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Surgical Recall > General Surgery - Hernias > Flashcards

General Surgery - Hernias Flashcards

1
Q

What is a hernia?

A

(L. rupture) Protrusion of a peritoneal sac through a musculoaponeurotic barrier (e.g. abdominal wall), a fascial defect

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2
Q

What is the incidence of hernias?

A

5-10% lifetime

50% indirect inguinal

25% direct inguinal

~5% are femoral

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3
Q

What are the precipitating factors of hernias?

A

Increased intra-abdominal pressure: straining at defecation or urination (rectal cancer, colon cancer, prostatic enlargement, constipation), obesity, pregnancy, ascites, valsavagenic (coughing) COPD, an abnormal congenital anatomic route (ie patent processus vaginalis)

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4
Q

Why should hernias be repaired?

A

To avoid complications of incarceration/strangulation, bowel necrosis, SBO (small bowel obstruction), pain

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5
Q

What is more dangerous: a small or large hernia defect?

A

Small defect! a tight defect is more likely to strangulate if incarcerated

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6
Q

Define Reducible

A

Ability to return the displaced organ or tissue/hernia contents to their usual anatomic site

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7
Q

Define Incarcerated

A

Swollen or fixed within the hernia sac (incarcerated = imprisoned), may cause intestinal obstruction (ie an irreducible hernia)

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8
Q

Define strangulated

A

Incarcerated hernia with resulting ischemia, will result in signs and symptoms of ischemia and intestinal obstruction or bowel necrosis (think: strangulated = choked)

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9
Q

Define complete

A

Hernia sac and its contents protrude all the way through the defect

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10
Q

Define incomplete

A

Defect present without sac or contents protruding completely through it

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11
Q

What is reducing a hernia “en masse”?

A

reducing the hernia contents and hernia sac

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12
Q

Define a Sliding hernia

A

Hernia sac partially formed by the wall of a viscus (ie, bladder/cecum)

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13
Q

Define Littre’s hernia

A

Hernia involving a Meckel’s diverticulum

(think alphabetically: Littre’s Meckel’s = LM)

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14
Q

Define Spigelian hernia

A

Hernia through the linea semilunaris (or spigelian fascia), also known as spontaneous lateral ventral hernia

(Think S: Spigelian = Semilunaris)

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15
Q

Define internal hernia

A

Hernia into or involving intra-abdominal structure

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16
Q

Define Petersen’s hernia

A

Seen after bariatric gastric bypass - internal herniation of small bowel through the mesenteric defect from the Roux limb

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17
Q

Define Obturator hernia

A

Hernia through obturator canal

females > males

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18
Q

Define lumbar hernia

A

Petit’s hernia or Grynfeltt’s hernia (next cards)

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19
Q

Define Petit’s hernia (a lumbar hernia)

A

RARE hernia through Petit’s triangle (aka inferior lumbar triangle)

Think: PETITe = small = inferior

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20
Q

Grynfeltt’s hernia (a lumbar hernia)

A

Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle)

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21
Q

Define Pantaloon hernia

A

Hernia sac exists as BOTH A DIRECT AND INDIRECT hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring (two sacs separated by the inferior epigastric vessels [the pant crotch] like a pair of pantaloon pants)

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22
Q

Define incisional hernia

A

Hernia through an incisional site; most common cause is a wound infection

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23
Q

Ventral hernia

A

Incisional hernia in the ventral abdominal wall

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24
Q

Define Parastomal hernia

A

Hernia adjacent to an ostomy (e.g. colostomy)

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25
Q

Define Sciatic hernia

A

Hernia through the sciatic foramen

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26
Q

Define Richter’s hernia

A

Incarcerated or strangulated hernia involving only ONE SIDEWALL OF THE BOWEL, which can spontaneously reduce, resulting in gangrenous bowel and perforation within the abdomen without signs of obstruction

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27
Q

Define Epigastric hernia

A

Hernia through the linea alba above the umbilicus

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28
Q

Define Umbilical hernia

A

Hernia through the umbilical ring, in adults associated with ascites, pregnancy, and obesity

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29
Q

Define Intraparietal hernia

A

Hernia in which abdominal contents migrate between the layers of the abdominal wall

