Fiser Chapter 38 HERNIAS, ABDOMEN, AND SURGICAL TECHNOLOGY Flashcards
What does the external oblique fascia form in inguinal canal?
Inguinal ligament (shelving edge) at inferior portion of inguinal canal
What does the internal oblique form in the inguinal canal?
Cremasteric muscles
What does the transversalis muscle and fascia form in the inguinal canal?
Conjoined tendon and inguinal floor (respectively)
Lacunar ligament
Where the inguinal ligament splays out to insert in the pubis
Cooper’s ligament (pectineal ligament)
Posterior to femoral vessels, lies against bone
What is the vas deferens in inguinal canal?
Runs medial to cord structures
Hesselbach’s triangle
Recus muscle lateral border, inguinal ligament, inferior epigastrics
Direct hernias are in the triangle, indirect hernias are lateral to epigastric vessels
Etiology of indirect hernia
Persistent patent processor vaginalis; most common
Direct hernias
Lower risk of incarceration, rare in females, higher recurrence than indirect
Pantaloon hernia
Both direct and indirect components
Risk factors for inguinal hernia in adults
Age
Obesity
Heavy lifting
COPD (coughing)
Chronic constipation
Straining (BPH)
Ascites
Pregnancy
Peritoneal dialysis
Incarcerated hernia
Can lead to bowel strangulation and should be repaired emergently
Sliding hernias
Retroperitoneal organ in hernia sac (ovaries, fallopian tubes, cecum, sigmoid bladder)
Tx of female with ovary in inguinal canal
Ligate the round ligament, return ovary to peritoneum, biopsy if looks abnormal
Infants and children with inguinal hernia
Open sac and then perform high ligation (almost always indirect)
Lichtenstein inguinal hernia repair
Mesh (less tension, decreases recurrence)
Bassini inguinal hernia repair
Approximate conjoined tendon and transversalis fascia to the free shelving edge of the inguinal ligament
Cooper’s (pectineal) ligament inguinal hernia repair
Approximate conjoined tendon and transversalis fascia to Cooper’s ligament
- Needs relaxing incision in external oblique fascia
- Can use for femoral hernia repair
Indication for laparoscopic inguinal hernia repair
Bilateral or recurrence
Most common early complication following inguinal hernia repair
-Urinary retention
- Recurrent 2%
- Wound infection 1%
- Testicular atrophy (d/t dissection of distal component of sac causing vessel disruption, spermatic cord vein thrombosis, usually with indirect hernias)
- Pain (ilioinguinal nerve compression, tx is local infiltration)
- Nerve injury to ilioinguinal or genitofemoral
Postop inguinal hernia repair, patient has loss of cremasteric reflex, numbness on ipsilateral penis, scrotum, and thigh
Ilioinguinal nerve injury, usual at external ring, runs on top of cord
Postop laparoscopic inguinal hernia repair, patient has loss of cremastric reflex, scrotum numbness, and upper lateral thigh numbness
-Genitofemoral nerve injury
Femoral hernia characteristics
Bulge on anterior-medial thigh, below inguinal ligament; usually repair through inguinal approach with Cooper’s ligament repair
Most common in females over males (but indirect inguinal hernia still most common in females)
Hernia passes under inguinal ligament, medial to femoral vein, lateral to lymphatics (in empty space)
High risk of incarceration -> may need to divide inguinal ligament to reduce bowel
Femoral canal boundaries
Cooper’s (pectineal) ligament posteriorly
Inguinal ligament anteriosuperiorly
Femoral vein laterally
Lacunar ligament medially
Contains lymph node of Cloquet
Umbilical hernia characteristics
Increased in African Americans
Delay repair until 5yo, often close on own
Risk of incarceration in adults, not kids
Spigelian hernia characteristics
Lateral border of rectus muscle, adjacent to linea semilunaris; almost always inferior to semicircularis
Occurs between muscle fibers of internal oblique muscle and insertion of external oblique aponeurosis into rectus sheath
Old woman with previous pregnancies, presents with tender medial thigh mass and SBO, has inner thigh pain with internal rotation (Hoship-Romberg sign)
Obturator hernia (anterior pelvis)
Tx: operative reduction, may need mesh; check other side for similar defect
