Chapter 38 - Hernias, Abdomen & Surgical Technology+

Question 1

What forms the shelving edge in inguinal hernias?

Answer 1

External abdominal oblique (and fascia; borders the inguinal ligament; inferior border for Lichtenstein repair)

Question 2

What forms the cremasteric muscles?

Answer 2

Internal abdominal oblique (superior border of Lichtenstein)

Question 3

What forms the inguinal canal floor?

Answer 3

Transversalis fascia (direct hernia through here)

Question 4

Where does the inguinal ligament run? What is it made from?

Answer 4

From ASIS to pubis. Made from external abdominal oblique (cut superior to access the cord). Sew this to the “triple layer” (transversalis fascia, transversus abdominis, and internal oblique) for a Bassini repair.

Question 5

What makes up the lacunar ligament?

Answer 5

Where the inguinal ligament splays out to insert in the pubis/pubic tubercle (the start of the main stitch in Lichtenstein)

Question 6

Where does the iliopubic tract run? What makes it up?

Answer 6

From ASIS to pubis running deep and parallel to the inguinal ligament. From thickened transversalis fascia. Used as a landmark in laparoscopic inguinal hernia repair. Do not tack or staple the mesh below the iliopubic tract lateral to the spermatic cord and the epigastric vessels to minimize the chance of damaging nerves and vascular structures. This area contains the “triangle of pain,” which contains the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve, and the adjacent “triangle of doom,” which contains the external iliac artery and vein defined medially by the vas deferens and laterally by the spermatic vessels.

Question 7

What is another name for Cooper’s ligament?

Answer 7

Pectineal ligament - periosteum and fascia along the superior ramus of the pubis; used in McVay repair (nonmesh repair of femoral hernia)

Question 8

What makes up the conjoined tendon?

Answer 8

Aponeurosis of the internal abdominal oblique and transversus abdominis muscle (sutured to the inguinal ligament in Bassini repair)

Question 9

Where does the vas deferens run in relation to the cord structures?

Answer 9

Medial to cord structures

Question 10

What are the borders of Hesselbach’s triangle?

Answer 10

Rectus muscle, inferior inguinal ligament, inferior epigastrics

Question 11

Where are direct hernias in relation to Hesselbach’s triangle? Indirect hernias?

Answer 11

Direct: inferior, medial to epigastric vessels (through triangle, transversalis) Indirect: Superior/lateral to epigastric vessels (through internal ring)

Question 12

Risk factors for inguinal hernia in adults?

Answer 12

Age, obesity, heavy lifting, COPD, chronic constipation, straining, ascites, pregnancy, peritoneal dialysis

Question 13

Which type of inguinal hernia is most common?

Answer 13

Indirect; from persistently patent processus vaginalis

Question 14

Which inguinal hernia has lower risk of incarceration? Higher recurrence?

Answer 14

Direct

Question 15

What is a pantaloon hernia?

Answer 15

Direct and indirect component

Question 16

What is most commonly contained in sliding hernias in females? Males?

Answer 16

Females: ovaries or fallopian tubes Males: cecum or sigmoid

Question 17

What is the procedure for a female with ovary in canal?

Answer 17

Ligate round ligament (passes through inguinal canal), return ovary to peritoneum, perform biopsy if looks abnormal

Question 18

What is the procedure for hernias in infants and children?

Answer 18

High ligation (almost always indirect), open sac prior to ligation

Question 19

What is a Lichtenstein repair?

Answer 19

Mesh repair over transversalis; decreased recurrence

Question 20

What is Bassini repair?

Answer 20

Requires relaxing incision in anterior rectus fascia. Can repair inguinal hernias if mesh contraindicated.

(a) The transversalis fascia is opened and the preperitoneal fat stripped away to prepare the deepest structure in the Bassini triple-layer (comprising the transversalis fascia, the transversus abdominis, and the internal oblique muscle).

Medially, the conjoined tendon and transversalis fascia (superior) are approximated to the free edge of the inguinal ligament (inferior).

(b) This triple-layer is approximated to the inguinal ligament extending laterally until the deep inguinal ring is sufficiently narrowed.

Question 21

What is a McVay repair?

Answer 21

Approximation of the conjoined tendon and transversalis fascia (superior) to Cooper’s ligament (inferior) with interrupted sutures to narrow the femoral ring.

Repairs femoral and inguinal hernias.

Requires a medial relaxing incision in anterior rectus fascia.

Question 22

What are the indications for lap hernia repair?

Answer 22

Bilateral or recurrent inguinal hernia

Question 23

What is the most common early complication following hernia repair?

Answer 23

Urinary retention

Question 24

What is the % of wound infections with hernia repair?

Answer 24

2%

Question 25

What is the recurrence rate after hernia repair?

Answer 25

2%

Question 26

When does testicular atrophy occur?

Answer 26

Usually with indirect hernias; secondary to dissection of the distal component of the hernia sac causing vessel disruption (pampiniform plexus) and thrombosis of spermatic cord veins. Tx starts conservatively.

