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06 - absite > chapter 38: hernias, abdomen, and surgical technology > Flashcards

chapter 38: hernias, abdomen, and surgical technology Flashcards

1
Q

forms the inguinal ligament (shelving edge) at inferior portion of the inguinal canal

A

External abdominal oblique fascia

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2
Q

forms cremasteric muscles

A

internal abdominal oblique

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3
Q

along with the conjoined tendon, forms inguinal canal floor

A

transversalis muscle

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4
Q

composed of the aponeurosis of the internal abdominal oblique and transversalis muscles

A

conjoined tendon

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5
Q

from external abdominal oblique fascia, runs from ASIS to the pubis; anterior to the femoral vessels

A

inguinal ligament (Poupart’s ligament)

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6
Q

where the inguinal ligament splays out to insert in the pubis

A

lacunar ligament

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7
Q

pectineal ligament; posterior to the femoral vessels; lies against bone

A

Cooper’s ligament

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8
Q

runs medial to cord structures

A

vas deferens

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9
Q

what composes hesselbach’s triangle?

A

rectus muscle, inferior inguinal ligament, and inferior epigastrics

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10
Q

hernia: inferior/medial to the epigastric vessels

A

direct hernias

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11
Q

hernia: superior/lateral to the epigastric vessels

A

indirect hernias

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12
Q

hernia: most common, from persistently patent processus vaginalis

A

indirect hernia

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13
Q

hernia: lower risk of incarceration; rare in females, higher recurrence than indirect

A

direct hernias

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14
Q

hernia: direct and indirect components

A

pantaloon hernia

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15
Q

risk factors for inguinal hernia in adults

A

age, obesity, heavy lifting, COPD (coughing), chronic constipation, straining (BPH), ascites, pregnancy, peritoneal dialysis

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16
Q

can lead to bowel strangulation; should be repaired emergently

A

incarcerated hernia

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17
Q

retroperitoneal organ that makes up part of the hernia sac

A

sliding hernia

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18
Q

female: component of sliding hernia

A

ovaries or fallopian tubes most common

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19
Q

males: component of sliding hernia

A

cecum or sigmoid most common

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20
Q

aside from ovarian/fallopian tubes or cecum/sigmoid, what else can be involved in a sliding hernia?

A

bladder can also be involved

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21
Q

management: females with ovary in canal

A
  • ligate the round ligament
  • return ovary to peritoneum
  • perform biopsy if looks abnormal
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22
Q

management: hernias in infants and children

A
  • just perform high ligation (nearly always indirect)

- open sac prior to ligation

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23
Q

what is a lichtenstein repair?

A

hernia repair with mesh; recurrence decreases with use of mesh (decreases tension)

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24
Q

hernia: approximation of the conjoined tendon and transversalis fascia (superior) to the free edge of the inguinal ligament (shelving edge, inferior)

A

bassini repair

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25
Q

hernia: approximation of the conjoined tendon and transversalis fascia (superior) to Cooper’s ligament (pectineal ligament, inferior)

A

Cooper’s ligament repair

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26
Q

incision necessary in cooper’s ligament repair

A

needs a relaxing incision in the external abdominal oblique fascia

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27
Q

when can you use cooper’s ligament repair?

A

can use this for femoral hernia repair

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28
Q

indications for laparoscopic hernia repair

A

indicated for bilateral or recurrent inguinal hernia

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29
Q

most commonly early complication following hernia repair

A

urinary retention

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30
Q

hernia repair: wound infection rate

A

1%

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31
Q

hernia repair: recurrence rate

A

2%

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32
Q

usually secondary to dissection of the distal component of the hernia sac causing vessel disruption

  • thrombosis of spermatic cord veins
  • usually occurs with indirect hernias
A

testicular atrophy

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33
Q

what veins are affected in testicular atrophy?

A

spermatic cord veins

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34
Q

when does testicular atrophy usually occur?

A

usually occurs with indirect hernias

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35
Q

what is the usual cause of pain after hernia?

A

usually compression of ilioinguinal nerve

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36
Q

tx: compression of ilioguinal nerve causing pain after hernia

A

local infiltration can be diagnostic and therapeutic

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37
Q

loss of cremasteric reflex; numbness on ipsilateral penis, scrotum, and thigh

A

ilioinguinal nerve injury

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38
Q

where is ilioinguinal nerve usually injured?

