Abdominal wall & Retroperitoneum & Urogenital Flashcards
Describe the borders of lumbar hernias.
Inferior lumbar hernia of petit:
Lateral = EO
Inferior = Iliac crest
Medial = Lat dorsi
Superior lumbar hernia of Grynfeltt:
Lateral = IO
Medial= Quadratus lumborum
Superior = 12th rib
Most commonly however is a diffuse lumber hernia outside of these anatomic triangels due to trauma, infection or surgery.
What is the pathogenesis of fascial dehisence?
The abdominal wall pressure overcomes the tissue, suture or knot integrity.
What is Hesselbach’s triangle?
An area of relative weakness in anterior abdominal wall where direct inguinal hernias arise. It is bordered medially by linea semilunaris, superiolaterally by inferior epigastric vessels and inferiorly by inguinal ligament.
What makes up the femoral triangle?
Where do femoral hernias pass through?
The femoral ring (which is bordered by the lacunar ligament medially, femoral vein laterally and pectineal ligament posteriorly) and into the femoral canal.
In a TEP repair what are the triangles of pain and triangles of doom and what are their contents?
Triangle of pain is lateral and bordered by superiorly by iliopubic tract, medially by spermatic vessels and laterally by peritoneal reflection. It contains
- Femoral nerve
- Femoral branch of genitofemoral nerve
- Lateral femoral cutaneous nerve of the thigh
- Anterior femoral cutaneous nerve of the thigh
Triangle of doom is bordered by the vas deferens medially, spermatic vessels laterally and the peritoneal reflection inferiorly. It contains the external iliac vessels and the genital branch of genitofemoral nerve.
What is the corona mortis and its relevance surgically?
common variant arterial anastomosis between either the external iliac artery or deep inferior epigastric artery and the obturator artery. Occurs in up to 33% of population.
Its relevant in pelvic pubic rami trauma as a cause of significant bleeding also relevant in TEP hernia repairs .
What is Palmers point? What is it used for and what are contraindications to using it?
3 cm below the left costal margin in the mid-clavicular line.
Used for laparoscopic direct optical entry.
Contraindicated in previous LUQ surgery, splenomegaly, portal hypertension.
Spot diagnosis
Amyands hernia (appendix in an indirect inguinal hernia)
Spot diagnosis
Aftermath of a Richters hernia (only antimessenteric border of small bowel has herniated).
Describe how indirect and direct inguinal hernias develop.
Indirect is due to patent processus vaginalis
Direct is due to weak transversalis fascia in Hesselbachs triangle.
What is the recurrence rate for inguinal hernia repair with and without mesh.
Quote 3-4% with mesh (no difference between open vs lap techniques) and 10-30% for tissue repair without mesh.
What is your approach to recurrent inguinal hernias?
Mitigate any modifiable risk factors for recurrence and then;
Asymptomatic or Minimal Symptoms: Watchful Waiting vs Surgical Repair
Choice Based on Patient Preference
Symptomatic: Surgical Repair
Previous Tissue Repair: Any Approach
Previous Mesh Repair: Approach Through Unviolated Tissue Planes
Failed Anterior Repair: Posterior Approach
Failed Posterior Repair: Anterior Approach
Leave a New Mesh, Even if Mesh Was Already Used Previously
Do Not Remove Old Mesh
Are femoral hernias more common in women?
Femoral hernias are 4x more common in women than men but inguinal hernia is still the most common hernia in women.
What are the following hernias?
1. Pantaloon
2. Sliding
3. Indirect
4. Direct
5. Femoral
6. Amyand
7. Littre
8. De Garengeot
9. Obturator
10. Athletic pubalgia
11. Richter
- Both direct and indirect inguinal hernias
- Contains retroperitoneal structure in wall of hernia sac e.g. sigmoid colon, bladder.
- Inguinal hernia through the internal ring due to patent processus vaginalis.
- Inguinal hernia through weakness in transversalis fascia at Hesselbach’s triangle.
- Hernia through femoral canal
- Appendix in indirect inguinal hernia
- Meckels diverticulum in inguinal or femoral hernia
- Appendix in femoral hernia
- Hernia through obturator foramen.
- Not a true hernia - groin pain without evidence of groin hernia.
- Only antimessenteric border is in the hernia.
What is this?
This is a femoral hernia (medial to the femoral vessels)
What is this?
Obturator hernia through obturator foramen.
What is obturator neuralgia?
Pain from groin to medial knee due to compression of the obturator nerve. Can be due to a number of things but consider obturator hernia. Howship-Romberg sign - this neuralgia is exacerbated by hi extension, internal rotation and abduction.
Describe the different open groin hernia repair techniques.
Mesh repairs;
Lichentenstein tension free mesh repair - uses mesh to decrease tension. 2cm overlap at pubic tubercle. sutured here with non-absorbable suture e.g. prolene.
Other mesh repairs patch and plug out of favour due to complications.
