Hernia - Inguinal & ventral Flashcards
What is a hernia - where do they typically occur
Abnormal protrusion of an organ or tissue through a defect in its surrounding walls - anterior abdominal wall
What is a ventral hernia
Protrusion through the anterior abdominal wall fascia. Occur only at sites which aponeurosis and fascia are not covered by striated muscle.
What are the 4 pairs of muscles that make up the abdominal wall?
External oblique
Internal oblique
Tranversus abdominus
Recuts abdominus
What is aponeurosis
A type of deep fascia in the form of a sheet of pearly-white fibrous tissue
where are the external oblique muscles located? How do the fibers travel
Deep to the skin and subcutaneous fat. The fibers extend inferiorly and medially (sliding one’s hands into pants pockets)
The first and most superficial muscle of the lateral abd. wall.
Linea Alba
midline fibrous band joining both sides of the abd. wall
Anterior rectus sheath - where is it located and what does it enclose?
Medial extension of the external oblique aponeurosis. Encloses the rectus abdominis muscles.
Aponeurosis of the external obliques
- Inserts on the linea semilunaris
- contributes to the anterior rectus sheath
- inserts on the linea alba
Where are the internal oblique locted
deep to the external oblique
How do the fibers travel - internal oblique
Extend superiorly and medially - opposite the external oblique
Aponeurosis of the internal oblique
-inserts on the linea semilunaris
- contributes to the anterior and posterior recuts sheath
- inserts on the linea alba
Transversus abdominus
deepest lateral muscle layer of the abdominal wall
How do the fibers travel - Transversus abdominis
Horizontal direction
- inserts on the linea semilunaris
- contributes to the posterior recuts sheath
- inserts on the linea alba
Rectus Abdominus
Medial muscle of the anterior abdominal wall. Deep to the anterior rectus sheath, on either side of the linea alba.
How do the fibers of the rectus abdominus run
longitudinally and down the entire length of the abdominal wall from the xiphoid to pubic symphysis
Tendinous intersections
3 transverse bands of collagen fibers that seperate the rectus abdominis muscle. Resulting in the look of 6 pack abs.
Linea semilunaris
Curved tendinous line one on either side of the rectus abdominis.
Arcuate Line
demacrates lower limit of the posterior recuts sheath
Posterior Rectus sheath - where is it located
Deep to the rectus abdominis (only above the arcuate line)
Transversalis fascia - what is it & where is it located.
the connective tissue layer that underlies the abdominal wall musculature, located inferior to the arcuate line
Arcuate line - what is it, where is it located
occurs about 1/2 of the distance from the umbilicus to the pubic crest (about 3-6cm below the umbilicus)
demarcates the lower limit of the posterior layer of the rectus sheath. - The rectus sheath is absent below the arcuate line.
Why is the arcuate line a weak spot?
the absence of the posterior recuts sheath below the arcuate line
Where do the Inferior epigastric vessels enter the rectus abdominis
At the level of the arcuate line
What is a TAPP hernia repair
Transabdominal Pre-peritoneal
What is a TAR hernia repair
Transversus Abdominus Release
What is the peritoneum, what and where is it located
Serous membrane that forms the lining of the abdominal cavity. Deep to the tranversalis fascia
What is the omentum - & where is it located
Large flat adipose tissue layer sitting on the surface of the intra-peritoneal organs. Deep to the peritoneum
What/where is the falciform ligament
Attached to the anterior side of the liver. Separates the right & left lobes of the liver. Anchors the liver to the abdomen
What is a common reason the falciform ligament is taken down?
to ensure the mesh lays flat during an intraperitoneal only mesh ventral hernia (IPOM)
What is an IPOM hernia repair
Intraperitoneal onlay mesh (IPOM)
How may the falciform ligament be used in a hernia repair
used as a natural patch for holes in the facial layer
When is a hernia classified as reducible
if the contents can be pushed back into the abdminal cavity with light manual pressure.
May or may not present with pain
Does not need immediate attention
may progress if untreated
What is an incarcerated/irreducible hernia
Its contents get trapped and cannot move back into the abdominal cavity.
Tissue trapped within the hernia sac still receives blood supply
May progress if untreated
patients should seek medical attention w/increased swelling, soreness, and pain
Strangulated Hernia
The blood supply to the herniated tissue has been cut off. The tissue can release toxins and infection into the bloodstream,
Medical emergencies
Any hernia can become strangulated
May require bowel resection
symptoms of strangulated hernia’s
severe abd. pain
profuse sweating
increased swelling w/ tight glistening red skin
severe nausea and vomitting
change in bowel habits - inablility to pass gas or a bowel movement
decrease in or absence of urine output
high fever - 101 or higher
Hernia mass contents
Covering tissue (skin, subcutaneous tissues) peritoneal sac, and any contained viscera
Fascial defect of the hernia
where the hernia protrudes from - a break in the fascia
neck of the hernia
innermost musculoaponeurotic layer
Causes of hernia - ventral
weakness at incision site of a previous surgery
Weakness in an abdominal wall area present at birth
Weakness in abd. wall caused by conditions that put strain or weakens tissue
activites that can increase pressure on abd. wall
Straining on the toilet
persistent cough
being overweight or obese
pregnancy
abd. fluid
lifting heavy items
physical exertion
activities that can weaken tissue
peritoneal dialysis
poor nutrition
smoking
diabetes
Diagnosis of hernia
Review med. history
Physical exam - determine stage
ultrasound - view contents
CT scan - view contents
MRI - view contents
Blood work - infection or shock
Why do an ultrasound or blood test
to study the contents of the hernia or check for infection or shock
Types of Hernias - Ventral
Umbilical
Epigastric
Incisional
Spigelian
Umbilical hernia
Occurs at the umbilicus. More common in women and in patients with intra-abdominal pressure.
