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MBBS Surgery > Hernia > Flashcards

Hernia Flashcards

1
Q

Paraumbilical vs umbilical hernia

A

Umbilical hernia: umbilicus everts as a round central lump, with skin of the center of the umbilicus attached to the center of the sac

Paraumbilical hernia has the umbilicus is pushed to one side and stretched into a crescent shape pit. The umbilical skin is pushed to the side of the sac (and not center of the sac) If the umbilical pit is too deep to clean, it may produce foul-smelling discharge or dried sebaceous secretion (ompholith)

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2
Q

Paraumbilical hernia RF

A

middle and old age, more common in women, obese, multiparity

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3
Q

Contents of paraumbilical hernia

A

Contains extraperitoneal fat and omentum

does not cause IO

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4
Q

Umbilical hernia RF/Causes

A

Acquired: raised intra-abdominal pressure
Congenital: usually disappear spontaneously during the first few years of life
- if >3cm, >3yo - sx
- no symptoms

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5
Q

Hernia mgx

A
  • RF management: weight loss, change jobs, avoid weight lifting. tx chronic cough/constipation
  • Binder (truss)
  • Pt education - RF, Cx (IO)

surgical repair

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6
Q

Parastoma hernia RF

A 
Patient factors:
- poor wound healing: age, DM, cancer, steroids, immunosupp, smoking, malnutrition
- increased Intra ab pr
- Early mobilisation post op
Technical factors
- type of sx: e op
- type of stoma: colo > ileo, loop > end
- wound infection

sx: if incarcerated, causes stoma leakage, dysfunction, skin excoriation

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7
Q

Contents of spermatic cord

A

3 layers: external spermatic fascia, cremasteric fascia, internal spermatic fascia
3 veins: testicular vein (pampiniform plexus), vas deferens, cremasteric vein
3 arteries: testicular, vas deferens, cremasteric
3 nerves: ilioinguinal n, sympathetic fibres, n to cremaster (genital br of genitofemoral n)
3 others: remains of procesus vaginalis, vas deferens, lymphatics

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8
Q

Inguinal canal boundaries

A 
MALT (sup>ant>lower>pos)
Superior:
- internal oblique muscle
- transversus abdominis
Anterior: aponeurosis
- Apo of ext oblique
- Apo of int oblique
Lower: 2 Ligaments
- inguinal lig
- lacunar lig
Posterior: 2Ts
- trasnversalis fascis
- conjoint tendon
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9
Q

Contents of inguinal canal

A

Male: spermatic cord + ilioinguinal n
Females: round ligament of uterus + ilioinguinal n

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10
Q

What is a

  • pantaloon hernia
  • sliding hernia
  • littre hernia
  • amyand hernia
A
  • both direct and indirect inguinal hernia
  • retroperitoneal structures makes up part of the wall of the hernia through abdominal wall defect (e.g. bladder, caecum, sigmoid)
  • contain meckel diverticulum
  • contain appendix
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11
Q

Differentials for groin lump

A

Hernia - femoral, inguinal
Vascular - femoral artery aneurysm, saphena varix
Lymphatics - LN, lymphoma
ST/bone - lipoma, groin abscess, rhabdomyosarcoma
Nerve - neuroma
Others - undescended testes, hydrocele of the spermatic cord

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12
Q

What is a

  • epigastric hernia
  • Richter hernia
  • spigelian hernia
  • obturator hernia
A
  • hernia through weakened linea alba
  • hernia involving only part of bowel (knuckle)
  • hernia of the semi-lunaris (lat border of rectus abdominis) *read spigelian belt
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13
Q

What is a lumbar hernia

A

herniation through superior vs inferior lumbar triangle

Superior: Grynfelt (more common)
Inferior: Little

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14
Q

Obturator hernia associations

A
  • elderly lady, thin
  • presents as IO
  • Howship Romberg sign: pain in medial thigh extending to knee due to compression of obturator nerve
  • Hannington-kiff sign: absent adductor reflex and positive patellar reflex
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15
Q

Boundaries of Hesselbach triangle

A

Medial: lateral border of rectus abdominis
Inferior: inguinal ligament
Lateral: inferior epigastric artery

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16
Q

recurrent hernias tend to be?

