Fiser - Hernias, Abd, Surg Tech Flashcards
What is the external abd oblique fascia’s contribution to the inguinal canal?
forms inguinal ligament (shelving edge & roof) at inferior portion
What is the internal abdominal oblique’s contribution to the inguinal canal?
Forms cremasteric muscles.
What is the transversalis muscle’s contribution to the inguinal canal?
Forms the floor of the canal.
What is the conjoined tendon made of?
Composed of aponeurosis of the internal abdominal oblique & transversalis fascia.
Describe the path of the inguinal ligament.
From External abd oblique fascia, runs from ASIS to the pubis; anterior to femoral vessels.
Alternative name to inguinal ligament?
Poupart’s (French physician & anatomist who described the ligament [16??-1708])
Describe the lacunar ligament.
Where the inguinal ligament splays out to insert to the pubis.
Describe Cooper’s ligament.
pectineal ligament; posterior to femoral vessels, lies against bone.
Where does the vas deferens run in relation to the cord structures?
It runs medial to cord structures.
Define the borders of Hesselbach’s triangle.
Medial border - rectus muscle.
Inferior border - inferior inguinal ligament.
Lateral border - inferior epigastric vessels.
Who was Hesselbach?
Franz Kaspar Hesselbach - 18th century German anatomist and surgeon who described multiple hernia operations.
Indirect hernias are derived from…
Persistently patent processus vaginalis. Most common.
Indirect inguinal hernia location is…
Superior/lateral to the epigastric vessels.
Direct inguinal hernia location is…
Inferior/medial to epigastric vessels.
Describe a pantaloon hernia.
Has direct and indirect components.
List the risk factors for inguinal hernias in adults. (9)
Age, obesity, heavy lifting, COPD (coughing), chronic constipation, straining (e.g. BPH), ascites, pregnancy, peritoneal dialysis
Describe sliding hernias.
Involve retroperitoneal organs making up part of the hernia sac. Bladder can also be involved.
Most common components of sliding hernia in females.
Ovaries or fallopian tubes.
Most common components of sliding hernia in males.
Cecum or sigmoid.
If an ovary is in the canal during repair, what do you do?
Ligate the round ligament.
Return ovary to peritoneum.
Perform biopsy if appearance abnormal.
Method of inguinal hernia repair in infants/children.
High ligation (nearly always indirect). Open sac prior to ligation.
Describe the Bassini repair.
B - approximation of conjoined tendon to free edge of inguinal ligament
Describe Cooper’s ligament repair.
Approximation of conjoined tendon to Cooper’s. Needs a relaxing incision in ext abd oblique fascia.
Indication for laparoscopic hernia repair.
Bilateral or recurrent inguinal hernia.
What is the most common early complication of a hernia repair?
Urinary retention.
What is the incidence rate of wound infection in hernia repairs? Recurrence rate?
Infection - 1%
Recurrence - 2%
What leads to testicular atrophy after a hernia repair?
Dissection of the distal component of the hernia sac causing vessel disruption. Thrombosis of spermatic cord veins.
Pain after IHR is usually cause by…
Compression of the ilioinguinal nerve.
How do you diagnose/treat pain secondary to ilioinguinal nerve compression?
Local infiltration of anesthetic near the ASIS.
What are signs of an ilioinguinal nerve injury?
Loss of cremasteric reflex. Numbness on ipsilateral penis, scrotum, thigh.
Where does an ilioinguinal nerve injury occur in IHR?
Usually at the external ring. Nerve runs on top of cord (anterior).
What are the signs of a genitofemoral nerve injury?
Genital branch - cremaster (motor), scrotum (sensory)
Femoral - upper lateral thigh (sensory) loss
When is the genitofemoral nerve injured?
Usually injured in laparoscopic repair.
Cord lipomas in IHR…
Should be removed.
Femoral canal boundaries?
Posterior - Cooper’s (pectineal)
Anterior - inguinal ligament
Medial - lacunar ligament
Space that femoral hernia fills?
medial to femoral vein, lateral to lymphatics (in empty space)
Maneuver to reduce risk of incarceration in femoral hernia?
divide the inguinal ligament
Approach to repair femoral hernia?