Sciatic thigh hernia characteristics
Posterior pelvis (versus obturator hernia)
Herniation through greater sciatic foramen
High rate of strangulation
Incisional hernia characteristics
Most likely to recur
Inadequate closure most common cause
Rectus sheath above and below arcuate line
Anterior present all the way down
Posterior is present until arcuate line: is made of posterior aponeurosis of internal oblique and transversalis aponeurosis
Painful abdominal wall mass after trauma, most prominent and painful with flexion of rectus muscle (Fothergill’s sign)
Recut sheath hematoma: epigastric vessel injury
Tx: Nonoperative, surgical if expanding
Woman with Gardner’s syndrome has a painless abdominal wall mass
Desmoid tumor, benign but locally invasive, high recurrence
Tx: WLE if possible
Medical tx: Sulindac and tamoxifen (If involves significant small bowel mesentery, may not be resectable)
Retroperitoneal fibrosis
Can occur with hypersensitivity to methysergide (5-HT antagonist formerly used for cluster headaches)
Dx: IVP most sensitive test: see constricted ureters. Symptoms usually related to trapped ureters and lymphatic obstruction
Tx: Steroids, nephrostomy if infection, surgery if renal function compromised (to free ureters and wrap in omentum)
Mesenteric tumors
Most are cystic
Malignant (liposarcoma, leiomyosarcoma) are closer to root of mesentery; benign are more peripheral
Dx: abdominal CT
Tx: Resection
Kid presents with vague abdominal and back pain, and found to have a retroperitoneal tumor
Malignant most common: 1. lymphoma, 2. liposarcoma
Sarcomas: < 25% are resectable, 40% have local recurrence, 10% 5-year survival
- Pseudocapsule but cannot shell out -> leave residual tumor
- Mets go to lung
Omental tumors
Most common omental solid tumor is metastatic disease
Omentectomy for some (e.g. ovarian cancer)
Usually asymptomatic but can undergo torsion
Primary solid omental tumors are rare, 1/3 are malignant
- do NOT biopsy, as can bleed
- Tx: resection
Peritoneal membrane and how peritoneal dialysis works
Blood absorbed through fenestrated lymphatic channels in peritoneum. Movement of fluid into peritoneal cavity can occur with hypertonic intra-peritoneal saline load (mechanism of peritoneal dialysis); can cause hypotension
NH3, Ca, Fe, lead removed
Most drugs NOT removed with PD.
CO2 pneumoperitoneum, physiological effects
- Cardiopulmonary dysfunction with intra-abdominal pressure > 20
- Increased MAP, pulmonary artery pressure, HR, systemic vascular resistance, CVP, mean airway pressure, peak inspiratory pressure, and CO2
- Decreased pH, venous return (IVC compression), CO (and renal flow), decreased myocardial contractility (from CO2)
Problem of hypovolemia with pneumoperitoneum
Lowers the pressure necessary to cause compromise of CO and venous return
Problem of PEEP and pneumoperitoneum
PEEP worsens effects of pneumoperitoneum
Sudden rise in ETCO2 and hypotension in pneumoperitoneum
CO2 embolus: head down, turn patient to left, try to aspirate CO2 through central line, prolonged CPR
Harmonic scalpel
- Cost-effective for medium vessels (short gastrics)
- Disrupts protein H-bond, causes coagulation
Surgical ultrasound
B-mode used most commonly (B - brightness; assesses relative density of structures)
Shadowing versus enhancement in ultrasound
Shadowing- dark area posterior to object indicates mass
Enhancement- brighter area posterior to object indicates fluid-filled cyst
Ultrasound duplex: lower versus higher frequencies
Lower for deep structures
Higher for superficial structures
Argon beam
Energy transferred across argon gas
Depth of necrosis related to power setting (2 mm); causes superficial coagulation
Is non-contact: good for hemostasis of liver and spleen; smokeless
Surgical laser
Return of electrons to ground state releases energy as heat -> coagulates and vaporizes
Used for condylomata acuminata (wear mask)
Nd:YAG laser
Good for deep tissue penetration, bronchial lesions
1-2 mm cuts, 3-10 mm vaporizes, 1-2 cm coagulates
Gore-Tex versus Dacron
Gore-Tex (PTFE): No fibroblast ingrowth
Dacron (polypropylene): allows fibroblast ingrowth
Incidence of vascular or bowel injury with Veress needle or trocar
0.1 %