Tissue repairs:
Bassini - suture conjoint tendon to inguinal ligament
McVay - suture conjoint tendon to coopers ligament (covers femoral canal and therefore used for femoral hernia repair)
Shouldice 2-4 layer closure. Layer 1: Inferolateral Transversalis Fascia Flap to Deep Muscular Fascia
Layer 2: Superior-Medial Transversalis Fascia Flap to Shelving Portion of Inguinal Ligament
Layer 3: Conjoint Tendon to Inferolateral Transversalis Fascia Flap
Layer 4: Conjoint Tendon to Inguinal Ligament
What are the anatomic remnants for each of the following?
1. Vitelline duct
2. Urachus
3. Umbilical arteries
4. Umbilical veins
- Should fully obliterate however can result in Meckels diverticulum if it hasn’t fully done so.
- Median umbilical ligament
- Medial umbilical ligaments
- Falciform ligament.
Describe the embryology of the fore, mid and hind gut.
Foregut
GI Tract: Esophagus to Proximal Duodenum (To Ampulla of Vater)
Organs: Liver, Gallbladder, Bile Ducts, Pancreas & Lungs
Arterial Supply: Celiac Artery
Hepatic Portal Drainage: Splenic Vein
Midgut
GI Tract: Distal Duodenum to Distal 1/3 Transverse Colon
Arterial Supply: Superior Mesenteric Artery
Hepatic Portal Drainage: Superior Mesenteric Vein
Rotates 270 Degrees Counterclockwise
Hindgut
GI Tract: Distal 1/3 Transverse Colon to Anal Canal
Arterial Supply: Inferior Mesenteric Artery
Hepatic Portal Drainage: Inferior Mesenteric Vein
Diagram:
Classic “En-Bloc Rotation” Model of Gut Morphogenesis: Midgut Herniates and Rotates 90-Degrees (B1), Forms Loops (B2), & Slides Back into the Abdomen (B3). The Midgut Then Rotates an Additional 180-Degrees to its Final Position (C)
Describe the different ligaments of the inguinal region.
Inguinal ligament = rolled edge of external oblique aponeurosis and goes from ASIS to PT.
Conjoint tendon = confluence of transversus abdominus and internal oblique fibres joined together and attach to the pubic tubercle and pectineal line.
Lacunar ligament = curvilinear fibres that go between inferior edge of inguinal ligament and attach to the pubic bone. Forms the medial wall of the femoral canal.
Coopers ligament = an extension of the lacunar ligament along the pectineal line of the pubic bone and creates the posterior wall of the femoral canal.
Describe the borders of the inguinal canal.
Bordered
Anterior = external oblique aponeurosis.
Inferior = rolled edge of external oblique creating the inguinal ligament.
Posterior = Transversalis fascia.
Superior = Conjoint tendon
Describe the boundaries of the femoral triangle.
Superior = inguinal ligament
Medial = medial border of adductor longus
Lateral = medial border of sartorius
Describe the boundaries of the femoral ring.
Anterior = inguinal ligament
Posterior = coopers ligament
Medial = lacunar ligament
Lateral = femoral vein
Describe the contents of the femoral sheath and the femoral canal.
Femoral sheath is a continuation of transversalis fascia anteriorly and iliacus fascia posteriorly and encases the femoral artery and vein and some lymphatics. It is divided vertically into 3 compartments. Medial most makes up the femoral canal, Intermediate = femoral vein, lateral = femoral artery
The femoral canal extends from femoral ring above to saphenous opening below. It occupies most of the medial compartment of the femoral sheath. It contains fat, lymphatics and lymph node of Cloquet.
Label the photo. TBC
What is the significance of the lymph node of cloquet?
This is groin lymph node located in the femoral canal and is the lymph node at the junction of deep inguinal nodes and the external iliac chain.
What are the contents of the spermatic cord?
3 arteries
- artery to vas deferens (origin inferior vesicular artery)
- cremasteric artery (origin inferior epigastrics)
- testicular artery (origin aorta)
3 nerves
- sympathetic branches
- testicualr nerve fibres
- genital branch of the genitofemoral nerve
(- ilioinguinal nerve runs outside but along it.)
pampiniform plexus of veins
cremasteric muscle fibres (continuation of internal oblique)
vas deferens
lymphatics
tunica vaginalis
Describe the layers of the scrotum from skin to testis.
Hint ‘Some Damn Englishman Called It The Testis.’
- Skin
- Dartos fascia and muscle
- External spermatic fascia
- Cremasteric fascia
- Internal spermatic fascia
- Tunica vaginalis
- Tunica albuginea
What is the bell clapper deformity and what is its significance?
The tunica vaginalis extends up over the entire testis to the origin of the vessels and so makes it easier for the testis to tort.
https://www.vumc.org/global-surgical-atlas/sites/default/files/public_files/PDF/Orchiectomy%20and%20Orchipexy%20for%20Testicular%20Torsion.pdf
What are the triangles of doom and pain in hernia repair surgery? What are their contents.
