Chapter 38 - Hernias, Abdomen & Surgical Technology Flashcards
What forms the shelving edge in inguinal hernias?
External abdominal oblique (and fascia)
What forms the cremasteric muscles?
Internal abdominal oblique
What forms the inguinal canal floor?
Transversalis muscle
Where does the inguinal ligament run? What is it made from?
From ASIS to pubis
From external abdominal oblique
What makes up the lacunar ligament?
Where the inguinal ligament splays out to insert in the pubis
Where does the ileopubic tract run? What makes it up?
Runs from ASIS to pubis below inguinal ligament
From transversalis
What is another name for Cooper’s ligament?
Pectineal ligament
What makes up the conjoined tendon?
Aponeurosis of the internal abdominal oblique and transversus abdominis muscle
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 (in triangle)
Indirect: Superior/lateral to epigastric vessels
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, 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; decreased recurrence
What is Bassini repair?
Approximation of conjoined tendon and transversalis fascia (superior) to the free edge of the inguinal ligament (inferior)
What is a McVay repair?
Approximation of the conjoined tendon and transversalis fascia (superior) to Cooper’s ligament (inferior); needs relaxing incision in external abdominal oblique 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 and thrombosis of spermatic cord veins
What is the most common cause of pain after hernia? Treatment?
Compression of ilioinguinal nerve
Local infiltration can be diagnostic and therapeutic
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
What is the trapezoid of doom?
In lap hernia repairs
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?
Through an inguinal approach with McVay or Bassini repair
How long do you delay repair of umbilical hernia in children?
Until after 5 years
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
What is Richter’s hernia?
Noncircumferential incarceration of the nonmesenteric bowel wall
What is Littre’s hernia?
Incarcerated Meckel’s
What is Petit’s hernia?
Inferior lumbar hernia
External abdominal oblique, lat dorsi, iliac crest
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 thigh pain with internal rotation; characteristic of obturator hernia
Who gets obturator hernias?
Elderly women, previous pregnancy, bowel gas below superior pubic ramus
Treatment for obturator hernia?
Operative reduction, may need mesh; check other side for similar defect
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%
