.
Obturator hernia
protrude through the obturator canal. They are much more common in women and usually occur in the seventh and eighth decades. An obturator hernia is classically diagnosed by the symptoms of intermittent bowel obstruction and paresthesias on the anteromedial aspect of the thigh as a result of compression of the obturator nerve (Howship-Romberg sign). The hernia can sometimes be palpated as a mass on rectal exam. The mortality rate is high (up to 40%), and urgent surgical intervention via laparotomy is warranted.
Hesselbach’s hernia
protrudes onto the thigh beneath the inguinal ligament, but courses lateral to the femoral vessels.
epigastric hernia
due to congenital or acquired weakness of the midline linea alba, protrudes through the crossing midline fibers above the umbilicus. It is more common in men than in women, and 20% of epigastric hernias are multiple. Surgical repair is recommended, and the hernias often can be closed primarily. Recurrences are frequently the result of failure to recognize multiple small defects.
diastasis recti
is not a hernia; it is a midline fascial weakness, not a fascial defect. It should be distinguished from an epigastric hernia. It occurs when the rectus muscles separate in the upper midline, making a wide linea alba, and is often associated with rapid weight change. When the patient contracts the recti (for instance, when trying to sit up), this widening can be mistaken for a hernia because it does cause a bulge, often cosmetically bothersome to the patient. Diastasis is not a true hernia (no fascial defect), so reassurance of the patient is the best treatment.
A 46-year-old man comes to your office 6 months after an open inguinal hernia repair complaining of pain, which has never resolved after his surgery. On further questioning, he complains of radicular pain Into the testicle, which worsens with sitting for longer than 10 minutes. On exam, he is hyperesthetic overlying his scar and has numbness over the ipsilateral scrotum and medial thigh. All else is normal. Injury to which nerve is the most likely cause for his pain?
Because of its path alongside the spermatic cord, lying on top of the internal oblique muscle, the ilioinguinal nerve is susceptible to entrapment by most anterior repair techniques. The symptoms described by this patient are most consistent with the distribution of sensory innervation of the ilioinguinal nerve.
A 40-year-old man comes to clinic because of a large incisional hernia. One year ago, he underwent a splenectomy for a ruptured spleen following a motor vehicle crash. There Is a large hernia In the epigastrium in the central portion of a long midline incision. A laparoscopic incisional hernia repair is recommended to the patient. Which of the following should be included in the discussion with the patient while obtaining informed consent?
In general, informed consent for a hernia repair should include the most common risks, which would include recurrence, chronic pain, urinary retention, and possible numbness of the area. If one needed to convert from a laparoscopic repair, the conversion would be to open, not hand assisted. While insurance coverage may be an issue for payment for the hospital, it is not part of informed consent, nor are the types and manufacturers of the materials used for the repair.
A 28-year-old man comes to clinic because of an inguinal hernia. He works as a stonemason and first noticed the hernia when he developed a painful bulge while lifting a bag of cement. He has otherwise been healthy and takes no medications. An open inguinal hernia repair with mesh has been recommended. During a discussion of the anticipated risks, which of the following represents the most common complication?
Recurrence after open inguinal hernia repair is reported to be between 1% and 6%. Urinary retention Is observed in approximately 10% of patients—particularly older men—and patients should be able to urinate before discharge home. Chronic neuropathic pain from nerve entrapment is observed In 6% to 13% of patients. Impaired fertility and ischemic orchitis from injury to the vas deferens and spermatic vessels, respectively, are rare complications (
A 62-year-old man Is in the operating room undergoing an open left inguinal hernia repair. A large indirect sliding hernia is found, and during the dissection, the sigmoid colon is inadvertently injured. The colotomy is easily repaired with sutures. Which of the following hernia repairs should be used in this situation?
-Bassini repair
An unexpected injury to the colon during an open hernia repair will change the wound classification to a contaminated procedure and significantly increase the risk of wound infection. Thus, mesh placement with a Lichtenstein repair should be avoided. Performing the more traditional Bassini repair that involves suturing Poupart’s ligament to the conjoint tendon will be associated with a higher risk of hernia recurrence but avoids significant wound complications. The Halsted repair is a largely historical procedure, which left the spermatic cord in the subcutaneous tissues. A Cooper repair (also known as a McVay repair) is more difficult to perform than a Bassini repair and would not offer additional benefit in the repair of a sliding hernia, while the Marcy repair would be insufficient to offer any meaningful prevention of recurrence of a sliding hernia.
A 32-year-old man comes to the emergency department with an acutely incarcerated inguinal hernia. With sedation, the hernia is reduced and he feels better. Eighteen hours later, he complains of Increasing abdominal pain and has diffuse tenderness on examination. He most likely had which of the following?
A Richter’s hernia involves only a portion of the circumference of a bowel wall and typically Is recognized with bowel incarceration or strangulation (sometimes after reduction of the hernia, causing an acute abdomen when the bowel perforates). Diastasis recti is a fascial weakness, not a true fascial defect, and does not require surgical intervention. Petit’s hernia is a broad, bulging hernia that usually does not Incarcerate. Amyand’s hernia contains the appendix and sometimes can present with findings of appendicitis. Epigastric hernias typically are small and often contain preperitoneal fat only. They are often recognized early by the patient in the event that the hernia becomes incarcerated, and strangulation is unlikely to ensue.
