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
conjoined tendon is composed of ___ + ___ aponeuroses
A
transversalis abdominus + internal oblique
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
vas deferens runs [medial/lateral] to spermatic cord
A
medial
9
Q
what composes hesselbach’s triangle?
A
rectus muscle, inguinal ligament, and inferior epigastrics
10
Q
hernia: inferior/medial to the epigastric vessels
A
direct inguinal hernia
11
Q
hernia: superior/lateral to the epigastric vessels
A
indirect hernias
12
Q
hernia: most common, from persistently patent processus vaginalis
A
indirect inguinal 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
hernia complication?
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
which type of hernias are testicular atrophy associated with?
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? open or lap?
usually injured with laparoscopic hernia repair
40
genitofemoral nerve - which branch?:
| - cremaster (motor) and scrotum (sensory)
genital branch of the genitofemoral nerve
41
genitofemoral nerve - which branch?:
| - upper lateral thigh (sensory)
femoral branch of the genitofemoral nerve
42
management: cord lipoma
should be removed
43
femoral hernias
| - MC in M/F?
MC in M
| femoral hernias are more common in inguinal hernias in F
44
femoral canal boundaries
- posterior: cooper's ligament
- anterior: inguinal ligament
- lateral: femoral vein
- medial: lacunar 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 inguinal 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
type of hernia?
- lateral border of rectus muscle, adjacent to the linea semilunaris
- almost always inferior to the semicircularis
- occurs bt int abd obl muscle + ext abd oblq aponeurosis into rectus sheath
spigelian hernia
51
type of hernia?
- can present as tender medial thigh mass or as small bowel obstruction
- elderly women, previous pregnancy, bowel gas below superior pubic ramus
- inner thigh pain w internal rotation (which sign?)
obturator hernia (anterior pelvis)
Howship-Romberg sign
52
which sign?
which hernia?
inner thigh pain with internal rotation
howship-romberg sign (obturator hernia)
53
tx: obturator hernia
operative reduction, may need mesh; check other side for similar defect
54
herniation through the greater sciatic foramen; high rate of strangulation
sciatic hernia (posterior pelvis)
55
hernia: most likely to recur; inadequate closure is the most common cause
incisional hernia
56
rectus sheath: anterior vs posterior
- which are present above the semicircularis?
- which is absent below?
- anterior: complete
| - posterior: absent below semicircularis (below umbilicus)
57
how does the posterior aponeurosis of the internal abdominal oblique descend below the umbilicus?
-anterior or posterior
the posterior aponeurosis of the internal abdominal oblique and transversalis aponeurosis move anterior below the umbilicus.
58
dx?
- 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
59
tx: rectus sheath hematomas
nonoperative usual, surgery if expanding
60
what vessel is injured in rectus sheath hematomas?
epigastric vessel injury
61
Fothergill's sign
rectus sheath hematomas: mass more prominent and painful with flexion of the rectus muscle.
62
dx?
- painless mass
- women
- benign but locally invasive; increased recurrences
- gardner's syndrome
desmoid tumors
63
surg tx: desmoid tumor
wide local excision if possible; if involving significant small bowel mesentery, excision may not be indicated -> often not completely resectable.
64
medical tx: desmoid tumor
sulindac and tamoxifen
65
hypersensitivity to what medicine causes retroperitoneal fibrosis?
can occur with hypersensitivity to methysergide (ergot derived prescription drug used for the prophylaxis of difficult to treat migraine)
66
most sensitive test for retroperitoneal fibrosis
IVP most sensitive test (constricted ureters)
67
symptoms usually related to trapped ureters and lymphatic obstruction
retroperitoneal fibrosis
68
tx: retroperitoneal fibrosis
steroids, nephrostomy if infection is present, and surgery if renal function becomes compromised (Free up ureters and wrap in momentum)
69
primary mesenteric tumors - most are: cystic/solid?
cystic
70
mesenteric tumors: location of malignant tumors
closer to the root of the mesentery
71
mesenteric tumors: location of benign tumors
more peripheral
72
```
MCC malignant mesenteric tumors
#1, #2
```
```
#1 liposarcoma
#2 leiomyosarcoma
```
73
dx / tx mesenteric tumors
dx: abdominal ct
tx: resection
74
retroperitoneal tumors
-bimodal age distrib ____ and ____
- more likely malignant/benign?
- sx?
retroperitoneal tumors
- 15% in children, others in 5th - 6th decade
- malignant > benign
- symptoms: vague abdominal and back pain
75
most common malignant retroperitoneal tumor
```
#1 lymphoma
#2 liposarcoma
```
76
RP sarcoma
| - mets go to ____
lung
77
MC omental solid tumor - primary/mets?
metastatic disease
78
management: mets to omentum
omentectomy for metastatic cancer has a role for some cancers (e.g. ovarian CA)
79
omental cysts - complication?
| sx?
torsion
usu asx
80
primary solid omental tumors
- common/rare?
- ___ are maligannt
- bx?
- tx?
rare
1/3 malignant
do not bx (bleeds)
resect
81
how is blood absorbed in the peritoneum?
blood is absorbed through fenestrated lymphatic channels in the peritoneum
82
are drugs removed with peritoneal dialysis?
most drugs are not removed with peritoneal dialysis
83
(4) things that can be removed with peritoneal dialysis
NH3, Ca, Fe, and lead
84
what parameters does CO2 pneumoperitoneum increase?
MAP, PAP, HR, SVR, CVP, mean airway pressure, PIP, CO2
85
what parameters does CO2 pneumoperitoneum decrease?
pH, venous return (IVC compression), CO, renal flow secondary to decreased CO
86
how does CO2 affect myocardial contractility?
CO2 can cause some decrease in myocardial contractility
87
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
88
- cost-effective for medium vessels (short gastric)
| - disrupts protein H-bonds, causes coagulation
Harmonic scalpel
89
most commonly used mode on ultrasound
b-mode (b= brightness; assess relative density of structures)
90
US - dark area posterior to object indicates mass
shadowing
91
US - brighter area posterior to object indicates fluid-filled cyst
enhancement
92
US - Duplex:
- Lower frequencies: show?
- higher frequencies: show?
lower: deep structures
higher: superficial structures
93
energy transferred against argon gas
Argon beam
94
argon beam: determines depth of necrosis
depth of necrosis related to power setting (2mm); causes superficial coagulation
95
what is good for hemostasis of the liver and spleen?
argon beam: is non-contact: good for hemostasis of the liver and spleen; smokeless
96
return of electrons to ground state releases energy as heat -> coagulates and vaporizers
laser
97
tx: condylomata accuminata
laser (wear mask)
98
good for deep tissue penetration; good for bronchial lesions
Nd:YAG laser
1-2mm cuts, 3-10 mm vaporizes, and 1-2 cm coagulates
99
cannot get fibroblast ingrowth
Gore-Tex (PTFE)
100
allows fibroblast ingrowth
Dacron (polypropylene)
101
incidence of vascular or bowel injury with Veress needle or trocar
0.1%
