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Surgery > Hernia > Flashcards

Hernia Flashcards

1
Q

What is reducibility?

A

Can be pushed back, and it comes out only when counter force is applied on cough/strain (seen in uncomplicated hernia)

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2
Q

What is compressibility?

A

When the swelling return spontaneously once the pressure to reduce it is removed . seen in vascular surgery like hemangioma or lymphangioma

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3
Q

What is obstructed hernia/incarcerated hernia

A

Occurs when the contents show obstruction but the blood supply is NormaL

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4
Q

Obstructed hernia is

A

Irreducible that means there is no cough impulse

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5
Q

What is strangulated hernia?

A

Obstructed + compromised blood supply . skin changes are seen

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6
Q

In uncomplicated hernia process of reduction/taxis is best

A

Left to the patient

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7
Q

Based on the content in the sac, what are the two types

A

Omentocele and enterocele

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8
Q

What would you feel on palpation of omentocele?

A

Doughy consistency ; easy to reduce first part ; difficult to reduce second part.

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9
Q

What would you feel on palpation of enterocele?

A

Difficult to reduce first part easy to reduce second part

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10
Q

In the Omentocele if the content is Meckel’s diverticulum, it is called as

A

Litter’s hernia

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11
Q

In the Omentocele if the content is Appendix, it is called as

A

Amyand hernia

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12
Q

What are the steps of herniotomy ?

A
  1. Identify the sac
  2. Open the sac.
  3. Push the contents.
  4. Cut the excess sac.
  5. Close the sac.
    (Highest recurrence rate)
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13
Q

Herniotomy is treatment of choice is

A

Congenital inguinal, hernia and congenital hydrocele

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14
Q

What is herniorrhaphy?

A

Step 12345+ suture the two adges of the defect together

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15
Q

What is the most common cause of failure of herniorrhaphy

A

Increase tension in the repair

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16
Q

What are the techniques of herniorrhaphy?

A

Bassini’s ;
Shouldice ;
Mayo / kell

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17
Q

What is the indication of herniorrhaphy

A

Infected/strangulated hernia’s

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18
Q

What is hernioplasty?

A

Step 12345+ put a mesh over the defect to repair it. It has leased the current state.

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19
Q

Which technique is used in hernioplasty?

A

Lichenstein’s tension free mesh hernioplasty

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20
Q

Which mesh is avoided when there is an infection

A

Synthetic

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21
Q

Example of synthetic mesh

A

Vipro : vicryl + Prolene &
PTFE

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22
Q

Example of Biological mesh

A

Alloderm ; Acellular procine dermis

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23
Q

Ideal mesh is

A

Low weight mesh ;
Thin fibers ;
Large pores

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24
Q

What is meshoma

A

Excessive collagen deposition in plug mesh ; nerves get entrapped leading to pain

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25
Q

What is the most common hernia in both male and female?

A

Inguinal

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26
Q

What are the boundaries of Hasselbach’s triangle

A

• medial: Outer border of rectus.
• inferior: Inguinal ligament.
• Superior: Inferior epigastric vessels.

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27
Q

How to decide if hernia is direct, or indirect

A

• Any hernia that comes lateral to the triangle - Indirect
• Through the triangle: Direct.

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28
Q

What is myopectineal orifice of fruchaud

A

Superior : Arching fibers of internal oblique.
Medial: Outer border of rectus.
Lateral: Tendon of ilio-psoas.
inferior: Pectineal / cooper’s ligament.

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29
Q

Standing position of examination, help us to differentiate between

A

Inguinal versus femoral hernia

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30
Q

inguinal hernia are

A

Above and medial to pubic tubercle

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31
Q

Femoral hernia are

A

Below and lateral to pubic tubercle

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32
Q

Complete hernia means

A

Reaches till the base of scrotum

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33
Q

What is a single best test for inguinal hernias

A

Deep ring occlusion test

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34
Q

Steps of Deep ring occlusion test

A

Reduce the hernia (taxis).
Localise the deep ring & put pressure by thumb of same side over it.
In standing position, ask the patient to cough.
Look for bulge. If bulge is seen : Direct hernia.
If no bulge: release thumb and ask the patient to cough
If bulge is seen : indirect inguinal hernia

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35
Q

What is the IOC in non palpable hernia

A

USG

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36
Q

What are the other test for hernia

A

Ring invagination Test ;;
Zieman 3 fingers test

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37
Q

What are the three type of herniorraphy are there in open surgery of inguinal hernia

A

Bassini ;
Shouldice repair ;
Lichenstein’s tension free mesh hernioplasty .

