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
2
Q
forms cremasteric muscles
A
internal abdominal oblique
3
Q
along with the conjoined tendon, forms inguinal canal floor
A
transversalis muscle
4
Q
composed of the aponeurosis of the internal abdominal oblique and transversalis muscles
A
conjoined tendon
5
Q
from external abdominal oblique fascia, runs from ASIS to the pubis; anterior to the femoral vessels
A
inguinal ligament (Poupart’s ligament)
6
Q
where the inguinal ligament splays out to insert in the pubis
A
lacunar ligament
7
Q
pectineal ligament; posterior to the femoral vessels; lies against bone
A
Cooper’s ligament
8
Q
runs medial to cord structures
A
vas deferens
9
Q
what composes hesselbach’s triangle?
A
rectus muscle, inferior inguinal ligament, and inferior epigastrics
10
Q
hernia: inferior/medial to the epigastric vessels
A
direct hernias
11
Q
hernia: superior/lateral to the epigastric vessels
A
indirect hernias
12
Q
hernia: most common, from persistently patent processus vaginalis
A
indirect hernia
13
Q
hernia: lower risk of incarceration; rare in females, higher recurrence than indirect
A
direct hernias
14
Q
hernia: direct and indirect components
A
pantaloon hernia
15
Q
risk factors for inguinal hernia in adults
A
age, obesity, heavy lifting, COPD (coughing), chronic constipation, straining (BPH), ascites, pregnancy, peritoneal dialysis
16
Q
can lead to bowel strangulation; should be repaired emergently
A
incarcerated hernia
17
Q
retroperitoneal organ that makes up part of the hernia sac
A
sliding hernia
18
Q
female: component of sliding hernia
A
ovaries or fallopian tubes most common
19
Q
males: component of sliding hernia
A
cecum or sigmoid most common
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
21
Q
management: females with ovary in canal
A
- ligate the round ligament
- return ovary to peritoneum
- perform biopsy if looks abnormal
22
Q
management: hernias in infants and children
A
- just perform high ligation (nearly always indirect)
- open sac prior to ligation
23
Q
what is a lichtenstein repair?
A
hernia repair with mesh; recurrence decreases with use of mesh (decreases tension)
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
25
hernia: approximation of the conjoined tendon and transversalis fascia (superior) to Cooper's ligament (pectineal ligament, inferior)
Cooper's ligament repair
26
incision necessary in cooper's ligament repair
needs a relaxing incision in the external abdominal oblique fascia
27
when can you use cooper's ligament repair?
can use this for femoral hernia repair
28
indications for laparoscopic hernia repair
indicated for bilateral or recurrent inguinal hernia
29
most commonly early complication following hernia repair
urinary retention
30
hernia repair: wound infection rate
1%
31
hernia repair: recurrence rate
2%
32
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
testicular atrophy
33
what veins are affected in testicular atrophy?
spermatic cord veins
34
when does testicular atrophy usually occur?
usually occurs with indirect hernias
35
what is the usual cause of pain after hernia?
usually compression of ilioinguinal nerve
36
tx: compression of ilioguinal nerve causing pain after hernia
local infiltration can be diagnostic and therapeutic
37
loss of cremasteric reflex; numbness on ipsilateral penis, scrotum, and thigh
ilioinguinal nerve injury
38
where is ilioinguinal nerve usually injured?
nerve is usually injured at the external ring; nerve runs on top of cord
39
when is genitofemoral nerve usually injured in hernia repair?
usually injured with laparoscopic hernia repair
40
genitofemoral nerve:
| - cremaster (motor) and scrotum (sensory)
genital branch of the genitofemoral nerve
41
genitofemoral nerve:
| - upper lateral thigh (sensory)
femoral branch of the genitofemoral nerve
42
management: cord lipoma
should be removed
43
most common in males, although incidence is increased in females compared to inguinal hernias
femoral hernias
44
femoral canal boundaries
- posterior: cooper's ligament
- anterior: inguinal ligament
- lateral: femoral vein
- medial: Poupart's ligament
45
where is a femoral hernia?
medial to the femoral vein and lateral to the lymphatics (in empty space)
- hernia passes under the inguinal ligament
46
femoral hernia: risk of incarceration
high risk of incarceration -> may need to divide the inguinal ligament to reduce the bowel
47
characteristic presentation of femoral hernia
characteristic bulge on the anterior-medial thigh below the ligament
48
how is femoral hernia usually repaired?
hernia is usually repaired through an inguinal approach with cooper's ligament repair
49
- increased incidence in African americans; often close on their own
- delay repair until 5 years
- risk of incarceration in adults, not children
umbilical hernia
50
- lateral border of rectus muscle, adjacent to the linea semilunaris
- almost always inferior to the semicircularis
spigelian hernia
51
where does spigelian hernia occur?
occurs between the muscle fibers of the internal abdominal oblique muscle and insertion of the external abdominal oblique aponeurosis into the rectus sheath
52
- can present as tender medial thigh mass or as small bowel obstruction
- elderly women, previous pregnancy, bowel gas below superior pubic ramus
obturator hernia (anterior pelvis)
53
inner thigh pain with internal rotation
howship-romberg sign (obturator hernia)
54
tx: obturator hernia
operative reduction, may need mesh; check other side for similar defect
55
herniation through the greater sciatic foramen; high rate of strangulation
sciatic hernia (posterior pelvis)
56
hernia: most likely to recur; inadequate closure is the most common cause
incisional hernia
57
rectus sheath: anterior vs posterior
- anterior: complete
| - posterior: absent below semicircularis (below umbilicus)
58
how does the posterior aponeurosis of the internal abdominal oblique descend below the umbilicus?
the posterior aponeurosis of the internal abdominal oblique and transversalis aponeurosis move anterior below the umbilicus.