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30
Q

Define Femoral hernia

A

Hernia medial to femoral vessels (under inguinal ligament)

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31
Q

Define Hesselbach’s hernia

A

Hernia under inguinal ligament LATERAL to femoral vessels

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32
Q

Define Bochdalek’s hernia

A

Hernia through the posterior diaphragm, usually on the left

Think: Boch da lek = back to the left, on the diaphragm

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33
Q

Define Morgagni’s hernia

A

Anterior parasternal diaphragmatic hernia

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34
Q

Define Properitoneal hernia

A

Intraparietal hernia between the peritoneum and transversalis fascia

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35
Q

Define Cooper’s hernia

A

Hernia through the femoral canal and tracking into the scrotum or labia majus

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36
Q

Indirect Inguinal Hernia

A

inguinal hernia LATERAL to Hesselbach’s triangle

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37
Q

Direct Inguinal Hernia

A

inguinal hernia WITHIN Hesselbach’s triangle

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38
Q

Hiatal hernia

A

Hernia through esophageal hiatus

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39
Q

Amyand’s hernia

A

Hernia sac containing a ruptured appendix

Think A: Amyand’s = Appendix

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40
Q

What are the boundaries of Hesselbach’s triangle?

A
  1. Inferior epigastric vessels
  2. Inguinal ligament (Poupart’s)
  3. Lateral border of the rectus sheath

Floor consists of internal oblique and the transversus abdominis muscle

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41
Q

What are the layers of the abdominal wall?

A

Skin

Subcutaneous fat

Scarpa’s fascia

External oblique

Internal oblique

Transversus abdominus

Transversalis fascia

Preperitoneal fat

Peritoneum

***All three muscle layer aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line

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42
Q

What is the differential diagnosis for a mass in a healed C-section incision?

A

Hernia

ENDOMETRIOMA

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43
Q

What is the differential diagnosis of a groin mass?

A

Lymphadenopathy, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC (epidermal inclusion cyst), undescended testicle, testicle torsion

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44
Q

What is a Direct Inguinal Hernia?

A

Hernia within the floor of Hesselbach’s triangle, ie the hernia sac does not traverse the internal ring

Think directly through the abdominal wall

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45
Q

What causes a Direct Inguinal Hernia?

A

Acquired defect from mechanical breakdown over the years

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46
Q

Incidence of a Direct inguinal Hernia?

A

~1% of all men, frequently increases with advanced age

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47
Q

What nerve runs with the spermatic cord in the inguinal canal?

A

Ilioinguinal nerve

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48
Q

What is an Indirect Inguinal Hernia?

A

Hernia through the internal ring of the inguinal canal, traveling down toward the external ring, it may enter the scrotum upon exiting the external ring (ie, if complete), think of the hernia sac traveling indirectly through the abdominal wall from the internal ring to the external ring

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49
Q

Cause of indirect inguinal hernia?

A

Patent processus vaginalis (ie congenital)

50
Q

Incidence of indirect inguinal hernia?

A

~5% of all men, most common hernia in both men AND women

51
Q

How is an inguinal hernia diagnosed?

A

Relies mainly on history and physical exam with index finger invaginated into the external ring and palpation of hernia; examine the patient standing up if diagnosis is not obvious

Note: if swelling occurs below the inguinal ligament, it is possibly a femoral hernia

52
Q

What is the differential diagnosis of an inguinal hernia?

A

Lymphadenopathy, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess

53
Q

What is the risk of strangulation of inguinal hernias?

A

Higher with indirect than direct inguinal hernia, but highest in femoral hernias

54
Q

What is the treatment of inguinal hernia?

A

Emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present; otherwise, elective herniorrhaphy is indicated to prevent the chance of incarceration/strangulation

55
Q

Bassini procedure

A

Sutures approximate reflection of inguinal ligament (Poupart’s) to the transversus abdominis aponeurosis/conjoint tendon

56
Q

McVay procedure

A

Cooper’s ligament sutured to transversus abdominis aponeurosis/conjoint tendon

57
Q

Lichtenstein procedure

A

“tension-free repair” using mesh

58
Q

Shouldice procedure

A

Imbrication of the floor of the inguinal canal (aka “Canadian repair”)

59
Q

Plug and patch

A

Placing a plug of mesh in hernia defect then overlaying a patch of mesh over inguinal floor (requires few if any sutures in mesh!)

