Ch. 1 Nausea, Vomiting, and Left Groin Mass

Question 1

Differential for groin mass

MINT

Answer 1

Differential for groin mass

Congenital and structural:

• Malformations
• Infection
• Neoplasm
• Trauma

Question 2

What is the dx in this patient?

Answer 2

SBO 2/2 strangulated femoral hernia

Bowel within the hernia sac is ischemic/gangrenous

In this setting, surgery is urgent –> anticipate the need to perform a bowel resection

Question 3

Why is it important to ask if a groin mass protrudes with straining and reduces in supine position?

Answer 3

Highly suggestive of hernia

Question 4

Pathology/Pathophysiology

What is a hernia?

Answer 4

Protrusion of tissue or organ(s) through a defect, most commonly in the abdominal wall

Question 5

What is the difference between a reducible and an incarcerated hernia?

Between an incarcerated and a strangulated one?

Answer 5

• Reducible: if contents within sac can be pushed back through defect into peritoneal cavity
• Incarcerated: contents are stuck in the hernia sac
• Strangulated: type of incarcerated hernia in which there is compromised blood flow to herniated organ (usually small intestine, but can also be omentum, large bowel, or ovary)
  
  • More commonly occurs when hernia defect is narrow
  • Loop of bowel protrudes through hernia and becomes entrapped by narrow neck –> closed-loop bowel obstruction –> nowhere for fluid and gas to egress –> as bowel continues to produce gas and secrete fluid, progressive distension leads to compromise of blood flow
  • Tx: PROMPT SURGICAL INTERVENTION –> w/o, can lead to intestinal ischemia, sepsis, bowel infarction, and death

Question 6

What clues on H&P indicate whether a pt with an incarcerated has progressed to a strangulated hernia?

Answer 6

Strangulated hernia leads to a compromise of blood supply of bowel and subsequent irreversible ischemia and necrosis

Ischemic bowel typically triggers SIRS

Cardinal signs of strangulated hernia:

• fever,
• tachycardia,
• elevated WBC,
• redness of skin overlying hernia,
• pain

SURGICAL EMERGENCY!!

Question 7

What are the different types of hernias?

Answer 7

1. Inguinal
   
   1. Direct
   2. Indirect
2. Femoral (10%)
   
   1. More common in women
   2. Highest rate of strangulation (bowel passes down narrow, rigid femoral canal)
3. Umbilical
   
   1. Prevalent in peds
   2. Common with congenital hypothyroidism
4. ​Ventral or incisional hernias
   
   1. Appear at site of previous surgery and can occur weeks, months, or even years after procedure

Question 8

What is the pathophysiology of an indirect inguinal hernia? A direct inguinal hernia?

Answer 8

Indirect: caused by persistent (patent) processus vaginalis

During embryologic development, processus vaginalis, an outpouching of peritoneum, descends into scrotum, bringing along the testicle with it. It subsequently closes prior to birth. If processus remains patent (open), peritoneal fluid can fill scrotum (communicating hydrocele) or bowel can pass through patent processus vaginalis into scrotum (indirect hernia).

In men, indirect hernia sac travels along with spermatic cord through internal ring, and into scrotum. In women, it follows tract of round ligament towards pubic tubercle.

** traverse deep ring and superficial ring

Direct: due to weakness in floor (transversalis fascia) of inguinal canal, directly through Hesselbach’s triangle

** only pass through superficial ring

Question 9

What are the borders of Hesselbach’s Triangle?

Answer 9

• Lateral border: inferior epigastric vessels
• Medial border: rectus sheath
• Base: posterior wall of inguinal ligament

Question 10

What is the significance of nausea, vomiting, and high-pitched bowel sounds in a pt px?

Answer 10

Suggests that patients have a SBO (hernia sac likely contains section of small intestine that is incarcerated, causing closed-loop obstruction)

Early in the course of a SBO< high-pitched, hyperactive bowel sounds are heard (result of hyperperistalsis, as intestines try to push luminal contents past the obstruction)

In a pt with bowel obstruction, a change in bowel sounds from hyperactive to absent, in association with increased pain, suggests progression to bowel ischemia

Question 11

What is a Richter’s Hernia?

What is a Sliding Hernia?

Answer 11

Richter’s Hernia:

• Only part of the circumference of the bowel wall is trapped within the hernia sac
• Herniated segment can become strangulated and result in ischemic changes

Sliding Hernia:

• Type of indirect hernia that occurs when retroperitoneal organ (usually colon or bladder) typically herniates with the sac and essentially makes up the posterior wall of the sac
• Usually occurs on left side

Question 12

How do you dx a hernia in an adult?

Answer 12

For both men and women: ask pt to stand

In men, the examiner’s index finger is inserted in a cephalad direction through the scrotum, inverting it, and placed at level of external ring. Pt is asked to Valsalva or cough. If hernia is present, bulge will be palpated.

Question 13

What is the recommendation for inguinal hernia repair in older infants/children?

Answer 13

Vast majority of hernias in infants = indirect hernias

Thus, open sac (anteriorly), reduce contents, perform high ligation of hernia sac to adequately correct this defect. Since the hernias are not usually long-standing, the internal ring and floor of inguinal canal do not need reinforcement. Approximately 5-10% of infants will have bilateral indirect inguinal hernias, so an attempt should be made to assess for contralateral hernia during initial exam.

Question 14

What is the recommended mgmt for umbilical hernia in an infant?

