EXAM #3: HERNIAS Flashcards
What is the general school of thought for the surgical management of hernias?
Repair before they cause problems
What is the most common type of all hernias?
Inguinal
Far more common in men
Review the abdominal wall layers.
1) Skin
2) Subcutaneous tissue
- Camper’s Fascia (fatty)
- Scarpa’s Fascia (fibrous)
3) External Oblique
4) Internal Oblique
5) Transversus Abdominis m.
6) Transversalis fascia
7) Peritoneum
Review the anatomy of the inguinal canal.
N/A
What is an indirect inguinal hernia?
- Hernia through the internal inguinal ring
- Lateral to the inferior epigastric vessels
- Within the spermatic cord
MD’s Don’t Lie
Where does a direct inguinal hernia pass through?
Hasselbach’s Triangle
What is a direct inguinal hernia?
Hernia that occurs
- Adjacent to rectus abdominus
- Medial to inferior epigastirc vessels
- Superior to inguinal ligament
What patient’s more commonly have femoral hernias?
Female
What is a femoral hernia?
Hernia that passes into the femoral canal, below the inguinal ligament
How can an inguinal hernia be repaired with a “tissue repair?”
1) Bassini repair= single layer reconstruction of inguinal floor
2) Shouldice repair= four layer reconstruction of inginal floor
3) McVay repair= inguinal floor brought to Cooper’s Ligament–closes the femoral space
What is the best tissue repair for an incarcerated femoral hernia?
McVay b.c is closes the femoral repair
Why perform a tissue repair?
1) No mesh available
2) INFECTION
What is the current standard hernia repair?
Lichtenstein Mesh Repair
What are the key characteristics of a Lichtenstein Mesh Repair?
1) Mesh reconstruction of inguinal floor
2) Tension-free
*Lowest risk of recurrence
What is the risk of a Lichtenstein Mesh Repair?
Prosthetic mesh infection
What is a Pre-Peritoneal Mesh Repair?
Mesh is placed INSIDE of fascia (vs. outside)
Mesh is between peritoneum and transversus abdominus
How do you place pre-peritoneal mesh?
Open or Laparoscopic
What are the benefits of Laparoscopic repair for pre-peritoneal mesh repair?
1) Less post-op pain
2) Less infection and hematoma
3) Quicker recovery with fewer work restrictions
What are the two approaches to the pre-peritoneal repair?
TAP and TEP
What is the TAP approach?
TransAbdominal Preperitoneal Laparoscopic Hernia Repair
What is the TEP approach?
Total Extraperitoneal Preperitoneal
How does the TEP differ from the TAP?
TAP= standard laprascopic approach
TEP= entry in RECTUS SHEATH
What are the evidence-based indications for laprascopic hernia repair?
1) Bilateral inguinal hernias
2) Comorbid umbilical
3) Young healthy individual that wants to return to work earlier
What is a Spigelian hernia?
Hernia along the semilunar line
What is the difference between an umbilical hernia in a kid and adult?
Kid= frequently regress (congenital)
Adult= acquired and progress/enlarge
How are umbilical hernias repaired?
1) Primary if 1-2cm
2) Mesh reinforcement for 2cm+ defects
What is an incisional hernia?
Failure of fascia healing
What are the risk factors for incisional hernias?
Infection Early return to work Obesity Old-age Male Sleep apnea* Emphysema*
*Chronic hypoxia states
How long should people be lifting restricted to prevent an incisional hernia?
6 weeks
What is a unique feature of epigastric hernias?
Small defect above the umbilicus that is PAINFUL
*Repaired to alleviate pain
What is the proposed etiology of Spigelian Hernias?
Vascular defects of the semilunar lines
What is a primary repair for an abdominal wall hernia?
Cut down a simply suture the defect
*Note that these are associated with a high recurrence rate
When is a primary repair done for a hernia?
1) Strangulation
2) Skin breakdown
3) Bowel resection
What is a mesh reinforeced repair for an abdominal wall hernia?
Mesh is placed to help reinforce the defect
When is a mesh reinforced repair CONTRAindicated?
Contaminated field/ infection
Where is abdominal wall mesh placed most commonly?
“Underlay” i.e. intraperitoneal
What is the gold standard for abdominal wall mesh placement?
“Retrorectus” i.e posterior to the rectus sheath
Is an incarcerated hernia a surgical emergency?
NO–an incarcerated hernia is one that cannot be reduced
A STRANGULATED hernia is an incarcerated hernia with compromised blood flow/ infection; this is a surgical emergency
What are the clinical features of a strangulated hernia?
1) Erythema of the overlying skin
2) Fever
3) Tachycardia
4) Elevated WBC count
