Hernia Flashcards
spigelian hernia definition
through the aponeurotic layer between the rectus muscle medially and the semilunar line laterally
typcally between oblique fibers and insertion of external apo into rectus sheath
at or below the arcuate line “semicircularis” (loss of posterior rectus sheath)
small (usually 1-2 cm)
dx spigelian
CT or US
mgmt spigelian
must be repaired because of the high risk of incarceration resulting from their narrow neck
perineal hernia after APR
protrusion of intra-abdominal contents through a pelvic floor defect
mgmt of perineal hernia
transabdominal or combined perineal approach repair with mesh
lap vs open hernia repair in the setting of obesity?
relatively small defect, lap > open
most likely injured artery in open inguinal hernia repair?
inferior epigastric aa
mesh selection hernia repair, clean case
LIGHT, MACROPOROUS, Polypropylene mesh = permanent synthetic mesh that becomes incorporated into native tissue and has a low rate of recurrence.
mesh selection hernia repair, contaminated field
Polyglycolic acid mesh, an absorbable mesh, is often used in contaminated fields because there is no prosthetic material remaining over the long term; however, it does not provide long-term tissue support!!!!
vs
Biologic mesh is typically composed of an acellular collagen matrix that theoretically promotes neovascularization and native collagen deposition; thus, it can be used in contaminated fields. However, the high cost of biologic mesh makes it less appropriate for routine repair in clean operative field
elective hernia a1c, BMI, tobacco
a1c <8%, BMI <40, tobacco 4-8 wks stop
decision to use mesh
if defect >3cm (primary closure recurrence is like 50%).
parastomal hernia incidence
highest for colostomies and occurs in up to 50% of stomas
mgmt parastomal hernia
laparoscopic Sugarbaker repair for IPOM: place UNDERLAY mesh as a flat sheet, lateralize stoma as it exits the abdomen
diastasis recti
NOT A TRUE HERNIA.
weakening of the linea alba, while the rectus fascia is intact
not associated with a risk of strangulation
lumbar hernia of Grynfeltt
between the 12th rib/LAT, paraspinal (&serrator posterior) muscles, and the internal oblique muscle; therefore, this is the mostly likely diagnosis
lumbar hernia of Petit
bordered by lat dorsi, iliac crest, and external oblique
Richter hernia
Mostly inguinal or femoral canal vs incisional
Involve antimesenteric border of the bowel (typically the distal ileum)
Richter mgmt
they incarcerate easily; so preperitoneal approach
Littre hernia
with meckel’s diverticulum in it; mostly inguinal 50%>. umb , femoral
Obturator hernia
obturator canal = union of pubic bones and ischium
usually presents with bowel ischemia, Howship Romberg sign (inner pain with internal rotation)
can help wtih repair by incising obturator canal
Anterior vs posterior component separation
Ant: higher wound morbidity which includes superficial or deep surgical site infection, seroma, wound dehiscence, wound necrosis, and the development of a chronic draining sinus
How much regain of domain do you get from anterior component separation?