Inguinal approach with Cooper’s ligament repair
Femoral hernia - characteristic exam
bulge on the anterior-medial thigh below inguinal ligament
Age of repair for umbilical hernia
Delay until age 5 yrs
Spigelian hernia - location
Lateral border of the rectus muscle, adjacent to linea semilunaris, inferior to semicircularis; between the muscle fibers of IAO muscle and insertion of EAO apo into the rectus sheath
Obturator hernia - presentation
tender medial thigh mass or SBO
XR - bowel gas below superior pubic ramus
Howship-Romberg sign
inner thigh pain with internal rotation in obturator hernia
Obturator hernia treatment
operative reduction, may need mesh; examine other side for defect
Obturator hernia risk factors
elderly women, prior pregnancy
Sciatic foramen location
posterior pelvis, through the greater sciatic foramen
High rate of strangulation
Posterior rectus sheath absent starting where?
Below semicircularis (below umbilicus). Posterior aponeurosis of IAO & transversalis moves anterior.
Rectus sheath hematoma - risk factors
most common after trauma, epigastric vessel injury
Rectus sheath hematoma - Presentation
Painful abdominal wall mass, more prominent and painful with flexion of rectus muscle (Fothergill’s)
Rectus Sheath hematoma - Management
Nonop, surgery if expanding
Rectus Sheath hematoma - Types
Type I - small, confined to muscle, does not cross midline
Type II - within muscle, but can cross midline or dissect along fascial plane
Type III - large, crosses midline, usually below arcuate line. Hemoperitoneum or blood in retropubic space (prevesical space of Retzius)
Desmoid Tumors - Presentation/Risk factors
Women, Gardner’s Syndrome, painless mass; increased recurrence
Desmoid tumors - Surgical Management
WLE if possible, may not be indicated if significant small bowel mesentery involvement
Desmoid tumors - Medical Management
Sulindac, tamoxifen
Retroperitoneal fibrosis - Risk factors, diagnostic test
Hypersensitivity to methysergide (migraine med)
IVP most sensitive - constricted ureters
Retroperitoneal fibrosis - Symptoms caused by
related to trapped ureters & lymphatic obstruction
Retroperitoneal fibrosis - Treatment
steroids, nephrostomy if infection present
Surgery if renal function compromised (free up ureters, wrap in omentum)
Mesenteric Tumors - Benign vs Malignant locations
Benign - more peripheral
Malignant - closer to root of mesentery
Mesenteric Tumors - Most common malignant
liposarcoma
Mesenteric Tumors - Dx & Tx
Dx: abdominal CT
Tx: resection
Retroperitoneal Tumors - Most common malignant types
#1 = Lymphoma #2 = Liposarcoma
Retroperitoneal Sarcomas - Characteristics
<25% resectable.
Pseudocapsule, but cannot shell out - would leave residual tumor.
Mets go to lung.
Omental Tumors - most common solid tumor, management
Metastatic disease
Omentectomy for some cancers (e.g. ovarian)
Omental cysts - presentation
usually asymptomatic, can undergo torsion
Primary solid omental tumors
Rare, 1/3 malignant
No biopsy, can bleed.
Tx: resection
Mechanism of peritoneal dialysis (peritoneal membrane function)
Blood absorbed through fenestrated lymphatic channels; movement of fluid can occur with hypertonic saline load, can cause hypotension
CO2 Pneumoperitoneum - Normal v Abnormal level
Normal = 10-15
Abnormal >20, IAP where cardiopulmonary dysfunction can occur
CO2 Pneumoperitneum increases…
MAP, PAP, HR, SVR, CVP, mean airway pressure, peak insp pressure, CO2
CO2 Pneumoperitneum decreases…
pH, venous return (IVC compression), CO, renal flow
PEEP in pneumoperitoneum
Can worsen effects
CO2 effect on myocardium
Can decrease contractility
CO2 embolus - presentation
sudden transient rise in ETCO2, followed by drop, then hypotension
CO2 embolus - Treatment
head down, pt turned to left; aspirate CO2 through central line, prolonged CPR
Harmonic scalpel
Disrupts protein H-bonds, causes coagulation
Okay for medium vessels (short gastrics)
Argon Beam
energy tranferred across argon gas.
Depth of necrosis related to power setting, causes superficial coagulation.
Non-contact, good for liver & spleen. Smokeless.
Laser use in hemostasis, clinical uses
return of electrons to ground state releases energy as heat, coagulates and vaporizes.
Clinical - condyloma acuminata (wear mask)
Nd:YAG Laser
Good for deep tissue penetration, bronchial lesions
1-2mm cuts, 3-10mm vaporizes, 1-2mm coagulates
Gore-Tex (PTFE) v Dacron
PTFE cannot get fibroblast ingrowth. Dacron allows fibroblast growth.
