clinical Flashcards
what are the different types of abdominal wall hernias?
Inguinal hernia (direct and indirect) Femoral hernia Lumbar hernia Pelvic floor hernia Umbilical hernia Hiatus hernia Incisional hernia Epigastric hernia Spigelian hernia
what are the boundaries of the inguinal canal?
anterior wall- aponeurosis of external and internal oblique
posterior wall- transversalis fascia; (and medially) conjoint tendon
roof- muscle fibers of internal oblique and transverse abdominis
floor- inguinal ligament
Where does the indirect inguinal hernia pass through?
it passes through the inguinal canal.
enters lateral to the inferior epigastric artery
Where does the direct inguinal hernia pass though?
it passes medial to the inferior epigastric arteries, through the Hasselbach triangle
What is the Hasselbach triangle? what are its borders?
(it is also called the inguinal triangle) the triangle demarcates an area of potential weakness in the abdominal wall through which herniation of abdominal contents can occur
medial border: lateral margin of rectus sheath
superolateral border: inferior epigastric vessels
inferolateral border: inguinal ligament
where does the femoral hernia pass through? which gender does it occur more frequently in? why does it require emergency surgery?
It passes through the femoral canal, below and lateral to the pubic tubercle
its more common in women.
Irreducibility and strangulation occur more commonly due to the narrow neck of the canal and so emergency surgery is necessary
what are the two types of Lumbar hernia? where do they occur?
the two types are Upper lumbar hernia (Grynfeltt-Lesshaft) and Lower lumbar hernia (Petit); both types occur on the posterior abdominal wall
Upper lumbar triangle–> defined by quadratus lumborum, 12th rib and internal oblique
Lower lumbar triangle–> external oblique, Iliac crest. and latissimus dorsi
what is the pelvic floor hernia also called?
what are the types of pelvic floor hernia?
where do they occur?
which type is more common and in whom?
it is called perineal hernia.
types of perineal hernia are: obturator hernia; sciatic hernia
obturator hernia occurs through the obturator canal(superolateral aspect of the obturator foramen)– between obturator externus and pectineus
obturator hernia is usually in elderly women
where does epigastric hernia develop?
what increases the chances of this occurring?
it develops in the epigastrium (upper, central part of abdomen)
it is due to the weakening in the linea alba
in a fat pendulous abdomen or after multiple pregnancies the rectus abdominis muscles on the two sides can separate (divarication of recti) – this can be with or without herniation
what are the two types of umbilical hernia?
talk about them!
congenital and acquired.
congenital umbilical hernia are seen in newborns as the anterior abdominal wall is relatively weak near the umbilical ring
acquired umbilical hernia may develop in obese people; this can include extraperitoneal fat, peritoneum and/or bowel protruding into the hernial sac.
what is hiatus hernia? how is it often discovered? who is at risk of hiatus hernia?
when the stomach bulges up into the chest through the hiatus in the diaphragm
it is often discovered during a test to determine the cause of heartburn or chest or upper abdominal pain. [tests could be X-ray, upper endoscopy esophageal manometry etc.]
a person may be born with a larger hiatal opening(so mostly cause not known); but increased pressure in the abdomen such as from pregnancy, obesity, coughing and straining during bowel movements may play a role.
As a result these are more common in women, people who are overweight and people over the age of 50.
for which type of incision are hernias most common? what is advised to avoid this from occurring?
hernias at the (incompletely healed) midline incisions are most common.
it is advised that a prosthetic mesh be used rather than a simple suture so that the repair system is tension free
what are the options for hernia repair? which is preferred and why?
hernia can be repaired by an open surgery or by laparoscopic (keyhole) surgery
laparoscopic surgery is preferred, as, there’s less post-operative pain, faster recovery, and low recurrence rate
what are the steps involved in laparoscopic surgery? describe each step.
- creation of a pneumoperitoneum –>
this can be achieved by a closed method (using a spring loaded Veress needle) or an open method (using the Hasson technique which employs a small subumbilical incision to dissect down to deep fascia and open the peritoneum)
a blunt tip trocar is then inserted and carbon dioxide insufflation is performed to 10-20 mmHg
- Insertion of a laparoscope
the obturator is removed from the trocar and a video camera (the laparoscope) is inserted - placement of additional ports
accessory trocars are then inserted into the anterior abdominal wall under direct visualization to avoid injury to blood vessels.
what are the common incisions used to gain access to the abdominal cavity
subcostal (Kocher's) loin gridiron (McBurney's) suprapubic (Pfannenstiel) inguinal paramedian midline
