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Hernia and Abdominal Wall Problems Flashcards

1
Q

1 hernia in both male AND females?

A

indirect inguinal

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2
Q

Hernia general info

A

Protrusion of a viscus through an abnormal opening in the wall of a cavity in which it is contained

10% of population develops some sort in life. 3-4% current male population

50% indirect inguinal
25% direct (mostly people over 50)
15% femoral

Abdominal wall hernia is #1 condition requiring major surgery

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3
Q

External hernia

A

Sac protrudes completely through the abdominal wall. Ex = inguinal (indirect and direct), femoral, umbilical, epigastric

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4
Q

Internal hernia

A

sac is within the visceral cavity.

Ex = diaphragmatic (congenital or acquired), small intestine herniating in the paraduodenal pouch

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5
Q

Intraparietal hernia

A

sac is contained within abdominal wall

Ex = spigelian hernia

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6
Q

Reducible vs irreducible

A

Irreducible = incarcerated

Cannot be returned to abdomen

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7
Q

Strangulated

A

vascularity of viscus is compromised

surgical emergency

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8
Q

Layers of abdominal wall

A 
skin
subq fat
camper's 
Scarpa's
External oblique
Internal oblique
transversalis abdominis 
transversalis fascia
peritoneal fat
peritoneum
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9
Q

Inguinal canal

A

Length = 4cm

Anterior = ext oblique aponeurosis

Posterior = transverse abdominal muscle aponeurosis and transversalis fascia

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10
Q

Spermatic cord

A

Begins at deep ring and contains:

Vas Deferens and its artery

1 testicular artery

2-3 veins

lymphatics

Autonomic nerves

Fat

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11
Q

Genital nerve

A

Travels along with cremaster vessels to form neurovascular bundle

From L1 and L2

Motor and sensory

Innervates cremaster, skin of side of scrotum and labia

May sub for ilioinguinal nerve if it doesn’t work

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12
Q

Iliohypogastric, ilioinguinal nerves, genital branch of genitofemoral nerve

A

Iliohypogastric and ilioinguinal intertwine

originate from T12 and L1

Sensory to groin skin, base of penis, medial upper thigh

Genital branch of genitofemoral nerve is located on top of spermatic cord in 60% of people but can be found behind or within the cremaster muscle. Often cannot be found or is too small to be seen

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13
Q

Femoral canal structures

A

Lateral to medial = NAVEL

Nerve
Artery
Vein
Empty space
LN
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14
Q

Hesselback’s triangle

A

lower abdominal wall

site of direct inguinal hernias

Inferior = inguinal ligament

Medial = rectus abdominis

Lateral = Inferior epigastric vessels (lateral umbilical fold)

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15
Q

Triangle of Grynfeltt

A

“superior lumbar triangle”

Bounded by 12th rib superiorly

Internal oblique anteriorly

Floor = fibers of quadratus lumborum muscle

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16
Q

Triangle of Petit

A

“inferior lumbar triangle”

Posterior = Lat
Anterior = ext oblique

Inferior = iliac crest

Floor = fibers from int oblique and transversus ab

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17
Q

Inguinal hernia - general

A

Hernias arising above the abdominocrural crease

Most common site for abdominal hernias

Male:Female = 25:1

Males: Indirect > direct (2:1)

Female: Direct is rare

Incidence, strangulation, and hospitalization all increase with age

Cause 15-20% of intestinal obstructions

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18
Q

Risk factors for inguinal hernia

A

1) Abdominal wall hernias occur in areas where aponeurosis and fascia are devoid of protecting support of striated muscle
2) They can be congenital or acquired by surgery or muscle atrophy
3) Female predisposition to femoral hernias: increased diameter of the true pelvis as compared to men, proportionally widens the femoral canal
4) Muscle deficiency of the internal oblique muscles in the groin exposes the deep ring and floor of inguinal canal, which are further weakened by intra-abdominal pressure
5) Connective tissue destruction (transverse aponeurosis and fascia): caused by physical stress 2/2 intra-abdominal pressure; smoking; aging; connective tissue disease; systemic illness; fracture of elastic fibers; alterations in structure, quantity and metabolism of collagen
6) Other: Abdominal distention, ascites with chronic increase in intra-abdominal pressure, peritoneal dialysis