10 cm on each side
anterior component separation steps
- dissect SQ from ant rectus sheath and external aponeurosis
- ext oblique incised 2 cm lateral to rectuas abdominis
- ext oblique separated from internal oblique
- dissect down to posterior axillary line
- more length by incising posterior rectus sheath above the arcuate line
diaphragmatic injury closure, traumatic
debride devitalized edges, then use nonabsorbable (polypropylene ie) interrupted or running in locked fashion
bridging mesh if absolutely necessary
complete diaphragmatic avulsion from chest wall injury mgmt
reattach primarily using PDS (?? should be using non-absorbable…) sutures circumferentially around the ribs
swiss cheese hernia repair
overlap between mesh adn abdominal wall by 3-5 cm
ilioinguinal injury
prox thigh numbness/burning
ilioinguinal course
exits abdominal wall lateral to internal inguinal ring and typically runs with cremasteric fibers along (but not in) the cord
most commonly injured at external ring when opening the oblique up
post inguinal hernia pain
10% of patinets
6 mo = chronic
mgmt post inguinal hernia pain
- nerve block
- triple or selective neruectomy
- groin exploration and mesh removal
MC hernia of all time
indirect inguinal hernia (lateral to epigastrics) from patent processus vaginalis
MIS inguinal hernia repari
TEP or TAPP
mcvay
tissue based repair (good fro contaminated; can’t do Lichtenstein)
onlay repair mesh overlap
4-6 cm
conjoint tendon
aponeurosis of internal oblique FASCIA and transversalis FASCIA
lacunar ligament
where inguinal ligament splays to insert into the pubis
coopers ligament
pectineal ligament posterior to femoral vessels; lies against the BONE
sliding inguinal hernia
RP organ involved (F: ovary, M: cecum/sigmoid)
sliding inguinal hernia mgmt ovary
ligate round ligament (runs in inguinal canal in F)
bassini repair
approximate conjoint tendon to free edge of cooper’s ligament (shelving edge, inferior) for inguinal hernia
shouldice: bassini in 4 layers
mcvay repair (ing or femoral repair)
approximate Conjoint tendon to Cooper’s ligament requires relaxing suture in external oblique
ilioinguinal nerve injury (runs on top of cord; injured at external ring)
loss of cremasteric reflex; numbness ipsilateral penis/thigh
where do cord structures run relative to the indirect inguinal hernia
the sac is DEEP to cremasters
the cord is POSTERIOR and INFERIOR to sac
genitofemoral nerve injury
genital branch: cremaster loss, scrotum numbness
femoral: numbness upper lateral thigh
femoral canal bounds
posterior: Coopers
anterior: inguinal
lateral: fem vein
medial: lacunar
when to repair umbilical hernia
5 YO
polypropylene fibroblast growth
YES
PTFE fibroblast growth
NO
incarceration risk inguinal hernia
0.18% per year
umbilical contents –> adult
vitelline duct = omphalomesenteric duct (can become Meckel’s)
urachus = median umbilical ligament
umbilical arteries x 2 = medial umbilical ligaments
umbilical vein = round ligament of the liver (ligamentum teres)
when does midgut hernia?
herniates at 6 wks, returns at 10 wks
omphalocele vs gastroschisis defect
omphalocele: through umbilical stalk
gastroschisis: inferior/RIGHT of umbilical stalk
when to repair umbilical hernia?
5 YO ( before go to school)
when to primarily repair umbo hernia
< 1 cm
cremasters are made of?
internal oblique muscle fibers
contents of spermatic cord
cremasters
testicular artery
vas def
pampiniform plexus
ilioinguinal N
genital branch of genitofemoral N.
MC nerve injury in LIchtenstein
ilioinguinal (when opening ext oblique)
MC nerve injured in lap/robotic hernia
lateral femoral cutaneous (tack during lateral dissection)
morbid obese hernia
staged with bari first
smoking hernia
just stop before elective repair
highest recurrence of mesh placement lOCATION
inlay
best LOCATION mesh
UNDERLAY
amyand hernia
appendix in inguinal hernia sac
corona mortis
branch between obturator and external iliac artery (arterial bleeding tack mesh to coopers)
location of mesh
Intraperitoneal
underlay: preperitoneal
sublay: retrorectus
inlay: interposition
overlay: subQ
IPOM
keyhole technique… intraperitoneal only tac it up
congenital diaphragmatic hernia
50% rate for chronic pulmonary disease regardless of repair
congenital diaphragmatic hernia lap vs open
LAP has more recurrence
obturator canal bounds
contents: obturator aa/v/N
1cm x 2-3cm long
inferior to cooper’s ligament
medial to femoral vessels
how to fix obturator hernia
if threatened bowel: TRANSABDOMINAL
you may need to incise obturator membrane to reduce (incise medially and downward direction to avoid vessels)
if large, needs mesh (all sites)
close peritoneum
myopectineal orificie
space covered in TAPP mesh repair (covers indirect, direct, and femoral areas)
if incarcerated symptomatic in pregnant woman, when to operate on umbilical hernia?
2nd trimester
fothergill’s sign
rectus sheath hematoma is bigger & more painful with flexed rectus muscle
desmoid tx
WLE if possible
if not, sulindac and tamoxifen
