Abdominal Wall Surgery Flashcards
Anatomically where would you feel for the deep inguinal ring?
Mid point of the inguinal ligament
- 2cm lateral to the mid-inguinal point
*this differs from the mid-inguinal point - which is where the femoral artery is felt.
What symptoms may be present in an inguinal hernia?
What investigation should be done?
- asymptomatic
- Dragging sensation, especially by the end of the day
- Aching
- Specific activity pain - like lifting
Investigations:
- Physical exam
- Ultrasound - if there is doubt
Compare and contrast direct and indirect hernias:
Indirect;
- usually younger
- congenital - patent processes vaginalis
- lateral to inferior epigastric
- often into scrotum
- deep ring occlusion controls it
- narrow neck
- strangulation is more likely
Direct:
- usually older patients
- acquired all weakness - not congenital
- medial to inferior epigastric
- deep ring occlusion doesn’t control it
- wide neck
- strangulation is rare
What are the complications that can occur with hernias?
Incarceration
Obstruction
Strangulation
What is the broad management approaches to hernias?
observe
- appropriate in patients with low risk of complications
Open repair
- open mesh
Laparoscopic repair
- Trans - abdominal preperitoneal ( TAPP)
What are the boundaries to hesselbach’s triangle?
RIP:
Rectus abdominis - medial
Inferior epigastric artery - lateral / superior border
Poupart’s ligament/ inguinal ligament - inferior border
What are some differentials to an inguinal hernia?
Femoral hernia
Enlarged lymph node
Ectopic/ undescended testis
Swollen teste
- hydrocele
- varicocele
- testis mass
Abscess
What are the borders of the femoral canal?
FLIP
Femoral vein - laterally
Lacunar ligament - medially
Inguinal ligament - superiorly
Pectineal ligament - posteriorly
List several types of hernias:
Inguinal Femoral Incisional Obturator Umbilical Paraumbilical Hiatus
How does an obturator hernia present?
How is it diagnosed?
Typically in females with multiple pregnancies
Pain on the inside of the thigh, radiating to the knee
- when hip is internally rotated
- compresses the obturator nerve
**the hernia is due to weakness in the pelvic floor
Diagnosed via MRI
What is the hernia called when there is a tear in the linea alba? how is it tested?
Diastasis Recti
Diagnosed by lying patient down and getting them to lift head up.
What is a hernia called when only part of the bowel wall protrudes out, and what is worrisome about them?
Richter’s hernia
- they can easily strangulate
If a new born presents with an umbilical hernia, what is the management?
Reassure parents vast majority disappear by age 4-5 years old.
If a new born presents with an inguinal hernia, what is the management?
Surgical - this is likely to be an indirect hernia and as such is at risk of rupturing
What are some complications of hernia repair surgery?
Scrotal haematoma
Urinary retention
Damage to the ilioinguinal nerve
- it is within the inguinal canal but not the spermatic cord
Recurrence
What are the options for inguinal hernias that are not going to be operated on?
Hernia Truss
- helps to hold the hernia in
What are some risk factors for inguinal hernia?
Age Obesity Male Increased intraabdominal pressure - sneezing, coughing, lifting heavy
How does a strangulated hernia present?
An irreducible lump which is tense and tender with pain being out of proportion to clinical signs. This may also be in combination with symptoms of obstruction
What key things are you assessing for when examining an inguinal hernia?
Reducibility
- lying down/ minimal pressure
Location - supra-medial to the pubis tubercle - inguinal
infra- lateral to the pubis tubercle - femoral
Cough impulse
What type of surgery is most applicable to recurrent inguinal hernias?
Laparoscopic repair
Define hernia:
A hernia is the protrusion of a tissue or viscus beyond the normal coverings or cavity in which it is usually contained
What are the principles of making incisions?
Follow Langer’s lines
- skin tension areas
- maximal wound strength and minimal scarring
How can wounds be closed?
Suturing
Staples
Tissue glue
Steri Strips
What incisions can be done to access the appendix?
Lanz Incision
Gridiron Incision
What is the type of incision made if access to the gallbladder is needed?
Kocher Incision
What are some features of generalised peritonitis?
Patient remains very still
- does not want to move
Tachycardia
Involuntary guarding
Rigid abdomen
Absent bowel sounds
What are some routine tests wanted in peritonism?
Bloods:
- FBC
- U&Es
- LFTs
- Amylase
- Group and Save *always do cause of surgery
Orifices:
- Pregnancy test
- Urine analysis - exclude GU causes
X-ray:
- CXR - erect
- ABX
- Ultrasound - kidneys, biliary tree, ovaries
ECG :
- all patients should get an ECG with abdominal pain to rule out cardiogenic causes
What is the general management into peritonism?
IV access
Nil by mouth
Analgesia
IV fluids
+/-
Antibiotics
NG tube
*monitor fluid output
Where does the direct inguinal hernia come through?
Hasselbach’s triangle
What are some key signs of a hernia:
Occur at anatomically weak spots
Reducible
- to begin with
Have a cough impulse
What are the differentials to an inguinal hernia?
Lipoma
Femoral hernia
Saphena varix (Varicose veins of the groin)
Inguinal Lymphadenopathy
In the scrotum:
- varicocele
- Hydrocele
What examinations should be done on a suspected inguinal hernia?
Palpation
Reducibility
- both lying down and standing
Cough Impulse
Ascertain if the hernia can be put into the deep inguinal ring and controlled
Auscultation
- listen for bowel sounds
Feel the other side `
If there strangulation but no signs of obstruction with a hernia, what type of hernia is it likely to be?
Richter’s hernia
- only part of the bowel wall is trapped with strangulation, but there is a still a patent lumen for contents.
What is it called when there is a direct and indirect hernia in the same groin?
Pantaloon hernia
What is the most common hernia in women?
Inguinal
*the femoral is just more common in women than men, but inguinal is still the most common
How are femoral hernias diagnosed and how are they managed?
Clinical but usually:
- US
- CT
is needed to clarify diagnosis
Managed with Surgical input as there is a high risk of strangulation
- high approach - used during surgical emergencies (above the inguinal canal)
- Low approach (below the inguinal canal)
What does the surgical operation for a femoral hernia consists of?
Reducing the hernia
Tightening the femoral canal to prevent reoccurance
What are the two things that may be inside the inguinal hernia:
Bowel
- will hear bowel sounds
Omentum
Why is looking for appendectomy scars important?
Damage to the Iliohypogastric nerve can lead to weakness in the transverse muscle causing hernia
What is Maydl’s hernia?
Where the bowel double backs and causes strangulation internally
Whats it called when the hernia is pushed back in but is still herniated causes incarceration:
Reduction-en-mass
What are the indications for laparoscopic repair?
Bilateral hernias
Reoccurring
Female
Complications of inguinal hernia surgery:
Haematoma
- into the groin
Wound infection
Urinary retention
Testicular damage to due to damage to testicular artery