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19
Q

Symptoms of inguinal hernia

A

Asymptomatic sometimes

Symptomatic - nonspecific discomforts vary by patient

Pain: Worse at the end of the day and relieved at night when patient lies down (bc hernia reduces)

Groin hernias do NOT usually cause testicular pain. Likewise, testicular pain doesn’t usually indicate the onset of a hernia

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20
Q

Dx of inguinal hernia

A

PE

In standing position, have patient strain or cough. Hernia sac will enlarge and transmit a palpable impulse

Hydroceles can resemble an irreducible groin hernia. To distinguish, transilluminate (hernia will not light up)

21
Q

Ddx of inguinal hernia

A

Abdominal wall mass

Desmoids

Neoplasm

Adenopathy

Rectus sheath hematoma

22
Q

Radiology role in inguinal hernias

A

diagnosis is clinical

imaging only used in special cases like when obesity limits clinical exam (US/CT)

23
Q

Management of inguinal hernia

A

Principles of Tx:
1) Tension-free repair of hernia defect

2) Repair using fascia, aponeurosis or mesh
3) Suture material used should hold until fibrous tissue is formed over it
4) Resuscitation in case of strangulated hernia with gangrene with shock or with intestinal obstruction

Nonsurgical:
1) No role for medical management in patient who can tolerate surgery

2) Can be considered in moribound patients
3) Hernia truss is a device to keep a reducible hernia contained by external pressure

Surgical:
1) Treatment of choice

2) Herniotomy is when hernia sac is ID’d, freed, its neck ligated and the sac is reduced. May be enough in young, muscular person and in kids
3) Herniorrhaphy and hernioplasty are herniotomy along with repair of posterior wall of inguinal canal and internal ring

24
Q

Complications of surgical repair

A

Ischemic orchitis with testicular atrophy

Residual neuralgia

Both: more common with anterior groin hernioplasty bc of the nerves and spermatic cord dissection and mobilization

