Hernia Flashcards
5 elements to reduce risk of hernia recurrence and chronic pain after surgery
1) Use large sheet of mesh (7x15cm)
2) Extends at least 3-4cm above Hesselbach’s triangle
3) 2cm medial to pubic tubercle
4) 5-6cm lateral to internal ring
Howship-Romberg sign
Confirms presence of obturator hernia
Positive when pain extends down medial aspect of thigh w/ abduction, extension, internal rotation of knee
Structures most likely injured when securing mesh inferiorly along shelving edge of inguinal ligament during open repair with mesh
external iliac/femoral vessels (especially veins)
ilioinguinal nerve function
cutaneous innervation to superior medial thigh
M: skin over anterior 1/3 of scrotum and root of penis
F: skin over anterior 1/3 of labium majus and root of clitorus
iliohypogastric nerve function
supplies skin to pubic region
Tx of Chronic inguinodynia after hernia repair
cont postop pain for >=3 mo
1st line: med mgmt
2nd line: groin nerve block superomedial to ASIS (local anesthetic injection, corticosteroids, hyaluronic acid)
3rd line: triple neurectomy (for pts who initially respond to nerve block but have recurrent pain)
McVay hernia repair
Conjoint (internal oblique and transverses abdomens aponeurosis) to Cooper’s ligament
Used for femoral hernia
Spigelian hernia
at or below arcuate line
b/w rectus and semilunar line
Bassini repair
Conjoint tendon to inguinal ligament
Closes direct and indirect spaces, not femoral space
Shouldice repair
Multi-layer closure
Most durable tissue repair, lowest recurrence rate
How does wound infection affect risk of hernia development after surgery
doubles risk of developing hernia
When should smoking be stopped prior to elective surgery
4 weeks prior
Ideal BMI for hernia repair
<40
HgA1c levels for hernia repair
<8.0%, BG <200 postop
3 nerves identified during inguinal hernia repair
iliohypogastric: located b/w external and internal oblique muscles
ilioinguinal: lies on top of the cord
genital branch of genitofemoral: inferior to the cord; covered and protected by cremasteric muscles
Boundaries of inguinal canal
Ant: external oblique
Posterior: transversalis fascia
Superior: internal oblique & transverse abdominis
inferior: inguinal ligament
Boundaries of femoral canal
Ant: inguinal ligament
Post: pectineal (cooper’s ligament)
Med: lacunar ligament
Later: femoral vein
Choice for mesh in IPOM hernia repair
Intraperitoneal only mesh (IPOM) means that mesh is placed intraperitoneally on anterior abdominal wall with contact to intra-abdominal orgns
need mesh that has a coating in order to protect the organs from adhering to polypropylene or polyester surface
coating: PTFE, hydrogel, etc.
MC injured nerves with open inguinal hernia repair
ilioinguinal, genital branch of genitofemoral, iliohypogastric
MC injured nerves with laparoscopic inguinal hernia repair
genitofemoral, and lateral femoral cutaneous nerve
