HERNIA Flashcards
Lichtenstein
see card bellow for very clear discription
General/ epidural/ spinal anesthesia was induced.
5,000 u Hep / SCDS
Anceph
1 cm lateral and superior to the anterior superior iliac spine and a fascial injection of lidocaine was made to block the ilioinguinal nerve.
Prep scrotum
incision natural skin crease planned to end near the pubic tubercle.
Scarpa’s and Camper’s fascia
aponeurosis of the external oblique cleaned
external ring was exposed.
incision midportion of the external oblique aponeurosis in the direction of its fibers.
The ilioinguinal nerve identified and protected
Flaps of the external oblique were developed cephalad and inferiorly.
cord identified gently dissected free at the pubic tubercle and encircled with a Penrose drain.
anteromedial aspect of the cord indirect hernia sac was identified.
sac dissected free of the cord down to the level of the internal ring.
vas and testicular vessels identified and protected
sac was opened and contents were reduced.
A finger was passed into the peritoneal cavity and the floor of the inguinal canal assessed and found to be strong.
The femoral canal palpated and no hernia identified.
The sac was twisted and suture ligated with 2-0 silk.
Redundant sac was excised and submitted to pathology.
The stump of the sac was checked for hemostasis and allowed to retract into the abdomen.
Attention then turned to the floor of the canal, which appeared to be grossly weakened without a well-defined defect or sac.
The polypropylene/ other mesh cut to the appropriate size with an oval medial portion and a longitudinal lateral opening.
Beginning at the pubic tubercle, the mesh was sutured to:
the conjoint tendon superiorly / medially (rectus faschia + internal oblique)
the inguinal ligament inferiorly
using two continuous running 2-0 nonabsorbable prolene.
Care was taken to assure that the mesh was placed in a relaxed fashion to avoid excessive tension and that no neurovascular structures were caught in the repair.
Laterally, the tails of the mesh were crossed and the internal ring recreated, allowing for passage of the surgeon’s fifth fingertip.
Hemostasis was again checked. The Penrose drain was removed.
The external oblique aponeurosis was closed with a running suture of 3-0 Vicryl, taking care not to catch the ilioinguinal nerve in the suture line.
Scarpa’s fascia was closed with interrupted 3-0 Vicryl.
The skin was closed with a subcuticular stitch
The testis was gently pulled down into its anatomic position in the scrotum.
LAPAROSCOPIC INGUINAL HERNIA REPAIR
Supine; arms tucked in,
Foley,
no antibiotics,
prep from costal margin down to (and including) genitalia
Trendelenburg to displace viscera away from operative area
Trochars:
one at umbilicus,
one on each side (lateral to rectus at mid abdomen level);
at least one must be 10/12 mm
Landmarks: spermatic vessels, median umbilical ligament, inferior epigastric vessels, external iliac vessels
PROCEDURE
MOBILIZATION –
Peritoneum
Using electrocautery with hook/curved scissors, incise peritoneum transversely starting just above border of internal ring
Continue medially to above pubic tubercle and laterally to 2 cm beyond internal ring
Retract median umbilical ligament medially and retract peritoneal flap with sac inferiorly
Create smaller peritoneal flap superiorly exposing transversus abdominus arch and posterior of rectus muscle
MOBILIZATION – Hernia Sac
Bluntly dissect sac from surrounding structures using traction/countertraction
Lipomas of cord are preperitoneal structures and lie posterolaterally on cord; should be removed
Larger sacs can be transected at level of internal ring
If adherent to cord, open sac on side opposite spermatic cord and complete division from inside
MOBILIZATION - Landmarks
Find pubic tubercle medially
palpate Cooper’s ligament along pectineal prominence of superior pubic ramus
Numerous vessels course along Cooper’s and often there is an aberrant obtruator artery; avoid these structures
1
Avoid dissection below iliopubic tract (inferior to internal ring) to avoid injury to genitofemoral nerve and lateral femoral cutaneous nerve of the thigh
MOBILIZATION - Mesh
Cut Prolene mesh to size (ACS: 6x10 cm), tapered at medial end, rounded corners; insert via one of the 10/12 mm ports
Lay flat in preperitoneal space and anchor with 5mm spiral tacker starting medially at pubic tubercle
Continue tacking superiorly along rectus and transversus abdominus arch/fascia staying ~1-2cm above internal ring
Travel laterally to several cm beyond internal ring or defect, avoiding inferior epigastric vessels, and stop
Use two hands for tacking; one hand on tacker and one hand providing counterpressure from outside abdomen
Inferior tacking starts at pubic tubercle and follows to Cooper’s ligament; lift mesh regularly to see cord and avoid it
Lateral to cord, place tacks only on iliopubic tract to avoid nerve injuries
If you can palpate tacker from outside abdomen you are too high (i.e. above iliopubic tract)
Close peritoneum by draping lower flap upward over upper flap; lower insufflation pressure to help; use tacker or clips
