chapter 38: hernias, abdomen, and surgical technology Flashcards
forms the inguinal ligament (shelving edge) at inferior portion of the inguinal canal
External abdominal oblique fascia
forms cremasteric muscles
internal abdominal oblique
along with the conjoined tendon, forms inguinal canal floor
transversalis muscle
composed of the aponeurosis of the internal abdominal oblique and transversalis muscles
conjoined tendon
from external abdominal oblique fascia, runs from ASIS to the pubis; anterior to the femoral vessels
inguinal ligament (Poupart’s ligament)
where the inguinal ligament splays out to insert in the pubis
lacunar ligament
pectineal ligament; posterior to the femoral vessels; lies against bone
Cooper’s ligament
runs medial to cord structures
vas deferens
what composes hesselbach’s triangle?
rectus muscle, inferior inguinal ligament, and inferior epigastrics
hernia: inferior/medial to the epigastric vessels
direct hernias
hernia: superior/lateral to the epigastric vessels
indirect hernias
hernia: most common, from persistently patent processus vaginalis
indirect hernia
hernia: lower risk of incarceration; rare in females, higher recurrence than indirect
direct hernias
hernia: direct and indirect components
pantaloon hernia
risk factors for inguinal hernia in adults
age, obesity, heavy lifting, COPD (coughing), chronic constipation, straining (BPH), ascites, pregnancy, peritoneal dialysis
can lead to bowel strangulation; should be repaired emergently
incarcerated hernia
retroperitoneal organ that makes up part of the hernia sac
sliding hernia
female: component of sliding hernia
ovaries or fallopian tubes most common
males: component of sliding hernia
cecum or sigmoid most common
aside from ovarian/fallopian tubes or cecum/sigmoid, what else can be involved in a sliding hernia?
bladder can also be involved
management: females with ovary in canal
- ligate the round ligament
- return ovary to peritoneum
- perform biopsy if looks abnormal
management: hernias in infants and children
- just perform high ligation (nearly always indirect)
- open sac prior to ligation
what is a lichtenstein repair?
hernia repair with mesh; recurrence decreases with use of mesh (decreases tension)
hernia: approximation of the conjoined tendon and transversalis fascia (superior) to the free edge of the inguinal ligament (shelving edge, inferior)
bassini repair
hernia: approximation of the conjoined tendon and transversalis fascia (superior) to Cooper’s ligament (pectineal ligament, inferior)
Cooper’s ligament repair
incision necessary in cooper’s ligament repair
needs a relaxing incision in the external abdominal oblique fascia
when can you use cooper’s ligament repair?
can use this for femoral hernia repair
indications for laparoscopic hernia repair
indicated for bilateral or recurrent inguinal hernia
most commonly early complication following hernia repair
urinary retention
hernia repair: wound infection rate
1%
hernia repair: recurrence rate
2%
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
what veins are affected in testicular atrophy?
spermatic cord veins
when does testicular atrophy usually occur?
usually occurs with indirect hernias
what is the usual cause of pain after hernia?
usually compression of ilioinguinal nerve
tx: compression of ilioguinal nerve causing pain after hernia
local infiltration can be diagnostic and therapeutic
loss of cremasteric reflex; numbness on ipsilateral penis, scrotum, and thigh
ilioinguinal nerve injury
where is ilioinguinal nerve usually injured?
nerve is usually injured at the external ring; nerve runs on top of cord
when is genitofemoral nerve usually injured in hernia repair?
usually injured with laparoscopic hernia repair
genitofemoral nerve:
- cremaster (motor) and scrotum (sensory)
genital branch of the genitofemoral nerve
genitofemoral nerve:
- upper lateral thigh (sensory)
femoral branch of the genitofemoral nerve
management: cord lipoma
should be removed
most common in males, although incidence is increased in females compared to inguinal hernias
femoral hernias
femoral canal boundaries
- posterior: cooper’s ligament
- anterior: inguinal ligament
- lateral: femoral vein
- medial: Poupart’s ligament
where is a femoral hernia?
medial to the femoral vein and lateral to the lymphatics (in empty space)
- hernia passes under the inguinal ligament
femoral hernia: risk of incarceration
high risk of incarceration -> may need to divide the inguinal ligament to reduce the bowel
characteristic presentation of femoral hernia
characteristic bulge on the anterior-medial thigh below the ligament
how is femoral hernia usually repaired?
hernia is usually repaired through an inguinal approach with cooper’s ligament repair
- increased incidence in African americans; often close on their own
- delay repair until 5 years
- risk of incarceration in adults, not children
umbilical hernia
- lateral border of rectus muscle, adjacent to the linea semilunaris
- almost always inferior to the semicircularis
spigelian hernia
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
- 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)
inner thigh pain with internal rotation
howship-romberg sign (obturator hernia)
tx: obturator hernia
operative reduction, may need mesh; check other side for similar defect
herniation through the greater sciatic foramen; high rate of strangulation
sciatic hernia (posterior pelvis)
hernia: most likely to recur; inadequate closure is the most common cause
incisional hernia
rectus sheath: anterior vs posterior
- anterior: complete
- posterior: absent below semicircularis (below umbilicus)
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.
