Cap.13 Pared abdominal y hernias Flashcards
What kind of hernia occurs between the rectus muscle medially and the semilunar line laterally?
Spigelian hernia
What ligament is formed by the periosteum and fascia along the superior pubic ramus?
Cooper ligament
What kind of femoral hernias need to be repaired?
All femoral hernias need to be repaired (high incidence of strangulation)
Type of hernia with an indirect and direct hernia component:
Pantaloon hernia
Most common malignant retroperitoneal tumor:
Lymphoma
Treatment for retroperitoneal sarcoma:
Complete en bloc resection of the tumor with any involved adjacent organs (primary treatment); if invading inferior vena cava (IVC), the IVC can be excised and bypassed in the absence of sufficient collaterals. There used to be no role for radiation secondary to visceral toxicity, but with the advent of better radiation some institutions are giving radiation either pre- or postoperatively. If inoperable, symptomatic disease can consider chemotherapy with radiation.
What is a Bochdalek hernia?
A posterior diaphragmatic hernia usually occurring on the left (Bochdalek = back and to the left)
Name the repair: a multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique by superimposing running suture lines progressing from deep to more superficial layers (initial suture line—transversus abdominis aponeurotic arch to iliopubic tract, next suture line—internal oblique and transversus abdominis muscles and aponeuroses to the inguinal ligament).
The Shouldice repair
Where do direct inguinal hernias occur with regards to Hesselbach triangle?
Direct hernias occur within Hesselbach triangle
Treatment for tuberculous peritonitis:
Antituberculous drugs (isoniazid and rifampin daily for 9 months commonly used)
What procedure do you perform to repair an inguinal hernia in infants and children?
High ligation of the hernia sac
Initial treatment for peritoneal dialysis–associated peritonitis:
Intraperitoneal administration of antibiotics (usually first-generation cephalosporin)
What kind of hernia occurs at sites where vessels and nerves perforate the linea alba?
Epigastric hernia
Name the hernia repair: a large piece of mesh is placed with an extensive fascial underlay in the retromuscular space on top of either the posterior rectus sheath or peritoneum.
Stoppa repair
Treatment for pseudomyxoma peritonei:
-Drainage of mucus and intraperitoneal fluid -Peritonectomy and omentectomy with cytoreduction of primary and secondary tumor implants -Right colectomy for appendiceal adenocarcinoma or total abdominal hysterectomy and bilateral salpingo-oophorectomy for ovarian carcinoma -Post-op intraperitoneal chemo/mucolytics
What nerves are most commonly affected during open hernia repair?
Ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve
Most common organ found in a sliding hernia in a male patient:
Cecum/sigmoid colon
Term for a congenital hernia in which the small intestine herniates behind the mesocolon:
Mesocolic (paraduodenal) hernia
Why is visceral pain felt in the midline rather than lateralize?
Organs transmit sympathetic sensory afferents to both sides of the spinal cord.
What type of hernia are most strangulated hernias?
Indirect inguinal hernia
What are the boundaries of the inguinal canal?
Anterior—external oblique aponeurosis Posterior—transversalis fascia and the aponeurosis of transversus abdominis Superior—internal oblique and transversus abdominis musculoaponeurosis Inferior—inguinal ligament and lacunar ligament
Treatment for a mesenteric hernia:
Reduce the hernia and close the mesenteric defect
What disease entails a mucous-secreting tumor coating the peritoneum and filling the peritoneal cavity with mucus and large loculated cystic masses?
Pseudomyxoma peritonei
Where do indirect inguinal hernias occur with regards to Hesselbach triangle?
Indirect inguinal hernias occur lateral to Hesselbach triangle
Treatment for an omental cyst:
Local excision
What is a Hesselbach hernia?
A hernia that is lateral to the femoral vessels and under the inguinal ligament
Overall complication rate from hernia repair:
10%
What are the borders of the Triangle of Doom?
-Vas deferens medially -spermatic vessels laterally -external iliac vessels inferiorly
Where does visceral pain from inflammation of the stomach, duodenum, or biliary tract (foregut) localize?
Epigastrium
Prognostic factors for retroperitoneal sarcoma:
Histologic grade and tumor size
What are the boundaries of the femoral canal?
Superior—iliopubic tract Inferior—Cooper ligament Lateral—femoral vein Medial—junction of iliopubic tract and Cooper ligament (lacunar ligament)
Name the repair: approximation of the transversus abdominis aponeurotic arch to the iliopubic tract with the use of interrupted sutures beginning at the pubic tubercle and extending laterally past the internal inguinal ring with or without the use of a relaxing incision.