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38
Q

What is the sx of choice in herniorraphy

A

Lichenstein’s tension free mesh hernioplasty

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39
Q

What is the most common nerve injured in open inguinal hernia sx

A

ilio inguinal nerve

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40
Q

What is the most common nerve entrapped in open inguinal hernia sx

A

ilio hypogastric nerve

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41
Q

What is stoppa’s repair

A

mesh is placed between peritoneum & posterior rectus sheath.
works on Pascal’s law . (mesh remains in place due to abdominal pressure. There is no need of Suturing/Staples ).

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42
Q

Lap inguinal hernia is useful for

A

BL inguinal hernia and recurrent IH

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43
Q

Laparoscopic repair includes

A

TEP and TAPP

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44
Q

During Lap repair two places where staplers should not be applied are

A

Triangle of DOOM and
Triangle of Pain

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45
Q

What are the boundaries of triangle of doom?

A

Vas deferens medially.
Testicular vessels laterally.
Peritoneal reflection inferiorly.

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46
Q

Contents of triangle of doom

A

External iliac artery and vein ;
Genital branch of genito femoral nerve(GFN)

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47
Q

What are the boundaries of triangle of pain?

A

Superiorly : Iliopubic tract /inguinal ligament.
medially: Testicular vessels.
Laterally: Peritoneal reflection.

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48
Q

What are the contents of triangle of pain?

A

Lateral cutaneous Nerve of Thigh.
Femoral nerve.
Femoral branch of Genito femoral nerve.

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49
Q

Most common, nerve entrapped in triangle of pain

A

Lateral cutaneous, nerve of thigh this leads to symptom complex called Meralgia parasthetica.

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50
Q

Triangle of pain is also known as

A

Electrical hazard zone as cautery is avoided in this area

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51
Q

What is trapezoid of disaster

A

Triangle of Doom (medial) + Triangle of pain (lateral)

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52
Q

What is corona mortis / circle of death

A

Abnormal communication b/w external and internal Iliac systems.
Aberrant obturator artery is situated behind the pubic tubercle and is injured during laproscopic surgery and leads to torrential haemorrhage and bleeding.

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53
Q

European hernia society classification

A

EHS GROIN HERNIA CLASSIFICATION;

P: primary Hernia
L: Lateral / Indirect
R: Recurrent
M: medial / direct
F: Femoral Hernia

54
Q

1 finger breath = how much defect

A

1.5 cm

55
Q

What is another classification of hernia

A

Nyhus classification

56
Q

What is gibbon hernia

A

Inguinal hernia + hydrocele

57
Q

What is pantaloon hernia

A

Direct + Indirect hernia (3b as per ESH)

58
Q

What is sliding hernia

A

Hernia en Glissade
Commonly seen in elderly males.
The posterior boundary of the sac is formed by a visceral structure.
mc on left side > Right side.
mc structure implicated: Sigmoid colon > Bladder.

59
Q

What is sportsman hernia

A

AKA glimore hernia
seen in Athletes.
severe inguinal / groin pain.
occurs o/+ tear in the posterior wall muscle.
Sometimes a very small Hernial sac can be there. usually non palpable.
IOC: MRI

60
Q

Management of sportsman hernia

A

MX: Rule out other causes of inguinal pain
Laparoscopic inguinal hernia surgery is done.
Pain may not resolve even after the surgery.

61
Q

What is bulbonocele

A

Hernial sac crosses deep ring, but does not reach up to the superficial thing. It remains in inguinal canal

62
Q

What is funicular

A

Hernial sac cross is the superficial ring, but doesn’t reach the base of the scrotum

63
Q

What is complete hernia/ inguinoscrotal

A

Reaches till the base of scrotum

64
Q

Boundaries of femoral ring

A

medially: Lacunar ligament.
Superiorly : Inguinal ligament.
Laterally: Septum which separates it from the veins (iliac or the femoral veins) Inferiorly : Pectineal/ Cooper’s ligament.

65
Q

Femoral hernias are often associated with

A

Richert’s hernia

66
Q

Location of Femoral hernia

A

Below and lateral to pubic tubercle .
F > M

67
Q

C/F of femoral hernia

A

Swelling / bulge below inguinal ligament / pubic tubercle.

68
Q

Location of inguinal hernia

A

Above the pubic tubercle

69
Q

DD Of femoral hernia are

A

Inguinal hernia
Psoas abscess
Inguinal LN
Saphenavarix
Lipoma in thigh

70
Q

What is Laugier’s hernia:

A

Femoral hernia through the lacunar ligament. Very high rate of strangulation.

71
Q

What is Narath’s hernia

A

Femoral hernia in patients with congenital dislocation of the hip. Prone to obstruction and strangulation.

72
Q

What is Serafini hernia ?

