Chapter 38 - Hernias, Abdomen & Surgical Technology+ Flashcards
What forms the shelving edge in inguinal hernias?
External abdominal oblique (and fascia; borders the inguinal ligament; inferior border for Lichtenstein repair)
What forms the cremasteric muscles?
Internal abdominal oblique (superior border of Lichtenstein)
What forms the inguinal canal floor?
Transversalis fascia (direct hernia through here)
Where does the inguinal ligament run? What is it made from?
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.
What makes up the lacunar ligament?
Where the inguinal ligament splays out to insert in the pubis/pubic tubercle (the start of the main stitch in Lichtenstein)
Where does the iliopubic tract run? What makes it up?
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.
What is another name for Cooper’s ligament?
Pectineal ligament - periosteum and fascia along the superior ramus of the pubis; used in McVay repair (nonmesh repair of femoral hernia)
What makes up the conjoined tendon?
Aponeurosis of the internal abdominal oblique and transversus abdominis muscle (sutured to the inguinal ligament in Bassini repair)
Where does the vas deferens run in relation to the cord structures?
Medial to cord structures
What are the borders of Hesselbach’s triangle?
Rectus muscle, inferior inguinal ligament, inferior epigastrics
Where are direct hernias in relation to Hesselbach’s triangle? Indirect hernias?
Direct: inferior, medial to epigastric vessels (through triangle, transversalis) Indirect: Superior/lateral to epigastric vessels (through internal ring)
Risk factors for inguinal hernia in adults?
Age, obesity, heavy lifting, COPD, chronic constipation, straining, ascites, pregnancy, peritoneal dialysis
Which type of inguinal hernia is most common?
Indirect; from persistently patent processus vaginalis
Which inguinal hernia has lower risk of incarceration? Higher recurrence?
Direct
What is a pantaloon hernia?
Direct and indirect component
What is most commonly contained in sliding hernias in females? Males?
Females: ovaries or fallopian tubes Males: cecum or sigmoid
What is the procedure for a female with ovary in canal?
Ligate round ligament (passes through inguinal canal), return ovary to peritoneum, perform biopsy if looks abnormal
What is the procedure for hernias in infants and children?
High ligation (almost always indirect), open sac prior to ligation
What is a Lichtenstein repair?
Mesh repair over transversalis; decreased recurrence
What is Bassini repair?
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.
What is a McVay repair?
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.
What are the indications for lap hernia repair?
Bilateral or recurrent inguinal hernia
What is the most common early complication following hernia repair?
Urinary retention
What is the % of wound infections with hernia repair?
2%
What is the recurrence rate after hernia repair?
2%
When does testicular atrophy occur?
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.
What is the most common cause of pain after hernia? Treatment?
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.
What is the result of ilioinguinal nerve injury?
Loss of cremasteric reflex; numbness on ipsilateral penis, scrotum and thigh
What is the result of genitofemoral nerve injury?
Usually injured with lap repair.
Genital branch: cremaster (motor), and sensory to scrotum.
Femoral branch: sensory to upper lateral thigh.
What should be done with cord lipomas?
Removal. Failure to recognize and manage a cord lipoma could result in recurrent hernia formation
What is the trapezoid of doom?
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.
What are femoral canal boundaries?
Cooper’s ligament, inguinal ligament, femoral vein
What may need to be done to reduce bowel in femoral hernia?
Divide the inguinal ligament
Where are Spigelian hernias?
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.