60
Q

High ligation procedure

A

Ligation and transection of indirect hernia sac without repair of inguinal floor (used only in CHILDREN)

61
Q

TAPP procedure

A

TransAbdominal PrePeritoneal inguinal hernia repair

62
Q

TEPA procedure

A

Totally ExtraPeritoneal Approach

63
Q

What are the indications for laparoscopic inguinal hernia repair?

A
  1. Bilateral inguinal hernias
  2. Recurring hernia
  3. Need to resume full activity as soon as possible
64
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is the first identifiable subcutaneous named layer?

A

Scarpa’s fascia (thin in adults)

65
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is the name of the subcutaneous vein that is ligated?

A

Superficial epigastric vein

66
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What happens if you cut the ilioinguinal nerve?

A

Numbness of inner thigh or lateral scrotum; usually goes away in 6 months

67
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

From what abdominal muscle layer is the cremaster muscle derived?

A

Internal oblique muscle

68
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

From what abdominal muscle layer is the inguinal ligament (aka Poupart’s ligament) derived?

A

External oblique muscle aponeurosis

69
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

To what does the inguinal (Poupart’s) ligament attach?

A

Anterior superior iliac spine to the pubic tubercle

70
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

Which nerve travels on the spermatic cord?

A

Ilioinguinal nerve

71
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

Why do some surgeons deliberately cut the ilioinguinal nerve?

A

First they obtain preoperative consent and cut so as to remove the risk of entrapment and postoperative pain

72
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is in the spermatic cord (6)?

A
  1. Cremasteric muscle fibers
  2. Vas deferens
  3. Testicular artery
  4. Testicular pampiniform venous plexus
  5. + hernia sac
  6. Genital branch of the genitofemoral nerve
73
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is the hernia sac made of?

A

Peritoneum (direct) or a patent processus vaginalis (indirect)

74
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What attaches the testicle to the scrotum?

A

Gubernaculum

75
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is the most common organ in an inguinal hernia sac in men?

A

Small intestine

76
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is the most common organ in an inguinal hernia sac in women?

A

Ovary/fallopian tube

77
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What lies in the inguinal canal in the female instead of the VAS?

A

Round ligament

78
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

Where in the inguinal canal does the hernia sac lie in relation to the other structures?

A

Anteromedially

79
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is a “cord lipoma’?

A

Preperitoneal fat on the cord structures (pushed in by the hernia sac); not a real lipoma; remove surgically if feasible

80
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is a small outpouching of testicular tissue off of the testicle?

A

Testicular appendage (aka the appendix testes); remove with electrocautery

81
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?

A

Remove the suture as soon as possible and apply pressure (ie do NOT tie the suture down!)

82
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What nerve is found on top of the spermatic cord?

A

Ilioinguinal nerve

83
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What nerve travels within the spermatic cord?

A

Genital branch of the genitofemoral nerve

84
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What are the borders of Hesselbach’s triangle?

A
  1. Epigastric vessels
  2. Inguinal ligament
  3. Lateral border of the rectus
85
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What type of hernia goes through Hesselbach’s triangle?

A

Direct hernia due to a weak abdominal floor

86
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is a “relaxing incision”?

A

Incision(s) in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal ligament without tension

87
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What is the conjoint tendon?

A

Aponeurotic attachments of the “conjoining” of the internal oblique and transversus abdominis to the pubic tubercle

88
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

Define inguinal anatomy

A
  1. Inguinal ligament (Poupart’s ligament)
  2. Transversus aponeurosis
  3. Conjoint tendon
89
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

How tight should the new internal inguinal ring be?

A

Should allow entrance of the tip of a Kelly clamp but not a finger (the new external inguinal ring should not be tight and should allow entrance of a finger)

90
Q

CLASSIC INTRAOPERATIVE HERNIA REPAIR QUESTIONS

What percentage of the strength of an inguinal floor repair does the external oblique aponeurosis represent?

91
Q

What is a Femoral Hernia?

A

Hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels

Think: FM radio, Femoral hernia = Medial

92
Q

What are the boundaries of the femoral canal?