A

direct

17
Q

where is the

  • inguinal ligament
  • deep ring
  • superficial ring
  • mid-inguinal point
A
  • betw pubic tubercle and ASIS
  • 2cm above midpoint of inguinal ligament
  • above and medial to pubic tubercle
  • between pubic symphysis and ASIS (femoral pulse)
18
Q

Direct vs indirect hernia

A

medial | lateral to inferior epigastric artery
within | out of hesselbach triangle

Reduces:

  • upwards and straight backwards, readily on lying down
  • upward, laterally, backwards, not readily

Controlled:

  • pressure over superficial
  • pressure over deep ring

not in | in scrotum

less risk | more risk of strangulation

Epidemiology:
old men | young adults/infants

19
Q

Layers of abdominal wall

A 
Skin
􏰀Camper Fascia
􏰀Scarpa Fascia
External Oblique Aponeurosis
􏰀Internal Oblique
􏰀Transverses Abdominis
􏰀Transversalis Fascia
􏰀Pre-peritoneal Fat
􏰀Peritoneum
20
Q

Acute mgx of obstructed/ strangulated hernia

A 
NBM
IV drip
NG tube on suction
IV Abx
E-OT: hernia repair
21
Q

Open vs Lap hernia repair

A

Patient factors
-Do they have CI to lap sx?
(Previous sx involving pre-peritoneal space/ cx inguinal hernia/ ascites, intolerance to GA)
-Presence of co-morbidities: Lap needs GA, open can be under LA
Disease factors
-Primary unilateral inguinal hernia: open/ lap
-Femoral hernia: lap
-Bilateral hernias: lap
-Recurrent hernia: open if previously lap, lap if previously open
Surgeon factors: expertise

22
Q

Surgical techniques of hernia repair

A

Open
- Mesh: tension free mesh repair (Lichtenstein)
- Non mesh: primary tissue approximation non mesh repair (shouldice)
Lap
- Totally extraperitoneal repair (TEP)
- Transabdominal preperitoneal patch repair (TAPP)

23
Q

what is the difference between herniotomy, herniorrhaphy, hernioplasty

A
  • Herniotomy: removal of hernia sac only
  • Herniorrhaphy: herniotomy + repair of posterior wall of inguinal wall (shouldice)
  • Hernioplasty: reinforcement of the posterior inguinal canal wall with a synthetic mesh (Lichtenstein)
24
Q

Cx of hernia repair

A
  • GA: AMI, CVA
  • Immed: ARU, bruising, bleeding, scrotal hematoma, injury to surrounding structures: paraesthesia, impotence
    -Early
    o Infx of wound/mesh
    o Hematoma (10%) – hard, non reducible, no cough impulse
    o Wound dehiscence
    o pain
    -Late
    o Chronic post op groin pain
    o Recurrence
    o Ischemic orchitis – thrombosis of pampiniform plexus
    o Testicular atrophy – test art damage
25
Q

Boundaries of femoral canal

A

Anterior: inguinal ligament
Medial: lacunar ligament
Lateral: femoral vein
Posterior: pectineus

26
Q

RF of incisional hernias

A

Patient factors – age, malnutrition, chronic dz (ESRF, CLD, CA), steroids, DM, obesity, increased abdominal pressure

Surgical Factors – wrong suture material, wrong technique

Wound factors – wound breakdown/ hematoma, ischemic wound from excessive tension, cx – anastomotic leak, infection

27
Q

mgx of umbilical/ paraumbilical hernia

A

Mayo vest over pants operation

or tension free mesh repair

MBBS Surgery (18 decks)

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