The iliopubic tract
What is the function of the peritoneum?
To promote sequestration and removal of bacteria from the peritoneal cavity, control the amount of fluid in the peritoneal cavity, and facilitate the migration of inflammatory cells from the microcirculation into the peritoneal cavity
Where does the aponeurosis, which is originally divided into anterior and posterior lamella that envelops the rectus abdominis muscle, begin to course anteriorly to the rectus abdominis muscle and become part of the anterior rectus sheath?
Semicircular line (of Douglas/arcuate line)
What is a Richter hernia?
Incarcerated/strangulated hernia involving only 1 sidewall of the bowel
What is the treatment for a vesicocutaneous fistula (patent urachus)?
Excision of the urachal remnant with closure of the bladder if needed
What are absolute contraindications to laparoscopic inguinal hernia repair?
Inability to tolerate general anesthesia
What is a Morgagni hernia?
An anterior parasternal diaphragmatic hernia
On what side do femoral hernias usually occur?
Right side (possibly from tamponading effect of sigmoid colon on left femoral canal)
What is a Sports hernia?
Characterized by a dilated superficial ring of the inguinal canal and chronic groin pain in athletes (not a true hernia)
What is the percentage risk for hernia incarceration with watchful waiting?
0.03%
What is the time period that hernias usually recur?
Usually within the first 2 years after repair
How many cm of mobilization can be obtained when component separation is applied to both sides of the abdominal wall?
Up to 20 cm of mobilization
Term for bacterial infection of ascitic fluid in the absence of an intra-abdominal, surgically treatable source of infection:
Spontaneous bacterial peritonitis
Most common hernia:
Indirect inguinal hernia
What does a SAAG <1.1 g/dL signify?
Absence of portal hypertension (biliary ascites, nephrotic syndrome, pancreatic ascites, peritoneal carcinomatosis, post-op lymphatic leak, serositis with connective tissue disease, tuberculous peritonitis)
What are the borders of the inferior lumbar (Petit) triangle?
Medial—latissimus dorsi Lateral—external abdominal oblique Inferior—iliac crest (floor—internal abdominal oblique)
What directions do the fibers of the internal oblique course?
Inferolateral to superomedial
Term for the space that is first entered in an extraperitoneal hernia repair that lies between the posterior rectus sheath and pubic bone anteriorly and the vesicoumbilical fascia posteriorly:
The space of Retzius
On what side do inguinal hernias usually occur?
Right side (delay in atrophy of processus vaginalis after slower descent of right testis to scrotum during fetal development)
Name the repair: the edge of the transversus abdominis aponeurosis is approximated to Cooper ligament with interrupted, nonabsorbable sutures; a transition suture is then placed to incorporate Cooper ligament and the iliopubic tract when the medial aspect of the femoral canal is reached; the transversus abdominis aponeurosis is then secured to the iliopubic tract lateral to the transition stitch; a relaxing incision is then made throughout the extent of the anterior sheath to near its lateral border.
McVay (Cooper ligament) repair
Next step if you cannot reduce an incarcerated femoral hernia:
Divide the inguinal or lacunar ligament
How much albumin should be given for every liter of ascites removed after large volume paracentesis (>5 L)?
6 to 8 g of albumin/L of ascites removed
How is the definitive diagnosis of an abdominal wall sarcoma made?
Core needle biopsy (choose this one on the test) or by incisional biopsy oriented in the same plane as the underlying muscle.
What directions do the fibers of the external oblique course?
Superolateral to inferomedial
What are the borders for the Triangle of Pain?
-Spermatic vessels medially -iliopubic tract superolaterally
What is a Littre hernia?
Hernia containing a Meckel diverticulum
What is the portion of the external oblique aponeurosis that extends from the anterior superior iliac spine to the pubic tubercle called?
Inguinal (Poupart) ligament
What is the primary danger associated with a sliding hernia?
Failure to recognize the visceral component of the hernia sac before injury to bowel/bladder
What is a Spigelian hernia?
Hernia through the linea semilunaris
What are relative contraindications to laparoscopic inguinal hernia repair?
Nonreducible, incarcerated inguinal hernia; prior laparoscopic herniorrhaphy; massive scrotal hernia; prior pelvic lymph node resection; prior groin irradiation
Which lumbar hernia is more common? Grynfeltt hernia or Petit hernia?
Grynfeltt hernia