A
  1. Cooper’s ligament posteriorly
  2. Inguinal ligament anteriorly
  3. Femoral vein laterally
  4. Lacunar ligament medially
93
Q

What factors are associated with femoral hernias?

A

Women, pregnancy & exertion

94
Q

What percentage of all hernias are femoral?

95
Q

What percentage of patients with a femoral hernia are female?

96
Q

What are the complications of a femoral hernia?

A

Approximately one third incarcerate (due to the narrow, unforgiving neck)

97
Q

What is the most common hernia in women?

A

indirect inguinal hernia

98
Q

What is the repair of a femoral hernia?

A

McVay (Cooper’s ligament repair), mesh plug repair

99
Q

HERNIA REVIEW QUESTIONS

Should elective TURP or elective herniorrhaphy be performed first?

100
Q

HERNIA REVIEW QUESTIONS

Which type of esophageal hiatal hernia is associated with GE reflux?

A

Sliding esophageal hiatal hernia

101
Q

HERNIA REVIEW QUESTIONS

Classically, how can incarcerated hernia be reduced in the ER?

A
  1. Apply ice to incarcerated hernia
  2. Sedate
  3. Use the Trendelenburg position for inguinal hernias
  4. Apply steady gentle manual pressure
  5. Admit and observe for signs of necrotic bowel after reduction
  6. Perform surgical herniorrhaphy ASAP
102
Q

What is appropriate if you cannot reduce an incarcerated hernia with steady, gentle compression?

A

Go directly to the OR for repair

103
Q

What is the major difference in repairing a pediatric indirect inguinal hernia and an adult inguinal hernia?

A

In babies and children it is rarely necessary to repair the inguinal floor; repair with “high ligation” of the hernia sac

104
Q

What is the Howship-Romberg sign?

A

Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia

105
Q

What is the “sillk glove” sign?

A

Inguinal hernia sac in an infant/toddler feels like a finger of a silk glove when rolled under the examining finger

106
Q

What must you do before leaving the OR after an inguinal hernia repair?

A

Pull the testical back down to the scrotum

107
Q

ESOPHAGEAL HIATAL HERNIAS

Define type I & type II hiatal hernias

A

Type I = sliding

Type II = paraesophageal

108
Q

What is a Sliding Esophageal Hiatal Hernia?

A

Both the stomach and GE junction herniate into the thorax via the esophageal hiatus, also known as type I hiatal hernia

109
Q

Incidence of Sliding Esophageal Hiatal Hernia?

A

>90% of all hiatal hernias

110
Q

Symptoms of sliding esophageal hiatal hernia?

A

Most patients are asymptomatic, but the condition can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration

111
Q

How is sliding esophageal hiatal hernia diagnosed?

A

UGI series, manometry, esophagogastroduodenoscopy (EGD), with biopsy for esophagitis

112
Q

Complications of sliding esophageal hiatal hernia?

A

reflux -> esophagitis -> Barrett’s esophagus -> cancer & stricture formation; aspiration pneumonia; it can also result in UGI bleeding from esophageal ulcerations

113
Q

Treatment of sliding esophageal hiatal hernia?

A

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 symptoms despite adequate medical treatment

114
Q

What is the surgical treatment for sliding esophageal hiatal hernia?

A

Laparoscopic Nissen fundoplication (LAP NISSEN) involves wrapping the fundus around the LES and suturing it in place

115
Q

What is a Paraesophageal hiatal hernia?

A

Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the gastroesophageal junction; aka type II hiatal hernia

116
Q

Incidence of paraesophageal hiatal hernias?

A

<5% of all hiatal hernias (rare)

117
Q

Symptoms of paraesophageal hiatal hernia?

A

Derived from mechanical obstruction; dysphagia, stasis gastric ulcer, and strangulation; many cases are asymptomatic and not associated with reflux because of a relatively normal position of the GE junction

118
Q

Complications of paraesophageal hiatal hernia?

A

Hemorrhage, incarceration, obstruction, and strangulation

119
Q

Treatment of paraesophageal hiatal hernia?

A

Surgical, because of frequency and severity of potential complications

120
Q

What is a type III hiatal hernia?

A

Combined type I and type II

121
Q

What is a type IV hiatal hernia?

A

Organ (eg colon or spleen) +/- stomach in the chest cavity

Surgical Recall (15 decks)

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