Remove trochars under direct vision and close incision
Component separation
Bilateral subcostal incisions three finger breast below cost a margin
Dissection carried down to external oblique aponeurosis
External oblique fascia into your she is released longitudinally with Metzenbaums scissors(Being careful of in pure epigastric) from costal margin to inguinal ligament
Post year rector she just lateral to linea Alba released
4 – 6 inches with external oblique
two – 3 inches with rectus sheath
Femoral hernia repair open without mash
Cooper’s ligament
(rectus sheath margin combines with )
Sew cooper’s ligament to transversalis Fashion
Transition stitch at femoral sheath
then sew to transversus
FEMORAL HERNIA REPAIR (INCARCERATED)
CONSENT
• May require laparotomy +/- bowel resection
OPERATIVE POSITION AND TECHNICAL CONSIDERATIONS
• Supine; if from below, can slightly extend hip and flex knee
- Below approach doesn’t allow for good anatomic repair, but can be done under local and in frail, elderly, or debilitated pts
- Inguinal approach is much better, done if suspect incarceration or strangulation and can explore for other inguinal hernias too
TECHNICAL STEPS
Below
• Incision parallel to inguinal ligament, 2 cm BELOW
- ID sac, free it from surrounding tissue, reduce contents
- May need to incise inguinal ligament to enlarge the canal
- Close canal from below using prosthetic mesh plug,
suture to iliopubic tract anteriorly and medially
(sometimes lacunar medially),
Coopers posteriorly,
venous periadventitial tissue laterally (not vein itself obviously)
Inguinal (Above)
- Open the inguinal canal in usual fashion
- Open floor of canal in inferior aspect by sharp and blunt dissection to id Cooper’s
- Identify neck of hernia as a diverticulum of peritoneum extending down from the abdomen through the femoral canal, a space medial to the femoral vein
- Again may need to cut inguinal ligament to allow for reduction of contents
• NOTE: the so called artery of death, which frequently runs along the underside of the inguinal ligament must be id’d and ligated if present
(from pubic branch of inferior epigastric artery; also called accessory obturator artery);
if damage not identified can lead to delayed bleeding
• Repair defect in classic McVay repair
Incarcerated contents
• With femoral hernias especially, be very careful not to allow contents to slip back into abdomen prior to inspection; this can happen once release inguinal ligament
- Open sac, inspect fluid; if bloody or turbid worry about strangulation or perf resp.
- Look for obvious clues of viability such as peristalsis, colour; warm up specimen using warm sponge, then re-examine if in doubt (Doppler and fluorescein is crap)
- If suspect non-viable tissue, if possible, can resect and anastomose from groin
- Often however, will need to go to low midline laparotomy incision
- If specimen slips back into abdomen prior to inspection, need to convert to midline laparotomy
COMPLICATIONS
• Anastomotic dehiscence, delayed peritonitis if missed strangulation
• Mesh infection
(Operative Anatomy)
Femoral hernia tissue repair
McVeigh = conjoined tendon
conjoint sewn to coopers
(transition stitch)
coopers to shelving edge
The skin crease incision
through Scarpa’s and Camper’s fascia
aponeurosis of the external oblique and the external ring was exposed.
incision was made in the midportion of the external oblique aponeurosis in the direction of its fibers.
ilioinguinal nerve was identified and protected
Flaps of external oblique were developed
cord gently dissected free at the pubic tubercle and encircled with a Penrose drain.
anteromedial aspect of the cord, where an indirect hernia sac was identified.
If male: The sac was carefully dissected free of the cord down to the level of the internal ring. The vas and testicular vessels were identified and protected from harm.
If female: The round ligament was doubly ligated and divided at a convenient point near the sac.
sac opened and contents were reduced.
A finger was passed into the peritoneal cavity and the floor of the inguinal canal assessed
and femoral canal was palpated and a hernia identified/
The conjoint tendon was identified and grasped with Allis clamps,
relaxing incision:
made in the anterior rectus sheath medial and well superior to the conjoint tendon.
The conjoint tendon then reached easily to Cooper’s ligament with no tension whatsoever.
conjoint sutured to the shelving edge of the inguinal ligament with multiple simple sutures of ___.
This suture line began at the pubic tubercle and commenced laterally to the femoral vessels. A transition stitch was placed incorporating both Cooper’s ligament and the anterior femoral sheath.
Remaining sutures were placed between the conjoint tendon and anterior femoral sheath.
Care was taken not to take deep bites and endanger the femoral vessels.
If male: At the conclusion of this, the internal inguinal ring accommodated the tip of a Kelly hemostat.
(Optional: A single suture was placed lateral to the cord to additionally tighten it.).
