Chapter 8 Flashcards
What plays a role in the development of a hernia?
Congenital maldevelopment of an abdominal support structure
Acquired physical stresses
What can increase the risk of hernia development?
Factors that weaken the integrity of fascial tissue and collagen strength
Factors that increase intra-abdominal pressure (morbid obesity, pregnancy, chronic pulmonary disease, constipation, urinary obstruction)
Reducible hernia
The herniated contents can return to their anatomic position spontaneously or can be returned to their anatomic position with manual manipulation
Incarcerated hernia
The herniated contents cannot be returned to their anatomic position in a nonsurgical manner and may be acute or chronic. Can cause a bowel obstruction.
Strangulated hernia
An incarcerated hernia with vascular compromise
Sliding hernia
When a portion of the hernia sac is composed of the herniating organ
Richter’s hernia
When less than the full circumference of the bowel wall is trapped in the hernia
Can present with incarceration, ischemia, and bowel perforation without obstruction
Littre’s hernia
A Richter’s hernia containing a Meckel’s diverticulum
What is the most common type of abdominal hernias?
Groin hernia
What comprises 2/3 of inguinal hernias?
Indirect
Indirect hernia anatomy
Pass lateral to the epigastric vessels, through the internal inguinal ring toward the external inguinal ring and into the scrotum
Direct hernia anatomy
Passes medially to the epigastric vessels and the internal inguinal ring directly through the floor of the inguinal canal
Pantaloon hernia
Has both indirect and direct components
What is the makeup of the lower abdominal wall in muscles?
Three layers:
External oblique
Internal oblique
Transverses abdominis
External oblique muscle
Arises from the lower eight ribs interdigiting with the serratus anterior and the latissimus dorsi laterally with its fibers running in an inferomedial direction
What contributes to the anterior rectus sheath before inserting into the linea alba in the midline?
Aponeurosis
What is the portion of the external oblique aponeurosis that stretches between the ASIS and the pubic tubercle that is somewhat thickened and folds back on itself?
Inguinal (Poupart) ligament
Lacunar ligament
The medial part of the inguinal ligament that reflects back onto the pectin pubis
In what direction do the internal oblique muscle fibers course?
Superomedial
Direction of the inguinal canal
Courses form the deep inguinal ring to the superficial inguinal ring
Deep inguinal ring
A natural defect in the transversalis fascia approximately halfway between the ASIS and the pubic tubercle through which the spermatic cord in men or the round ligament in women exits the abdominal cavity and enters the inguinal canal
Superficial inguinal ring
A triangular opening in the aponeurosis of the external oblique muscle just superior to the medial part of the inguinal ligament
Pathway of the spermatic cord
Passes through deep inguinal ring and consists of vas deferens, testicular artery, pampiniform venous plexus, and processus vaginalis
Hesselbach’s triangle boundaries
Inferior epigastric artery on lateral border
Inguinal ligament on inferior side
Rectus sheath on medial border
What is a thickening of the endoabdominal fascia where the transversalis fascia and the iliopsoas fascia meet?
Iliopubic tract
Femoral canal
A potential space deep to the inguinal ligament
Anatomy of the iliopubic tract
Courses fraom the ASIS to the superior pubic ramus and pubic tubercle
Located deep to and slightly superior to the inguinal ligament, forming the inferior margin of the deep inguinal ring
Medially, forms the anterior and medial walls of the femoral canal.
Anatomy of the femoral canal
Bounded laterally by the common femoral vein, superoanteriorly by the inguinal ligament, posterior by Cooper’s ligament and medially by the lacunar ligament
Ilioinguinal nerve
Arises from L1 nerve root and runs superior tot he spermatic cord through the superficial inguinal ring to innervate the scrotum or labium majus
Iliohypogastric nerve
Arises with the ilioinguinal nerve from the L1 nerve root and courses between the internal oblique and transverses abdominis where it branches into an anterior branch and a lateral branch
Genital branch of genitofemoral nerve
Arises from the L1 and L2 nerve roots and enters the inguinal canal inferior to the deep inguinal ring
Provides motor innervation for the cremaster muscle and sensory innervation to the scrotum and medial thigh
Hx of groin hernias
Pain and/or swelling in the groin
Radiation into the scrotum
Intermittent or continuous
May get worse after extended periods of standing, may improve with rest
What also must be asked about with a groin hernia?
Sx of bowel obstruction: Nausea Vomiting Abdominal distention Abdominal pain Constipation
What is concerning in a groin hernia for strangulation and ischemia of the hernia contents?
Erythema of the skin overlying the hernia
How to examine for an inguinal hernia
Pt stands and in the supine? position with and without the pt performing a Valsalva maneuver (e.g., bearing down, coughing)
How is a dx of a groin hernia made?
Primary by hx and PE
What can be assessed in the superficial canal in addition to an indirect hernia?
The integrity of the floor of the inguinal canal
When should women be considered for surgical exploration and hernia repair even if the exam is negative?
Those who report a hx of a palpable or reducible mass in the appropriate location
What else should be included in a hernia PE?