A

Retro-vascular hernia, sac lies beyond the femoral vessels.

73
Q

What is velpeau hernia

A

Pre-vascular hernia, sac lies in front of the femoral vessels.

74
Q

Lockwood approach is used in

A

It is a Low approach (below inguinal ligament) use in open hernioplasty used in uncomplicated femoral hernia

75
Q

Examples of high approach in open hernioplasty are

A

Mcevdy : in obstructed and strangulated hernia ..
Lotheissen’s : Trans inguinal approach

76
Q

Ventral hernia are

A

• They are abdominal wall hernias and are as follows
• Epigastric.
• umbilical.
• paraumbilical.
• Traumatic.
• Spigelian.
• Lumbar.
• Parastomal.
• Incisional:

77
Q

MC ventral hernia is

A

Incisional hernia: forms in the region of incision.

78
Q

MC hernia overall is

A

Indirect Inguinal hernia

79
Q

Which mgt Is preferred in ventral hernia

A

Hernioplasty

80
Q

Onlay repair

A

If mesh is kept above the rectus sheath
between skin, subcutaneous tissue and anterior rectus sheath.

81
Q

Inlay repair

A

If the mesh is merged with the anterior rectus sheath/at the same level.

82
Q

Retromuscular repair

A

If the mesh is placed behind the rectus muscle.

83
Q

• Preperitoneal/ sublay repair

A

If the mesh is kept between the peritoneum and sheath.

84
Q

Intraperitoneal repair

A

Called as IPOM /Intraperitoneal placement of mesh. used in laparoscopic repair. To prevent fecal fistula and adhesion (bowel-mesh adherance) PTFE meshes are used.

85
Q

IPOM Procedure

A

ventral hernia defect is dissected -> content of the hernia (preperitoneal fat globule) is pulled down -> defect visualized -> mesh placed after adequate dissection -> Covering atleast 4-5cm across the defect -> to avoid mesh shrinkage. mesh is anchored to the abdominal wall using tackers or staplers to prevent movement of mesh.

86
Q

What is remirez component separation technique

A

Done in complex incisional hernias . where incisional hernia volume is >25% of abdominal volume

87
Q

What is the location of epigastric hernia/fatty hernia of linea alba

A

It can be seen anywhere in between xiphisternum to umbilicus. Scene in young fit males > females.

88
Q

epigastric hernia comes through

A

Transverse split in the median Raphe

89
Q

Most common content of epigastric hernia is

A

Preperitoneal fat

90
Q

What is the most distinguish clinical features of epigastric hernia?

A

Pain which mimics pain of peptic ulcer

91
Q

High rate of obstruction and strangulation seen in which kind of hernia

A

Paraumbilical hernia

92
Q

Which hernia is more common in premature babies

A

Umbilical hernia

93
Q

Management of umbilical hernia in children

A

Conservative management wait for 2 to 3 years of age if defect does not close by itself do mesh repair surgery after 2 to 3 years

94
Q

Management of paraumbilical hernia

A

Open laparoscopic hernioplasty

95
Q

What is omphalocele

A

Defect through the umbilicus in which bowel fails to return inside during embryogenesis, covered with peritoneal sac. Liver can also herniate .

96
Q

Omphalocele is associated with

A

Associated with Beckwith weidmann syndrome (wilms tumor), trisomy 13, 18, 21.

97
Q

Management of omphalocele and gastroschisis

A

management is done after ruling out other congenital abnormalities.
Pushing bowel inside the abdomen can cause abdominal compartment syndrome.
Silo/cylinder is created using mesh -> defect covered
Child reviewed periodically -> reduce the height of silo -> gradually push bowel into abdomen across multiple visits.
Once it reaches the level of rectus sheath, the contents are pushed inside and abdomen is closed..

98
Q

What kind of lumber hernia are common?

A

Secondary(to trauma ,sx nephrectomy)

99
Q

Majority of lumber hernias are come out through

A

Inferior lumbar triangle of petit

100
Q

Boundaries of inferior lumber triangle of petit

A

• Inferiorly: lliac crest
• Laterally: Exteral oblique
• medially: Latissimus dorsi

101
Q

Boundaries of superior lumber triangle of grynfelt

A

• Superiorly: 12th rib
• Laterally: Internal oblique
• medially: Sacrospinalis

102
Q

Which repair is used specifically to treat lumbar hernia

A

Dowd-Ponca repair

103
Q

spigelian hernia / Intra-parietal hernia comes out through

A

It comes out through spigelian fascia (modification of fascia tranversalis).