If female: The internal ring was completely obliterated at the conclusion of this procedure.
Hemostasis was again checked. The Penrose drain was removed. The external oblique aponeurosis was closed with a running suture of 3-0 Vicryl, taking care not to catch the ilioinguinal nerve in the suture line. Scarpa’s fascia was closed with interrupted 3-0 Vicryl. The skin was closed with a subcuticular stitch of ___/ skin clips/ other. A dressing was applied. If male: The testis was gently pulled down into
triangle of doom
External iliac vessels
Deep circumflex iliac vein
Femoral nerve
Genital branch of the GF nerve
triangle of pain
Iliopubic tract lateral
gonadal vessles - medial
triangle of pain” is an inverted “V”
apex at the internal (deep) inguinal ring.
anteriorly by the inguinal ligament
testicular (spermatic) vessels posteromedially.
why are spigalian hernias hard to feel
the external oblique Hoover lies the hernia
basic components of baccini repair
Shuldice hernia repair
(but no conjoint to coopers like in the femoral mcvay / coopers repair)
conjoint tendon to shelving edge
McVay repair
— The McVay repair can be used for the repair of inguinal or femoral hernias [93].
incising the transversalis fascia in the region of Hesselbach’s triangle to enter the preperitoneal space to expose the pectineal ligament (Cooper’s ligament).
conjoined tendon is sutured to Cooper’s ligament from the pubic tubercle laterally as far as the vicinity of the femoral sheath as it crosses Cooper’s ligament
a transition stitch is placed incorporating”
conjoined tendon,
Cooper’s ligament,
femoral sheath at the medial aspect of the femoral vein,
and
inguinal ligament
(occasionally the femoral sheath cannot be identified and can be excluded).
The remainder of the inguinal floor is repaired by approximating:
the conjoined tendon
to the
inguinal ligament
extending laterally to the area of the internal ring.
This repair generates considerable tension, and requires:
relaxing incision-
anterior rectus sheath behind the external oblique aponeurosis exposed from the pubic tubercle cephalad for several centimeters and it is then incised from the pubic tubercle extending cephalad for approximately 6 centimeters along the fusion of the external oblique aponeurosis with the sheath’s other components.
This type of relaxing incision can also be used with other non-mesh repairs.
Lichtenstein
Clear discription from scenarios
Reverse Trendelenburg (may help keep from spont reduction before can eval bowel)
prep scrotum so testicle can be checked at end of case
ileoinguinal block inferiror lateral to Ant Sup Iliac Spine
A 6- to 8-cm incision is made above and parallel to the inguinal ligament.
dissection to the level of the external oblique aponeurosis
cut along the line of the external oblique fibers from the level of the internal ring and through the external ring.
Watch the ilioinginal nerve here
Do not let the bowel slip back into the abdomin if what to resect from groin
groin exploration is warranted in the case of suspected incarceration/ strangulation.
If the viability of the bowel is in question, a resection can be performed via the inguinal incision.
Tissue flaps are mobilized.
Through blunt finger dissection, the cord (and hernia sac) are freed circumferentially and encircled in a Penrose drain.
separation of the hernia sac from the cord structures with division of the cremasteric fibers.
sac anterior and medial with respect to the cord.
The internal ring is inspected for evidence of indirect hernia.
If found, the sac is dissected free and ligated under direct vision.
Care is taken to avoid injury to the contents of the hernia.
If a direct hernia is encountered, the hernia is reduced.
The inguinal floor should be inspected for weakness.
repairing the ring and floor with mesh.
polypropylene mesh (precut or 6-in2)
medial point is secured to the lateral aspect of the pubic tubercle, periosteum and not the bone itself.
prosthesis is positioned over the inguinal floor and secured to the lateral edge of the conjoint (rectus sheath and internal oblique)
The cord structures are placed through a slit in the lateral portion of the mesh,
two tails are crossed and secured to each other to create a new internal ring.
The inferior tail of the mesh is secured to the shelving edge of the inguinal ligament
The external oblique aponeurosis and Scarpa’s fascia are closed in layers. The skin is approximated.
triangle of doom
vas - medial
external iliac - inferior
gonadal vessels - latteral
contents:
external iliac artery and vein
deep circumflex iliac vein
Triangle of pain
(“lame triangle - includes skin (medial) and inguinal “L” ligament “L” laterally and already sim stucture as tringle of doom with spermatic vessels but oposite orientation.
SPERMATIC vessels MEDIAL
INFERIOR - edge of skin
inguinal ligament - laterally
Contents:
lateral femoral cutaneous nerve
Interior femoral cutaneous nerve of the thigh
Cooper’s ligament structure
also called the pectineal ligament
extension of the lacunar ligament that runs on the pectineal line of the pubic bone