A

nerve is usually injured at the external ring; nerve runs on top of cord

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39
Q

when is genitofemoral nerve usually injured in hernia repair?

A

usually injured with laparoscopic hernia repair

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40
Q

genitofemoral nerve:

- cremaster (motor) and scrotum (sensory)

A

genital branch of the genitofemoral nerve

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41
Q

genitofemoral nerve:

- upper lateral thigh (sensory)

A

femoral branch of the genitofemoral nerve

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42
Q

management: cord lipoma

A

should be removed

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43
Q

most common in males, although incidence is increased in females compared to inguinal hernias

A

femoral hernias

44
Q

femoral canal boundaries

A
  • posterior: cooper’s ligament
  • anterior: inguinal ligament
  • lateral: femoral vein
  • medial: Poupart’s ligament
45
Q

where is a femoral hernia?

A

medial to the femoral vein and lateral to the lymphatics (in empty space)
- hernia passes under the inguinal ligament

46
Q

femoral hernia: risk of incarceration

A

high risk of incarceration -> may need to divide the inguinal ligament to reduce the bowel

47
Q

characteristic presentation of femoral hernia

A

characteristic bulge on the anterior-medial thigh below the ligament

48
Q

how is femoral hernia usually repaired?

A

hernia is usually repaired through an inguinal approach with cooper’s ligament repair

49
Q
  • increased incidence in African americans; often close on their own
  • delay repair until 5 years
  • risk of incarceration in adults, not children
A

umbilical hernia

50
Q
  • lateral border of rectus muscle, adjacent to the linea semilunaris
  • almost always inferior to the semicircularis
A

spigelian hernia

51
Q

where does spigelian hernia occur?

A

occurs between the muscle fibers of the internal abdominal oblique muscle and insertion of the external abdominal oblique aponeurosis into the rectus sheath

52
Q
  • can present as tender medial thigh mass or as small bowel obstruction
  • elderly women, previous pregnancy, bowel gas below superior pubic ramus
A

obturator hernia (anterior pelvis)

53
Q

inner thigh pain with internal rotation

A

howship-romberg sign (obturator hernia)

54
Q

tx: obturator hernia

A

operative reduction, may need mesh; check other side for similar defect

55
Q

herniation through the greater sciatic foramen; high rate of strangulation

A

sciatic hernia (posterior pelvis)

56
Q

hernia: most likely to recur; inadequate closure is the most common cause

A

incisional hernia

57
Q

rectus sheath: anterior vs posterior

A
  • anterior: complete

- posterior: absent below semicircularis (below umbilicus)

58
Q

how does the posterior aponeurosis of the internal abdominal oblique descend below the umbilicus?

A

the posterior aponeurosis of the internal abdominal oblique and transversalis aponeurosis move anterior below the umbilicus.

59
Q
  • most common after trauma; epigastric vessel injury
  • painful abdominal wall mass
  • mass more prominent and painful with flexion of the rectus muscle (Fothergill’s sign)
A

rectus sheath hematomas

60
Q

tx: rectus sheath hematomas

A

nonoperative usual, surgery if expanding

61
Q

what vessel is injured in rectus sheath hematomas?

A

epigastric vessel injury

62
Q

Fothergill’s sign

A

rectus sheath hematomas: mass more prominent and painful with flexion of the rectus muscle.

63
Q
  • women, benign but locally invasive; increased recurrences
  • gardner’s syndrome
  • painless mass
A

desmoid tumors

64
Q

sx tx: desmoid tumor

A

wide local excision if possible; if involving significant small bowel mesentery, excision may not be indicated -> often not completely resectable.

65
Q

medical tx: desmoid tumor

A

sulindac and tamoxifen

66
Q

what causes retroperitoneal fibrosis?

