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