Triangle of doom is bordered medially by the vas deferens, laterally by the testicular vessels and inferiorly by the peritoneal fold. It contains the external iliac artery and vein. It also contains the genital branch of the genitofemoral nerve.
Triangle of pain is bordered medially by the testicular vessels, laterally by the lateral margn of the peritoneal reflection and superiorly by the iliopubic tract. It contains (laterally to medially) the Lateral femoral cutaneous nerve of the thigh, the anterior femoral cutaneous nerve of the thigh, the femoral branch of the genitofemoral nerve and the femoral nerve. It also has the deep circumflex iliac vessels.
You encounter arterial bleeding when placing a tack medially around the pubic tubercle at time of laparoscopic hernia repair. What have you likely hit?
Corona mortis. It is a vascular anastomosis between the obturator and external iliac or inferior epigastric arteries.
What are Bochdalek and Morgagni hernias?
Bochdalek = congential diaphragmatic hernia (makes up ~70% of them). Is posteroinferior defect. Usually on the left.
Morgagni = congential diaphragmatic hernia (least common). Is a defect anteriorly and often smaller and present later.
Describe the embrology of visceral herniation and return and its relation to exomphalos and gastroschisis
AT around 6th week of gestation bowel herniates out due to rapid growth phase and not enough intraabdominal space.
Around 10th week the bowel returns to the abdominal cavity and is completed by 12th week.
Exomphalos is remaining umbilical defect resulting in herniated (usually bowel) contained in a sac inside the umbilicus.
Gastroschisis is also associated with malrotation and incomplete return of the bowel to the abdomen but is through a defect usually inferolateral to the right of the umbilicus and the contents are not contained within a sac.
Describe anatomical course and function for each of the following nerves;
- Ilioinguinal nerve
- Iliohypogastric nerve
- Genitofemoral nerve
- Lateral femoral cutaneous nerve
Ilioinguinal Nerve
Enters Through Superior Border Between Internal Oblique & Transversus Abdominis
Near Iliohypogastric Nerve
Runs Parallel Over the Spermatic Cord
Not Inside
Function: Cutaneous Sensation Over Penis Root & Scrotum
liohypogastric Nerve
Enters Through Superior Border Between Internal Oblique & Transversus Abdominis
Near Ilioinguinal Nerve
Runs Transverse Over Internal Oblique, Superior to Deep Ring
Function: Hypogastric Cutaneous Sensation
Genitofemoral Nerve
Genital Branch
Travels Through Deep Ring to Cremaster Muscle
Function: Cremaster Muscle & Scrotal Skin
Femoral Branch
Parallels Iliac Vessels Through Femoral Canal
Function: Inner Thigh Sensation
Lateral Femoral Cutaneous Nerve
Initially Parallels Ilioinguinal and Iliohypogastric Nerves
Exits Posterior to Inguinal Ligament Through Femoral Canal
Function: Lateral Thigh Sensation
Provide an outline of different mesh types available.
What is a proboscoid hernia?
Umbilical hernia with excsessive stretching of the skin such that it hands down like an elephant trunk or the nose of a proboscis monkey which it is named after.
Describe an anterior component seperation.
Primary goal is to facilitate fascial closure in the midline in patients with loss of abdominal domain.
Priniciple of anterior component separation is to isolate and divide the external oblique (EO) muscle.
Steps are as follows:
Generally performed as part of a retrorectus ventral hernia repair after hernia reduction and lysis of adhesions
- Create subcutaneous flaps
- extend to anterior axillary lines laterally (lateral to the EO insertion)
- avoid excessively large flaps (source of morbidity)
2.. Incise EO aponeurosis
-start 2cm lateral to the semilunar line and rectus sheath
- extend from costal margin to the pubis.
3.. Free the EO from the IO.
- extend as far laterally as possible.
Generally reinforced with a retrorectus mesh placement.
Complete with closure of anterior rectus sheath in midline and close skin.
How are parastomal hernias repaired?
Takedown stoma where appropriate
If unable to options include repositioning and primarily closing defect or
Sugarbaker vs Key hole mesh repair
Describe techniques for ureteric repair if noticed intraoperatively.
Primary repair by ureteroureterostomy over a stent for proximal 2/3rd injury
Ureteroneocystostomy in distal 1/3rd i.e. reimplant into bladder.
Options to reduce tension;
- psoas hitch (bladder mobilised and sutured to psoas) - preferred
- transureteroureterostomy (implantation into contralateral ureter)
- Boari flap (use slip of bladder to tubularise and anastomose to ureteric end.
- ilieal interposition
Patient has recurrent umbilical infections, fluid leakage and urinary infections. What is most likely diagnosis?
Urachal remnant due to maldescent/incomplete descent of the bladder. Can have patent urachus, urachal sinus, urachal cyst or urachal/bladder diverticulum. The question would suggest most likely a patent urachus as this is the only one that has bladder in continuity with umbilicus.
NB: does confer increased malignancy risk as adult.