A

can occur with hypersensitivity to methysergide

67
Q

most sensitive test for retroperitoneal fibrosis

A

IVP most sensitive test (constricted ureters)

68
Q

symptoms usually related to trapped ureters and lymphatic obstruction

A

retroperitoneal fibrosis

69
Q

tx: retroperitoneal fibrosis

A

steroids, nephrostomy if infection is present, and surgery if renal function becomes compromised (Free up ureters and wrap in momentum)

70
Q

mesenteric tumors: of the primary tumors, most are…

A

of the primary tumors, most are cystic

71
Q

mesenteric tumors: location of malignant tumors

A

closer to the root of the mesentery

72
Q

mesenteric tumors: location of benign tumors

A

more peripheral

73
Q

MCC malignant mesenteric tumors

A 
#1 liposarcoma
leiomyosarcoma
74
Q

dx / tx mesenteric tumors

A

dx: abdominal ct
tx: resection

75
Q
  • 15% in children, others in 5th - 6th decade
  • malignant > benign
  • symptoms: vague abdominal and back pain
A

retroperitoneal tumors

76
Q

most common malignant retroperitoneal tumor

A 
#1 lymphoma
#2 liposarcoma
77
Q
  • would leave residual tumor

- mets go to lung

A

retroperitoneal sarcomas

78
Q

MC omental solid tumor

A

metastatic disease

79
Q

management: mets to omentum

A

omentectomy for metastatic cancer has a role for some cancers (e.g. ovarian CA)

80
Q

omentum: usually asymptomatic, can undergo torsion

A

omental cysts

81
Q

omentum:

  • rare, 1/3 are malignant
  • NO Biopsy: can bleed
  • tx: resection
A

primary solid omental tumors

82
Q

how is blood absorbed in the peritoneum?

A

blood is absorbed through fenestrated lymphatic channels in the peritoneum

83
Q

drugs removed with peritoneal dialysis

A

most drugs are removed with peritoneal dialysis

84
Q

elements removed with peritoneal dialysis

A

NH3, Ca, Fe, and lead

85
Q

how does fluid move into the peritoneal cavity?

A

movement of fluid into the peritoneal cavity can occur with hypertonic intra-peritoneal saline load (mechanism of peritoneal dialysis); can cause hypotension

86
Q

CO2 pneumoperitoneum causing cardiopulmonary dysfunction

A

can occur with intra-abdominal pressure > 20

87
Q

what parameters does CO2 pneumoperitoneum increase?

A

MAP, PAP, HR, SVR, CVP, mean airway pressure, PIP, CO2

88
Q

what parameters does CO2 pneumoperitoneum decrease?

A

pH, venous return (IVC compression), CO, renal flow secondary to decreased CO

89
Q

what lowers pressure necessary to cause compromise in CO2 pneumoperitoneum?

A

hypovolemia

90
Q

what worsens effects of pneumoperitoneum?

A

PEEP

91
Q

how does CO2 affect myocardial contractility?

A

CO2 can cause some decrease in myocardial contractility

92
Q

tx: CO2 embolus

A

head down, turn patient to the left (sudden rise in ETCO2 and hypotension); can try to aspirate CO2 thru central line; prolonged CPR

93
Q
  • cost-effective for medium vessels (short gastric)

- disrupts protein H-bonds, causes coagulation

A

Harmonic scalpel

94
Q

most commonly used mode on ultrasound

A

b-mode (b= brightness; assess relative density of structures)

95
Q

US - dark area posterior to object indicates mass

A

shadowing

96
Q

US - brighter area posterior to object indicates fluid-filled cyst

A

enhancement

97
Q

US - Duplex:

  • Lower frequencies: show?
  • higher frequencies: show?
A

lower: deep structures
higher: superficial structures

98
Q

energy transferred against argon gas

A

Argon beam

99
Q

argon beam: determines depth of necrosis

A

depth of necrosis related to power setting (2mm); causes superficial coagulation

100
Q

what is good for hemostasis of the liver and spleen?

A

argon beam: is non-contact: good for hemostasis of the liver and spleen; smokeless

101
Q

return of electrons to ground state releases energy as heat -> coagulates and vaporizers

A

laser

102
Q

tx: condylomata accuminata

A

laser (wear mask)

103
Q

good for deep tissue penetration; good for bronchial lesions

A

Nd:YAG laser

1-2mm cuts, 3-10 mm vaporizes, and 1-2 cm coagulates

104
Q

cannot get fibroblast ingrowth

A

Gore-Tex (PTFE)

105
Q

allows fibroblast ingrowth

A

Dacron (polypropylene)

106
Q

incidence of vascular or bowel injury with Veress needle or trocar

A

0.1%

06 - absite (44 decks)

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