104
Q

MC location of Spigelian hernia / Intra-parietal hernia

A

Below the umbilicus but above the arcuate line (midpoint between umbilicus and pubic symphysis) along the outer border of rectus.
Below the arcuate line, posterior rectus sheath is absent.

105
Q

What is Intraparietal hemia

A

Sac lies at the outer border of rectus and in between the muscle layers (invisible). usually detected when obstruction or strangulation occurs.
It is a small defect in young children, whereas in adults it is large defect.

106
Q

What is obturator hernia / french hernia

A

Little old lady’s hernia.
common in elderly, multiparous woman.
It comes out through narrow defect/obturator canal, hence prone to obstruction and strangulation.
They can also develop Richter’s hernia

107
Q

What is Howship Romberg sign.

A

Shooting pain along obturator nerve during abduction and medial rotation of hip.

108
Q

What is Hannington Kiff sign

A

Absent adductor reflex in “the presence of a positive patellar reflex because of obturator nerve compression. Swelling is usually not felt, and so diagnosed late.

109
Q

What is Ritchter’s hernia

A

There is a very narrow defect resulting in herniation of only a portion of bowel wall, while the rest of the bowel lumen continuity is maintained -> no features of obstruction like vomiting/distension/obstipation-> vigorous bowel contractions -> early presentation is gastroenteritis -> peritonitis/ strangulation.

110
Q

Hernias with narrow defect can give rise to Richter’s hernia. They are

A

• Femoral hemia.
• Paraumbilical hernia.
• Obturator hernia.
Early repair is mandated in thse hernias.

111
Q

What is Maydl’s hernia

A

Defect is very wide, multiple loops of bowel can go through causing a W’ shaped hernia.
If strangulation is to occur, it occurs in the intraperitoneal portion.
Significance: Intra-abdominal strangulation may be missed as normal bowel is seen upon incision.

112
Q

What are the two types of CDH?

A

• Bochdalek (65-709).
• morgagni.

113
Q

What is bochdalek hernia

A

more common
Left posterolateral
Defective development of pleuroperitoneal canal/ membrane of diaphragm stomach, spleen and transverse colon can herniate.

114
Q

What is morgagni hernia

A

Less common
Right anteromedial
Defective central tendon of diaphragm.
Transverse colon usually herniates.

115
Q

Most common cause of death in CDH patient

A

Pulmonary hypoplasia

116
Q

Second, most common cause of death impatient with CDH

A

Pulmonary hypertension

117
Q

 Best ventilation in patient with CDH

A

IPPV ;; if IPPV fails ECMO .
Bag and mask ventilation is contraindicated .

118
Q

Which medicine has revolutionized the treatment of diaphragmatic hernia

A

Inhaled nitrates as they can mange pulmonary hypertension

119
Q

What is definitive mgt of CDH

A

Sx (circumferential incision around the diaphragm) 

120
Q

What is stemmer’s hernia:

A

Through transverse mesocolon window after Roux en y gastrojejunostomy.

121
Q

What is Peterson’s hernia

A

Behind the roux limb after sure

122
Q

What is Left paraduodenal hernia

A

Through fossa of Landzert, due to defective fusion of descending colon mesentery. As descending colon is supplied by inferiormesenteric vessels, the hernia lies behind the inferior mesenteric vessels.

123
Q

What is Right duodenojejunal hernia

A

: This is due to defective fusion of ascending colon mesentery. As ascending colon is supplied by superior mesenteric vessels, the hernia lies behind the superior mesenteric vessels.

124
Q

What are the two main types of mesenteric cyst?

A

Chylolymphatic and Enterogenous

125
Q

What is Tillaux triad and sign

A

Moves at right angles to attachment of mesentery but not along the line of attachment of mesentery. Line of attachment of the mesentery: From the DJ flexure to the right sacro-iliac joint.
This is Tillaux sign.
Transverse band of resonance over the swelling (transverse colon goes over it).

126
Q

What is IOC of mesenteric cyst

A

Contrast enhanced CT scan

127
Q

Mgt of Chylolymphatic cyst

A

Sx -> enucleation without damaging the bowel (independent blood supply).

128
Q

What is mgt of Enterogenous cyst -

A

Sx > resection and anastomosis (shared blood supply with bowel

129
Q

What is misty mesentary

A

Seen secondary to pancreatitis, edema, hemorrhage, cancer. Should be differentiated from medenteric panniculitis ( inflammation of fat) which is manifestation of weber Christian disease

130
Q

Borchardt’s triad seen in

A

Gastric volvulus

131
Q

Borchardt’s triad consists of

A

• consists of unproductive retching.
• Epigastric pain and distention.
• Inability to pass a nasogastric tube.

132
Q

What is the serious complication of hernia

A

Strangulated

Surgery (30 decks)

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