Question 27

What is the most common cause of pain after hernia? Treatment?

Answer 27

Compression of ilioinguinal nerve. Local infiltration can be diagnostic and temporarily therapeutic. Percutaneous nerve ablation is permanent. Triple neurectomy can be done if percutaneous methods fail.

Question 28

What is the result of ilioinguinal nerve injury?

Answer 28

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

Question 29

What is the result of genitofemoral nerve injury?

Answer 29

Usually injured with lap repair. Genital branch: cremaster (motor), and sensory to scrotum. Femoral branch: sensory to upper lateral thigh.

Question 30

What should be done with cord lipomas?

Answer 30

Removal. Failure to recognize and manage a cord lipoma could result in recurrent hernia formation

Question 31

What is the trapezoid of doom?

Answer 31

In lap hernia repairs. Combination of "pain" and "doom." Femoral branch of genitofemoral nerve, lateral cutaneous nerve, femoral artery. Need to dissect lateral to vessels, stay along inguinal ligament.

Question 32

What are femoral canal boundaries?

Answer 32

Cooper's ligament, inguinal ligament, femoral vein

Question 33

What may need to be done to reduce bowel in femoral hernia?

Answer 33

Divide the inguinal ligament

Question 34

How is a femoral hernia usually repaired?

Answer 34

All require repair. Laparoscopically preferred d/t more direct access to hernia. If open, an inguinal approach with bilayer mesh is preferred. McVay repair if unable to use mesh.

Question 35

How long do you delay repair of umbilical hernia in children?

Answer 35

Until after 5 years of age.

Question 36

Where are Spigelian hernias?

Answer 36

Lateral border of the rectus muscle, through linea semilunaris. Almost always inferior to the semicircularis. Occurs between internal abdominal oblique muscle and line of insertion of the external abdominal oblique aponeurosis into rectus sheath. All need elective repair.

Question 37

What is Richter's hernia?

Answer 37

Noncircumferential incarceration of the nonmesenteric bowel wall causing pain without obstruction.

Question 38

What is Littre's hernia?

Answer 38

Incarcerated Meckel's

Question 39

What is Petit's hernia?

Answer 39

Inferior lumbar hernia. External abdominal oblique, lat dorsi, iliac crest are boundaries.

Question 40

What is Grynfeltt's hernia?

Answer 40

Superior lumbar hernia Internal abdominal oblique, lumbodorsal aponeurosis, 12th rib

Question 41

What is Sciatic hernia?

Answer 41

Herniation through greater sciatic foramen; high rate of strangulation

Question 42

What is Howship-Romberg sign?

Answer 42

Inner (medial) thigh pain with lower extremity internal rotation; characteristic of obturator hernia. The obturator foramen is bounded superiorly by the superior pubic ramus and is formed by the ischial rami.

Question 43

Who gets obturator hernias?

Answer 43

Elderly women, previous pregnancy, bowel gas below superior pubic ramus. Often present with obstruction.

Question 44

Treatment for obturator hernia?

Answer 44

Operative reduction through abdominal approach, may need mesh; check other side for similar defect (often bilateral). If the bowel is difficult to reduce, may need to incise the obturator membrane to improve exposure (avoid injury to the obturator nerve, vein, and artery).

Question 45

What type of hernia is most likely to recur?

Answer 45

Incisional hernia

Question 46

What causes rectus sheath hematomas? Treatment?

Answer 46

Most common after trauma, due to epigastric vessel injury. Nonoperative, surgery if expanding.

Question 47

What is Fothergill's sign?

Answer 47

Rectus sheath hematoma: mass more prominent and painful with flexion of the rectus muscle

Question 48

Characteristics of desmoid tumors?

Answer 48

Women, benign but locally invasive, high rate of recurrence

Question 49

What syndrome is associated with desmoid tumors?

Answer 49

Gardner's

Question 50

Treatment for desmoid tumor?

Answer 50

WLE; if involving small bowel may need excision Often not completely resectable and can cause worsening fibrosis NSAIDs, antiestrogens

Question 51

What is a possible cause of retroperitoneal fibrosis?

Answer 51

Hypersensitivity to methysergide

Question 52

What is the most sensitive test for retroperitoneal fibrosis?

Answer 52

IVP

Question 53

Symptoms of retroperitoneal fibrosis? Treatment?

Answer 53

Symptoms related to trapped ureters and lymphatic obstruction Steroids, nephrostomy and surgery if renal fxn becomes compromised

Question 54

Where are malignant mesenteric tumors? Benign?

Answer 54

Malignant: closer to root of mesentery Benign: more peripheral

Question 55

What are malignant mesenteric tumor types?

Answer 55

Liposarcoma, leiomyosarcoma

Question 56

What age group at risk for retroperitoneal tumors?

Answer 56

15% in children 5th-6th decade

Question 57

What is the most common malignant retroperitoneal tumor?

