EOR GI part 2: hernias Flashcards
What is a hernia?
Protrusion of a peritoneal sac through a musculoaponeurotic barrier; a fascial defect
What are the precipitating factors of a hernia?
Increased intra-abdominal pressure Straining at defecation or urination Obesity Pregnancy Ascites Valsalvagenic (cough) COPD An abnormal congenital anatomic route
Why should hernias be repaired?
To avoid complications of incarceration/strangulation, bowel necrosis, SBO, pain
What is more dangerous: a small or large hernia defect?
Small defect is more dangerous because a tight defect is more likely to strangulate if incarcerated
Reducible hernia
Ability to return the displaced organ or tissue/hernia contents to their usual anatomic site
Incarcerated hernia
Swollen or fixed within the hernia sac
May cause intestinal obstruction
Strangulated hernia
Incarcerated hernia with resulting ischemia
Will result in signs and sx of ischemia and intestinal obstruction or bowel necrosis
Complete hernia
Hernia sac and its contents protrude all the way through the defect
Incomplete hernia
Defect present without sac or contents protruding completely through it
What is reducing a hernia en masse?
Reducing the hernia contents and hernia sac
Incisional hernia
Hernia through an incisional site
MCC is a wound infection
Femoral hernia
Hernia medial to femoral vessels (under inguinal ligament)
Indirect inguinal hernia
Inguinal hernia lateral to Hesselbach’s triangle
Direct inguinal hernia
Inguinal hernia within Hesselbach’s triangle
Hiatal hernia
Hernia through esophageal hiatus
What are the boundaries of Hesselbach’s triangle?
- Inferior epigastric vessels (lateral border)
- Inguinal ligament (base)
- Lateral border of the rectus sheath (medial border)
Floor consists of internal oblique and the transversus abdominis muscle
What are the layers of the abdominal wall?
Skin Subcutaneous fat Scarpa's fascia External oblique Internal oblique Transversus abdominus Transversalis fascia Preperitoneal fat Peritoneum
What is the DDx for a mass in a healed C-section incision?
Hernia
Endometrioma
What is the DDx of a groin mass?
LAD Hematoma Seroma Abscess Hydrocele Femoral artery aneurysm EIC Undescended testicle Sarcoma Hernias Testicular torsion
What is the cause of a direct hernia?
Acquired defect from mechanical breakdown over the yrs
What nerve runs with the spermatic cord in the inguinal canal?
Ilioinguinal nerve
What is the cause of an indirect hernia?
Patent processus vaginalis
How is an inguinal hernia diagnosed?
Relies mainly on hx and PE with index finger invaginated into the external ring and palpation of hernia
Examine the pt standing up if dx is not obvious
DDx of inguinal hernia
LAD Psoas abcess Ectopic testis Hydrocele of the cord Saphenous varix Lipoma Varicocele Testicular torsion Femoral artery aneurysm Abscess
What is the risk of strangulation with inguinal hernias?
Higher with indirect than direct inguinal hernia, but highest in femoral hernias
Tx for inguinal hernia
Emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present
Otherwise, elective herniorrhpahy is indicated to prevent the chance of incarceration/strangulation
Bassini procedure
Sutures approximate reflection of inguinal ligament to the transversus abdominis aponeurosis/conjoint tendon
McVay procedure
Cooper’s ligament sutured to transversus abdominis poneurosis/conjoint tendon
Lichtenstein procedure
Tension free repair using mesh
Plug and patch repair
Placing a plug of mesh in hernia defect and then overlaying a patch of mesh over inguinal floor
High ligation procedure
Ligation and transection of indirect hernia sac without repair of inguinal floor (used only in children)
TAPP procedure
TransAbdominal PrePeritoneal inguinal hernia repair
TEPA procedure
Totally ExtraPeritoneal Approach
What are the indications for a laparoscopic inguinal hernia repair?
Bilateral inguinal hernias
Recurring hernia
Need to resume full activity ASAP
What are the boundaries of the femoral canal?
Cooper’s ligament posteriorly
Inguinal ligament anteriorly
Femoral vein laterally
Lacunar ligament medially
What factors are associated with femoral hernias?
Women
Pregnancy
Exertion
What are the complications of femoral hernias?
Approximately one third incarcerate (d/t narrow unforgiving neck)
What is the repair of a femoral hernia?
McVay (Cooper’s ligament repair)
Mesh plug repair
Sliding esophageal hiatal hernia definition
Both the stomach and GE junction herniate into the thorax via the esophageal hiatus
AKA type I hiatal hernia
What is the incidence of type I hiatal hernias?
> 90% of all hiatal hernias
What are the sx of a type I hiatal hernia?
Most pts are asymptomatic, but the condition can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration
How is a type I hiatal hernia diagnosed?
UGI series
Manometry
EGD with bx for esophagitis
What is the tx for type I hiatal hernia?
85% of cases treated medically with antacids, H2 blockers/PPIs, head elevation after meals, small meals, and no food prior to sleeping
15% of cases require surgery for persistent sx despite adequate medical tx
What is the surgical tx for type I hiatal hernia?
Laparoscopic Nissen fundoplication (LAP NISSEN) involves wrapping the fundus around the LES and suturing it in place
What is a type II hiatal hernia?
Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the GE junction; aka paraesophageal hiatal hernia
What are the complications of a type II hiatal hernia?
Hemorrhage
Incarceration
Obstruction
Strangulation
What is the tx for type II hiatal hernia?
Surgical, because of frequency and severity of potential complications