Abdominal exam
Abdominal distention may suggest a bowel obstruction d/t an incarcerated hernia
Peritonitis may suggest a bowel perforation d/t a strangulated hernia
When to get a CT or u/s for a hernia
Confirm the diagnosis in cases with atypical sx or inconclusive findings
Alternate diagnoses for a groin hernia
Inguinal adenopathy Undescended testis Spermatocele Varicocele Hydrocele Lipoma Testicular cancer
Additional use for imaging in hernias
Identifying the hernia contents
Purpose of labs for hernias
No labs are diagnostic of a hernia
Tx of groin hernias
Although watchful waiting is a safe strategy for asymptomatic or minimally symptomatic pts, it may be preferable to offer surgical repair, esp to older pts, given that eventually these pts will require surgery
Open general hernia repair procedure- groin
Supine position
Incision made approximately 2cm above and parallel to the inguinal ligament
Dissection through skin, subcutaneous fat, and Camper’s and Scarpa’s fascia to the external oblique aponeurosis
Incision made parallel with its fibers and spread to expose the inguinal canal
Ilioinguinal and iliohypogastric nerves either spared or sacrificed to prevent post-op neuralgia
Open indirect hernia procedure after initial steps
Exposed and separated from the cord by dividing the cremaster muscle
Hernia contents can be replaced into the peritoneal cavity and the hernia sac can either be replaced into the peritoneal cavity as well or it can be divided and ligated at its base
Open direct hernia procedure after initial steps
Without opening or excising the sac, the hernia is reduced and the posterior wall of the inguinal canal is repaired
If the sac extends into the scrotum, no attempt should be made to retrieve the sac distal to the pubic tubercle
Sac should be divided at the pubic tubercle
What additional step needs to be done in an open direct hernia procedure?
The floor of the inguinal canal needs to be repaired
What are the four methods of inguinal canal floor repair?
Bassini
Shouldice
McVay
Mesh repair- Lichtenstein or Rutkow
Bassini repair
The aponeurosis of the transversus abdominis muscle is sewn to the shelving edge of the inguinal ligament
Shouldice repair
The transversalis fascia is divided from the internal ring tot he pubic tubercle
The fascia is then imbricated onto itself and sewn to the inguinal ligament with two suture lines
McVay or Cooper’s ligament repair
The floor of the inguinal canal is excised and reconstructed by sewing the conjoined tendon to the femoral sheath and inguinal ligament laterally and Cooper’s ligament medially from the pubic tubercle to the femoral vein
Lichtenstein repair
The floor of the inguinal canal is reconstructed with prosthetic mesh. The mesh lies posterior to the spermatic cord and is sutured to the inguinal ligament inferiorly and transversus abdominis aponeurosis or internal oblique aponeurosis superiorly and is split laterally to create an opening for the cord to exit the deep inguinal ring
Rutkow repair
A mesh plug is placed within the deep ring beside the spermatic cord to help attenuate the opening of the deep inguinal ring.
What can be used to repair femoral hernias?
Infrainguinal approach
Posterior/preperitoneal approach
How should groin hernias that are strangulated with a high suspicion for ischemic bowel or bowel perforation be approached?
Lower midline incision
What are the three different methods of laparoscopic repair?
Transabdominal preperitoneal (TAPP) Total extraperitoneal (TEP) Intraperitoneal onlay mesh (IPOM)
TAPP repair
Peritoneal cavity entered in the standard fashion
Peritoneum on the posterior surface of the anterior abdominal wall is incised transversely above the level of the hernia and then reflected inferiorly
Indirect hernias are mobilized and dissected away from the cord structures
Direct hernias are isolated from the transversalis fascia
Mesh patch is placed
What must be done after placement of mesh in TAPP repair?
Must resecure the peritoneal flap to the abdominal wall
TEP repair
Periumbilical incision
Anterior rectus sheath is incised on the side opposite the hernia
Dissecting balloon is placed into the preperitoneal space
5-mm trocars are placed either in the midline or laterally.
Remainder is same as TAPP repair
IPOM repair
Similar to TAPP repair, but no peritoneal flap raised
Why has IPOM repair been largely abandoned in inguinal hernia repair?
There is risk of bowel herniation under the mesh
Complications of groin hernia repair
If hernia contains ischemic bowel requiring bowel resection, risk of infection is increased
Testicular atrophy
Neuralgia
Recurrence
When do clinical manifestations of primary arterial ischemia to the testicle present?
What establishes the diagnosis?
2-5 days following the repair
Doppler flow studies or a nuclear medicine flow scan
Care is supportive pain management
When is orchiectomy indicated for primary arterial ischemia of the testicle?
Intractable pain or lack of blood flow to the testicle
Presentation of neuralgia
Variable pain that may present as burning pain at the incision with intermittent shooting pain that radiates into the scrotum with or without skin hypersensitivity
Management of neuralgia
Analgesics Antidepressants Anxiolytics Transcutaneous electrical stimulation Steroid injections Ilioinguinal and iliohypogastric nerve blocks or paravertebral block at L1 and L2 can be diagnostic and therapeutic
Who absolutely must undergo an open repair?
Pts at high risk for for general anesthesia
Risks of laparoscopic repair
Injury to surrounding structures during port placement
Port site hernia
Gas embolism
Bowel obstruction secondary to adhesions in the TAPP and iPOM reapirs that enter the peritoneum
Nerve injuries
Origin of umbilical hernias
Commonly congenital in origin but may be acquired in adults
When to surgically repair umbilical hernias in the pediatric population
Defer until at least the age of 2 unless there is abdominal pain referable to the hernia, incarceration, skin maceration, or a very large hernia
What are a population that is particularly at risk for developing hernias and are at a higher risk for incarceration and strangulation as well as a higher risk of perioperative morbidity and mortality?
Cirrhotic pts with ascites
Adult umbilical hernia repair
Periumbilical curvilinear incision
ID the hernia sac, fascial defect and intact surrounding fascia
Hernia and its contents are reduced or excised
Fascial edges are reapproximated primarily for small defects or brought together using a piece of mesh to reinforce the repair and relieve tension on the fascia
What are epigastric hernias possibly due to?
Congenital variation sin the decussation patterns of the linea alba
Who more commonly gets epigastric hernias?
Men
MC location of epigastric hernias?
Slightly off the midline
Spigelian hernias
Hernias of the lateral abdominal wall
When are spigelian hernias indicated for repair?
Whenever they are identified because of the high likelihood of incarceration or strangulation