Answer 57

#1 lymphoma, #2 liposarcoma

Question 58

What is the 5 yr survival rate for retroperitoneal sarcomas? % resectable?

Answer 58

10% 5yr survival \<25% resectable

Question 59

Where do mets from retroperitoneal sarcomas go?

Answer 59

Lung

Question 60

What is the most common omental solid tumor?

Answer 60

Metastatic disease

Question 61

Treatment of omental tumors?

Answer 61

Resection, do not biopsy due to risk of bleed

Question 62

At what rate is saline absorbed from peritoneal membrane?

Answer 62

35cc/hr

Question 63

What is removed with peritoneal dialysis?

Answer 63

NH3, Ca, Fe, lead; most drugs not removed

Question 64

At what intraabdominal pressure can cardiopulmonary dysfunction occur?

Answer 64

\>20mmHg

Question 65

Treatment for CO2 embolus?

Answer 65

Head down, turn pt to the left (Sudden risk in ETCO2 hypotension)

Question 66

How does the harmonic scalpel work?

Answer 66

Disrupts protein H-bonds, causes coagulation

Question 67

How does Argon beam work? What is it's depth of penetration?

Answer 67

Energy transferred across argon gas Depth of necrosis related to power setting (2mm)

Question 68

What type of graft (Gore-Tex/PTFE vs Dacron/polypropylene) allows fibroblast ingrowth?

Answer 68

Dacron

Question 69

What is the incidence of vascular or bowel injury with Veress needle?

Answer 69

0.1%

Question 70

In a patient with an ostomy and parastomal hernia, what are the options?

Answer 70

Elective repair. See if the ostomy can be reversed. If not, lap mesh repair should be considered.

Question 71

In a patient with an indication for elective hernia repair, what can be done pre-op to reduce complications?

Answer 71

quit smoking, lose weight, maintain good nutrition, glucose control

Question 72

What kind of mesh is preferred in laparoscopic repair?

Answer 72

composite mesh - visceral side facing bowel can reduce adhesions/erosions, with the other side incorporating into the abdominal wall

Question 73

Where should mesh be placed in a patient with Crohn's disease and a large incisional hernia?

Answer 73

avoid intraperitoneal mesh; open anterior component separation with primary fascial closure and retrorectus placement of mesh is a good option

Question 74

What is the suggested method of approaching a recurrent hernia?

Answer 74

In general, failed posterior repairs should be repaired using an anterior approach, and vice versa, failed anterior repairs should be repaired using a posterior approach.

Question 75

Patients with an acutely incarcerated inguinal hernia but without signs of strangulation or obstruction should be managed how?

Answer 75

require surgery, typically urgently

Question 76

How much mesh overlap is needed in laparoscopic ventral hernia repair?

Answer 76

5 cm if placed as underlay.

Question 77

At what point should a component separation be considered?

Answer 77

a hernia that is 10 cm

Question 78

Where in the abdominal wall does mesh placement have the lowest chance of recurrence?

Answer 78

sublay (retrorectus; preferred for open) and underlay (below peritoneum aka intraperitoneal onlay; preferred for laparoscopic)

Question 79

Should primary fascial closure be done for hernia repair?

Answer 79

Yes. It has been associated with fewer complications compared with not closing the fascial primarily.

Question 80

How do you manage an umbilical hernia in a patient with leaking abdominal ascites, thin skin over umbilicus, or eschar over the apex?

Answer 80

Leaking abdominal ascites: urgent problem that requires aggressive management. Immediately admitted for risk of bacterial peritonitis and/or hernia rupture. Attempting to control the ascites prior to repair with aggressive diuresis and sodium and fluid restriction is prudent. Bedrest to remove undue strain on the weak and leaking site as well as administration of intravenous antibiotics to help prevent bacterial peritonitis are also indicated. If operation must be undertaken emergently (true rupture), or diuretic therapy fails to control the ascites, combined umbilical herniorrhaphy without mesh and with a peritoneal-venous shunt is effective in achieving a stable repair with a relatively low morbidity.

Question 81

How do you manage an asymptomatic umbilical hernia in a patient with cirrhosis?

Answer 81

Manage conservatively. If they are on transplant list, repair the hernia at time of transplant.

Question 82

What nerve is at most risk in laparoscopic inguinal hernia repair?

Answer 82

Laparoscopic placement of mesh has the potential to entrap the lateral femoral cutaneous nerve as it exits the peritoneum.

Question 83

As part of the anterior component separation, which layer of the abdominal wall is incised to gain additional length on the abdominal wall?

Answer 83

External oblique aponeurosis

Question 84

During open inguinal hernia repair you notice a lot of blood coming from the undersurface of the abdominal wall. What happened?

Answer 84

The inferior epigastric artery arises from the external iliac artery immediately superior to the inguinal ligament, and this is the most likely to be injured during inguinal herniorrhaphy.