Answer 14

Very common in newborns

Rarely incarcerate and most close spontaneously by age 2

Indications for surgery:

• persistence beyond age 4
• hernia defect larger than 2 cm in diameter (unlikely to close spontaneoulsy)
• strangulation
• progressive enlargement after 1-2 years of age

Question 15

What nerves can be injured during hernia repair? What is the mechanism of injury? What are the consequences?

Answer 15

Question 16

Mgmt for direct hernia (older men):

Answer 16

DO NOT open sac (no patent processus vaginalis)

Reinforce floor with mesh (Lichtenstein) repair

Question 17

What are the layers of the abdominal wall?

Answer 17

1. Skin
2. Subcutaneous fat
3. Scarpa’s fascia
4. External oblique
5. Internal oblique
6. Transversus abdominus
7. Transversalis fascia
8. Preperitoneal fat
9. Peritoneum

Note: all three muscle layer aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line

Question 18

What is the diferential diagnosis for a mass in a healed C-section incision?

Answer 18

Hernia, ENDOMETRIOMA

Question 19

What nerve runs with the spermatic cord in the inguinal canal?

Answer 19

Ilioinguinal n.

Question 20

Intraoperative Inguinal Hernia Questions:

1. What is the first identifiable subcutaneous named layer?
2. What is the name of the subcutaneous vein that is ligated?
3. What happens if you cut the ilioinguinal nerve?
4. From what abdominal muscle layer is the cremaster muscle derived?
5. From what abdominal muscle layer is the inguinal ligament derived?
6. To what does the inguinal ligament attach?
7. What nerve travels on the spermatic cord?
8. Why do some surgeons deliberately cut the ilioinguinal nerve?
9. What is in the spermatic cord (6)?

Answer 20

Intraoperative Inguinal Hernia Questions:

1. What is the first identifiable subcutaneous named layer? Scarpa’s fascia
2. What is the name of the subcutaneous vein that is ligated? Superficial epigastric vein
3. What happens if you cut the ilioinguinal nerve? Numbness of inner thigh or lateral scrotum; usually goes away in 6 mo.
4. From what abdominal muscle layer is the cremaster muscle derived? Internal oblique m.
5. From what abdominal muscle layer is the inguinal ligament derived? External oblique muscle aponeurosis
6. To what does the inguinal ligament attach? ASIS to pubic tubercle
7. What nerve travels on the spermatic cord? Ilioinguinal n.
8. Why do some surgeons deliberately cut the ilioinguinal nerve? First they obtain pre-op consent and cut so as to remove the risk of entrapment and post-op pain
9. What is in the spermatic cord (6)?
   
   1. Cremasteric muscle fibers
   2. Vas deferens
   3. Testicular a.
   4. Testicular pampiniform venous plexus
   5. +/- hernia sac
   6. Genital branch of the genitofemoral n.

Question 21

Intraoperative Inguinal Hernia Questions:

1. What is the hernia sac made of?
2. What attaches the testicle to the scrotum?
3. What is the most common organ in an inguinal hernia sac in men?
4. What is the most common organ in an inguinal hernia sac in women?
5. What lies in the inguinal canal in the female instead of the VAS?
6. Where in the inguinal canal does the hernia sac lie in relation to other structures?
7. What are the borders of Hesselbach’s triangle?

Answer 21

Intraoperative Inguinal Hernia Questions:

1. What is the hernia sac made of? Peritoneum (direct) or a patent processus vaginalis (indirect)
2. What attaches the testicle to the scrotum? Gubernaculum
3. What is the most common organ in an inguinal hernia sac in men? Small Intestine
4. What is the most common organ in an inguinal hernia sac in women? Ovary/fallopian tube
5. What lies in the inguinal canal in the female instead of the VAS? Round ligament
6. Where in the inguinal canal does the hernia sac lie in relation to other structures? Anteromedially
7. What are the borders of Hesselbach’s triangle?
   
   1. Epigastric vessels
   2. Inguinal ligament
   3. Lateral border of rectus

Question 22

Femoral Hernias

1. What are the boundaries of the femoral canal?
2. What are the complications?
3. What is the most common hernia in women?
4. What is the repair of a femoral hernia?

Answer 22

1. Boundaries of femoral canal:
   
   1. Cooper’s ligament posteriorly
   2. Inguinal ligament anteriorly
   3. Femoral vein laterally
   4. Lacunar ligament medially
2. Approximately 1/3 incarcerate (due to narrow, unforgiving neck)
3. Indirect inguinal hernia
4. ALWAYS SURGICAL (NOT OBSERVATION)***
   
   1. ​McVay (cooper’s ligament repair), mesh plug repair
      
      1. Cooper’s ligament sutured to transversus abdominis aponeurosis/conjoint tendon

Question 23

A 22 y/o woman is seen in a surgery clinic for a bulge in the R groin. She denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. She has never experienced N or V. On exam, she has a reducible hernia below the inguinal ligament. Which of the following is the most appropriate mgmt of this pt?

a. Observation for now and f/u in surgery clinic if she develops any further symptoms
b. Elective surgical repair of hernia
c. Emergent surgical repair of hernia

Answer 23

b. Elective surgical repair of hernia

The incidence of strangulation in femoral hernias = high. Therefore, all femoral hernias, even asymptomatic ones, should be repaired. This patient has no evidence of an acute incarceration and does not need emergent repair of her hernia at this time.