59
- 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)
rectus sheath hematomas
60
tx: rectus sheath hematomas
nonoperative usual, surgery if expanding
61
what vessel is injured in rectus sheath hematomas?
epigastric vessel injury
62
Fothergill's sign
rectus sheath hematomas: mass more prominent and painful with flexion of the rectus muscle.
63
- women, benign but locally invasive; increased recurrences
- gardner's syndrome
- painless mass
desmoid tumors
64
sx tx: desmoid tumor
wide local excision if possible; if involving significant small bowel mesentery, excision may not be indicated -> often not completely resectable.
65
medical tx: desmoid tumor
sulindac and tamoxifen
66
what causes retroperitoneal fibrosis?
can occur with hypersensitivity to methysergide
67
most sensitive test for retroperitoneal fibrosis
IVP most sensitive test (constricted ureters)
68
symptoms usually related to trapped ureters and lymphatic obstruction
retroperitoneal fibrosis
69
tx: retroperitoneal fibrosis
steroids, nephrostomy if infection is present, and surgery if renal function becomes compromised (Free up ureters and wrap in momentum)
70
mesenteric tumors: of the primary tumors, most are...
of the primary tumors, most are cystic
71
mesenteric tumors: location of malignant tumors
closer to the root of the mesentery
72
mesenteric tumors: location of benign tumors
more peripheral
73
MCC malignant mesenteric tumors
```
#1 liposarcoma
leiomyosarcoma
```
74
dx / tx mesenteric tumors
dx: abdominal ct
tx: resection
75
- 15% in children, others in 5th - 6th decade
- malignant > benign
- symptoms: vague abdominal and back pain
retroperitoneal tumors
76
most common malignant retroperitoneal tumor
```
#1 lymphoma
#2 liposarcoma
```
77
- would leave residual tumor
| - mets go to lung
retroperitoneal sarcomas
78
MC omental solid tumor
metastatic disease
79
management: mets to omentum
omentectomy for metastatic cancer has a role for some cancers (e.g. ovarian CA)
80
omentum: usually asymptomatic, can undergo torsion
omental cysts
81
omentum:
- rare, 1/3 are malignant
- NO Biopsy: can bleed
- tx: resection
primary solid omental tumors
82
how is blood absorbed in the peritoneum?
blood is absorbed through fenestrated lymphatic channels in the peritoneum
83
drugs removed with peritoneal dialysis
most drugs are removed with peritoneal dialysis
84
elements removed with peritoneal dialysis
NH3, Ca, Fe, and lead
85
how does fluid move into the peritoneal cavity?
movement of fluid into the peritoneal cavity can occur with hypertonic intra-peritoneal saline load (mechanism of peritoneal dialysis); can cause hypotension
86
CO2 pneumoperitoneum causing cardiopulmonary dysfunction
can occur with intra-abdominal pressure > 20
87
what parameters does CO2 pneumoperitoneum increase?
MAP, PAP, HR, SVR, CVP, mean airway pressure, PIP, CO2
88
what parameters does CO2 pneumoperitoneum decrease?
pH, venous return (IVC compression), CO, renal flow secondary to decreased CO
89
what lowers pressure necessary to cause compromise in CO2 pneumoperitoneum?
hypovolemia
90
what worsens effects of pneumoperitoneum?
PEEP
91
how does CO2 affect myocardial contractility?
CO2 can cause some decrease in myocardial contractility
92
tx: CO2 embolus
head down, turn patient to the left (sudden rise in ETCO2 and hypotension); can try to aspirate CO2 thru central line; prolonged CPR
93
- cost-effective for medium vessels (short gastric)
| - disrupts protein H-bonds, causes coagulation
Harmonic scalpel
94
most commonly used mode on ultrasound
b-mode (b= brightness; assess relative density of structures)
95
US - dark area posterior to object indicates mass
shadowing
96
US - brighter area posterior to object indicates fluid-filled cyst
enhancement
97
US - Duplex:
- Lower frequencies: show?
- higher frequencies: show?
lower: deep structures
higher: superficial structures
98
energy transferred against argon gas
Argon beam
99
argon beam: determines depth of necrosis
depth of necrosis related to power setting (2mm); causes superficial coagulation
100
what is good for hemostasis of the liver and spleen?
argon beam: is non-contact: good for hemostasis of the liver and spleen; smokeless
101
return of electrons to ground state releases energy as heat -> coagulates and vaporizers
laser
102
tx: condylomata accuminata
laser (wear mask)
103
good for deep tissue penetration; good for bronchial lesions
Nd:YAG laser
1-2mm cuts, 3-10 mm vaporizes, and 1-2 cm coagulates
104
cannot get fibroblast ingrowth
Gore-Tex (PTFE)
105
allows fibroblast ingrowth
Dacron (polypropylene)
106
incidence of vascular or bowel injury with Veress needle or trocar
0.1%