- 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
tx: rectus sheath hematomas
nonoperative usual, surgery if expanding
what vessel is injured in rectus sheath hematomas?
epigastric vessel injury
Fothergill’s sign
rectus sheath hematomas: mass more prominent and painful with flexion of the rectus muscle.
- women, benign but locally invasive; increased recurrences
- gardner’s syndrome
- painless mass
desmoid tumors
sx tx: desmoid tumor
wide local excision if possible; if involving significant small bowel mesentery, excision may not be indicated -> often not completely resectable.
medical tx: desmoid tumor
sulindac and tamoxifen
what causes retroperitoneal fibrosis?
can occur with hypersensitivity to methysergide
most sensitive test for retroperitoneal fibrosis
IVP most sensitive test (constricted ureters)
symptoms usually related to trapped ureters and lymphatic obstruction
retroperitoneal fibrosis
tx: retroperitoneal fibrosis
steroids, nephrostomy if infection is present, and surgery if renal function becomes compromised (Free up ureters and wrap in momentum)
mesenteric tumors: of the primary tumors, most are…
of the primary tumors, most are cystic
mesenteric tumors: location of malignant tumors
closer to the root of the mesentery
mesenteric tumors: location of benign tumors
more peripheral
MCC malignant mesenteric tumors
#1 liposarcoma leiomyosarcoma
dx / tx mesenteric tumors
dx: abdominal ct
tx: resection
- 15% in children, others in 5th - 6th decade
- malignant > benign
- symptoms: vague abdominal and back pain
retroperitoneal tumors
most common malignant retroperitoneal tumor
#1 lymphoma #2 liposarcoma
- would leave residual tumor
- mets go to lung
retroperitoneal sarcomas
MC omental solid tumor
metastatic disease
management: mets to omentum
omentectomy for metastatic cancer has a role for some cancers (e.g. ovarian CA)
omentum: usually asymptomatic, can undergo torsion
omental cysts
omentum:
- rare, 1/3 are malignant
- NO Biopsy: can bleed
- tx: resection
primary solid omental tumors
how is blood absorbed in the peritoneum?
blood is absorbed through fenestrated lymphatic channels in the peritoneum
drugs removed with peritoneal dialysis
most drugs are removed with peritoneal dialysis
elements removed with peritoneal dialysis
NH3, Ca, Fe, and lead
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
CO2 pneumoperitoneum causing cardiopulmonary dysfunction
can occur with intra-abdominal pressure > 20
what parameters does CO2 pneumoperitoneum increase?
MAP, PAP, HR, SVR, CVP, mean airway pressure, PIP, CO2
what parameters does CO2 pneumoperitoneum decrease?
pH, venous return (IVC compression), CO, renal flow secondary to decreased CO
what lowers pressure necessary to cause compromise in CO2 pneumoperitoneum?
hypovolemia
what worsens effects of pneumoperitoneum?
PEEP
how does CO2 affect myocardial contractility?
CO2 can cause some decrease in myocardial contractility
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
- cost-effective for medium vessels (short gastric)
- disrupts protein H-bonds, causes coagulation
Harmonic scalpel
most commonly used mode on ultrasound
b-mode (b= brightness; assess relative density of structures)
US - dark area posterior to object indicates mass
shadowing
US - brighter area posterior to object indicates fluid-filled cyst
enhancement
US - Duplex:
- Lower frequencies: show?
- higher frequencies: show?
lower: deep structures
higher: superficial structures
energy transferred against argon gas
Argon beam
argon beam: determines depth of necrosis
depth of necrosis related to power setting (2mm); causes superficial coagulation
what is good for hemostasis of the liver and spleen?
argon beam: is non-contact: good for hemostasis of the liver and spleen; smokeless
return of electrons to ground state releases energy as heat -> coagulates and vaporizers
laser
tx: condylomata accuminata
laser (wear mask)
good for deep tissue penetration; good for bronchial lesions
Nd:YAG laser
1-2mm cuts, 3-10 mm vaporizes, and 1-2 cm coagulates
cannot get fibroblast ingrowth
Gore-Tex (PTFE)
allows fibroblast ingrowth
Dacron (polypropylene)
incidence of vascular or bowel injury with Veress needle or trocar
0.1%
