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
How is a femoral hernia usually repaired?
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.
How long do you delay repair of umbilical hernia in children?
Until after 5 years of age.
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.
What is Richter’s hernia?
Noncircumferential incarceration of the nonmesenteric bowel wall causing pain without obstruction.
What is Littre’s hernia?
Incarcerated Meckel’s
What is Petit’s hernia?
Inferior lumbar hernia. External abdominal oblique, lat dorsi, iliac crest are boundaries.
What is Grynfeltt’s hernia?
Superior lumbar hernia Internal abdominal oblique, lumbodorsal aponeurosis, 12th rib
What is Sciatic hernia?
Herniation through greater sciatic foramen; high rate of strangulation
What is Howship-Romberg sign?
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.
Who gets obturator hernias?
Elderly women, previous pregnancy, bowel gas below superior pubic ramus. Often present with obstruction.
Treatment for obturator hernia?
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).
What type of hernia is most likely to recur?
Incisional hernia
What causes rectus sheath hematomas? Treatment?
Most common after trauma, due to epigastric vessel injury. Nonoperative, surgery if expanding.
What is Fothergill’s sign?
Rectus sheath hematoma: mass more prominent and painful with flexion of the rectus muscle
Characteristics of desmoid tumors?
Women, benign but locally invasive, high rate of recurrence
What syndrome is associated with desmoid tumors?
Gardner’s
Treatment for desmoid tumor?
WLE; if involving small bowel may need excision Often not completely resectable and can cause worsening fibrosis NSAIDs, antiestrogens
What is a possible cause of retroperitoneal fibrosis?
Hypersensitivity to methysergide
What is the most sensitive test for retroperitoneal fibrosis?
IVP
Symptoms of retroperitoneal fibrosis? Treatment?
Symptoms related to trapped ureters and lymphatic obstruction Steroids, nephrostomy and surgery if renal fxn becomes compromised
Where are malignant mesenteric tumors? Benign?
Malignant: closer to root of mesentery Benign: more peripheral
What are malignant mesenteric tumor types?
Liposarcoma, leiomyosarcoma
What age group at risk for retroperitoneal tumors?
15% in children 5th-6th decade
What is the most common malignant retroperitoneal tumor?
1 lymphoma, #2 liposarcoma
What is the 5 yr survival rate for retroperitoneal sarcomas? % resectable?
10% 5yr survival <25% resectable
Where do mets from retroperitoneal sarcomas go?
Lung
What is the most common omental solid tumor?
Metastatic disease
Treatment of omental tumors?
Resection, do not biopsy due to risk of bleed
At what rate is saline absorbed from peritoneal membrane?
35cc/hr
What is removed with peritoneal dialysis?
NH3, Ca, Fe, lead; most drugs not removed
At what intraabdominal pressure can cardiopulmonary dysfunction occur?
>20mmHg
Treatment for CO2 embolus?
Head down, turn pt to the left (Sudden risk in ETCO2 hypotension)
How does the harmonic scalpel work?
Disrupts protein H-bonds, causes coagulation
How does Argon beam work? What is it’s depth of penetration?
Energy transferred across argon gas Depth of necrosis related to power setting (2mm)
What type of graft (Gore-Tex/PTFE vs Dacron/polypropylene) allows fibroblast ingrowth?
Dacron
What is the incidence of vascular or bowel injury with Veress needle?
0.1%
In a patient with an ostomy and parastomal hernia, what are the options?
Elective repair. See if the ostomy can be reversed. If not, lap mesh repair should be considered.
In a patient with an indication for elective hernia repair, what can be done pre-op to reduce complications?
quit smoking, lose weight, maintain good nutrition, glucose control
What kind of mesh is preferred in laparoscopic repair?
composite mesh - visceral side facing bowel can reduce adhesions/erosions, with the other side incorporating into the abdominal wall
Where should mesh be placed in a patient with Crohn’s disease and a large incisional hernia?
avoid intraperitoneal mesh; open anterior component separation with primary fascial closure and retrorectus placement of mesh is a good option
What is the suggested method of approaching a recurrent hernia?
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.
Patients with an acutely incarcerated inguinal hernia but without signs of strangulation or obstruction should be managed how?
require surgery, typically urgently
How much mesh overlap is needed in laparoscopic ventral hernia repair?
5 cm if placed as underlay.
At what point should a component separation be considered?
a hernia that is 10 cm
Where in the abdominal wall does mesh placement have the lowest chance of recurrence?
sublay (retrorectus; preferred for open) and underlay (below peritoneum aka intraperitoneal onlay; preferred for laparoscopic)
Should primary fascial closure be done for hernia repair?
Yes. It has been associated with fewer complications compared with not closing the fascial primarily.
How do you manage an umbilical hernia in a patient with leaking abdominal ascites, thin skin over umbilicus, or eschar over the apex?
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.
How do you manage an asymptomatic umbilical hernia in a patient with cirrhosis?
Manage conservatively. If they are on transplant list, repair the hernia at time of transplant.
What nerve is at most risk in laparoscopic inguinal hernia repair?
Laparoscopic placement of mesh has the potential to entrap the lateral femoral cutaneous nerve as it exits the peritoneum.
As part of the anterior component separation, which layer of the abdominal wall is incised to gain additional length on the abdominal wall?
External oblique aponeurosis
During open inguinal hernia repair you notice a lot of blood coming from the undersurface of the abdominal wall. What happened?
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.