25
Prognosis following surgery
Expert surgeons 1-3% in 10y follow up Caused by excessive tension on repair, deficient tissue, inadequate hernioplasty or overlooked hernias Decreased with relaxing incisions More common with direct hernias
26
Direct inguinal hernia
A direct hernia enters inguinal canal through its weakened posterior wall. The hernia does NOT pass through internal ring - Lies posterior to spermatic cord - Practically never enters scrotum - wide neck (strangulation rare) - almost all in men - common in older age groups - common in smokers due to weakened connective tissue - predisposing factors = hard labor, cough, straining, and so on - can lead to damage to ilioinguinal nerve Symptoms: - bulge in groin - Dull dragging pain in inguinal region referred to testis - Pain increases with hard work and straining
27
Indirect inguinal hernia
Herniation through internal ring traveling to external ring. If complete, it can enter the scrotum while exiting external ring If congenital, associated with patent processus vaginalis B/l in 33% of cases Most common hernia in men AND women Occurs at all ages More common in men In first decade of life, the right-sided hernia is more common than left bc of late descent of R testis
28
Femoral hernia def
Form of indirect hernia arising out of the femoral canal beneath the inguinal ligament (medial to femoral vessels) Female: Male = 2:1 Males affected are in younger group Rare in children Uncommon - 2.5% of all groin hernias Left side 1:2 right side 2/2 sigmoid colon tamponading the left femoral canal Common in elderly patients High incidence of incarceration due to narrow neck 22% strangulate after 3 months 45% after 21 months
29
Anatomy of femoral hernia
Femoral canal is 1.25cm long and arises from femoral ring to the saphenous opening Femoral sac originated from femoral canal through defect on the medial side (common) or anterior (rare) side of femoral sheath
30
Symptoms of femoral hernia
Dull dragging pain in groin with swelling If obstructed, can cause vomiting and constipation If strangulated, can lead to severe pain and shock Swelling arises from below the inguinal ligament
31
Ddx for femoral hernia
Inguinal hernia Saphenous varix Enlarged femoral lymph node Lipoma Femoral artery aneurysm Psoas abscess
32
Acquired umbilical hernia
Abdominal contents herniate through defect in the umbilicus Common site of herniation, esp in women A/w ascites, obesity, repeated pregnancies Complications = strangulation of colon and omentum is common - rupture occurs in chronic ascitic cirrhosis. emergency portal decompression needed tx = surgical - small partial defect - closed by loosely placed polypropylene suture - large parital defect - managed with a prosthesis repair - mayo hernioplasty is classical repair
33
Pediatric umbilical hernia
2/2 fascia defect in linea alba with protruding abdominal contents, covered by umbilical skin and subq tissue Caused by failure of timely closure of umbilical ring, and leaves a central defect in linea alba Common in infants Incarceration is rare and reduction is contraindicated
34
Management of pediatric umbilical hernia
Usually close spontaneously within 3 years if the defect is 2cm Child > 3-5yrs old Protrusion is disfiguring and disturbing to child or parents
35
Esophageal hiatal hernia
Hernia in which an anatomical part (such as stomach) protrudes through esophageal hiatus in diaphragm 3 types: 1) Sliding hernia, type 1 = upward dislocation of cardia in the posterior mediastinum 2) Rolling or paraesophageal hernia, type 2 = upward dislocation of gastric fundus alongside a normally positioned cardia 3) Combined sliding-rolling or mixed hernia, type 3 - upward dislocation of both cardia and gastric fundus End stage of type 1 and 2 hernias occurs when whole stomach migrates up into chest by rotating 180 degrees around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation, the abnormality is usually referred to as an intrathoracic stomach
36
Sliding esophageal hernia (type 1)
GE junction and stomach herniate into thoracic cavity Accounts for 90% of hiatal hernias Can lead to reflux and esophagitis that can predispose to Barrett's Management can be done medically with antacids and head elevation Only 15% require surgery, consisting of wrapping of the stomach fundus around the LES (Nissen)
37
Paraesophageal hiatal hernia (type 2)
herniation of stomach into thorax by way of esophageal hiatus, without disruption of GEJ Rare (
38
Richter's hernia
Only part of intestine wall circumference is in hernia May strangulate without obstruction Seen in femoral and obturator hernias
39
Littre's hernia
Hernial sac contains Meckel's diverticulum. May become inflamed
40
Garengoff's hernia
Hernial sac has the appendix Importance is that it may form an inflamed hernia
41
Pantaloon hernia
Combo of direct and indirect straddling inferior epigastrics
42
Madyl's hernia
W type of intestinal loop herniates May strangulate with the gangrenous part being inside the abdomen, or may be reduced into the abdomen without noticing the gangrenous part
43
Spigelian hernia
Sac passes through the spigelian or semilunaris fascia
44
Sliding inguinal hernia
Any hernia in which part of the sac is the wall of a viscus. On the right, the cecum, ascending colon, or appendix is commonly involved. In left, sigmoid is involved
45
Cooper's hernia
involves femoral canal and tracts to the labia majora in females and to scrotum in males
46
Lumbar hernia
Divided into congenital, spontaneous, traumatic and incisional Can pass through triangle of Grynfeltt, through inferior lumbar triangle, or previous incision
47
Perineal hernia
located through pelvic diaphragm, anterior (passes through labia majora) or posterior (male: enters the ischirectal fossa; females: close to vagina) to superficial transverse perineal muscle
48
Incisional hernia
from surgical complication Could enlarge beyond repair Associated with obesity, diabetes, and infection
49
Eventration hernia
loss of integrity of abdominal wall, reducing the intraabdominal pressure and resulting in external herniation of bowel

Surgery (27 decks)

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