More common in patients who have only a single layer of midline aponeurotic crossing
Epigastric Hernia
located between the xiphoid process and the umbilicus - usually w/in 5-6cm of the umbilicus
More common w/single aponeurotic decussation ~ 3-5%
Often small and produce pain beyond their size
Incisional Hernia
occur at the healing site. These can be the most frustrating and difficult to treat.
They enlarge over time, leading to pain, bowel obstruction, incarceration, and strangulation.
Obesity, advanced age, malnutrition, pregnancy, and conditions that increase intra-abdominal pressure.
Spigelian Hernia
Occurs through the linea semilunaris. Almost all occur at or below the arcuate line.
Most are small and develop during the 4th-7th decade of life.
It is repaired because it often has a narrow neck
Another name for inguinal ligament
Poupart’s ligament
Pubic Tubercle
a common landmark for medical dissection during an inguinal hernia repair. It also serves as a common location for fixation of mesh with suture or a tack
Inguinal ligament (Poupart’s ligament)
spans from the ASIS to pubic tubercle.
The medial half of the inguinal ligament is curled inwardly, forming a trough
what is another name for Cooper’s ligament
Pectineal ligament
Cooper’s ligament
fibrous extension of the inguinal ligament. Travels posteriorly along the superior edge of the suprapubic ramus
What is coopers ligament used for in a hernia repair
useful to anchor suture to
Inguinal canal
a passage through the lower abdominal wall and is about 4cm long. There are 2, 1 on each side of the lower abd.
Inguinal canal boundaries
Posterior wall: transversalis fascia
Inferior boundary: inguinal ligament
Superior boundary: Transversus Abd. & internal oblique
Anterior wall: External oblique
Superficial ring
lies at the pubic tubercle
Deep ring
at the midpoint of the inguinal ligament
What does the inguinal canal contain in males
Spermatic cord: Vas deferens and testicular vessels
Vas Deference
the duct that transports sperm from the epididymis to ampulla for ejaculation
What does the inguinal canal contain in women
Round ligament
Round ligament
supports the uterus within the pelvic cavity and travels through the inguinal canal to the labia majora
Indirect hernia
Occurs when abdominal contents protrude through the deep ring of the inguinal canal
Lateral to the inferior epigastric vessels
Spermatic cord
passes through the inguinal canal and connects to the testicles.
Carries sperm from the testicles to the penis
Inguinal region
Aka the groin - located on the lower portion of the anterior abd. wall
It falls between the anterior superior iliac spine and the pubic tubercle
ASIS
Anterior superior Iliac spine
3 umbilical folds
Median umbilical fold
Medial umbilical folds
lateral umbilical folds
Where are the umbilical folds located and how are they used?
On the posterior surface of the anterior abd. wall
They are used as surgical landmarks
What does the median umbilical fold contain?
the Urachus: an embryonic remnant of the allantoic duct
What do the medial umbilical folds contain
remnant of the umbilical artery. They also suspend the bladder with the urachus
what do the lateral umbilicus folds contain
inferior epigastric vessels
Vessels of the inguinal region
Inferior epigastric vessels
testicular vessels
external iliac vessels
Hesselbach’s triangle
an area of potential weakness in the anterior abd. wall. A hernia through hesselbach’s triangle is referred to as a direct hernia
Boarders of hesselbach’s triangle
Lateral border of the rectus abdominis
inferior epigastric vessels
Inguinal ligament
Triangle of doom
an area that contains the external iliac vessels
Boarders of the triangle of doom
Deep ring
Vas deferens
testicular vessels
Triangle of Pain
an area with a high concentration of nerves
Borders of the triangle of pain
Deep ring
inguinal ligament
testicular vessels
What are the nerves that are contained within the triangle of pain
Lateral femoral cutaneous nerve
genitofemoral nerve
femoral nerve
Lateral femoral cutaneous nerve
provides sensory innervation to the anterior skin of the thigh
Genitofemoral nerve
provides sensory and motor innervation to the scrotum and cremaster muscles in males, as well as labia majora and mons pubis in females
femoral nerve
provides motor and sensory innervation to the anterior compartment of the thighs as well as sensory branches to the hip joint
Signs and symptoms of an inguinal hernia
bulge in the groin area
discomfort or pain in the groin with increased pain during activity
weakness, heaviness, burning, or aching in the groin
swollen or an enlarged scrotum in men or boys
how to distinguish between a direct and indirect hernia
based off of the inferior epigastric vessels
Direct - medial
indirect - lateral
Indirect hernia
caused by a defect in the abd. wall that is congenital (present at birth)
More common than direct
Lateral to the inferior epigastric vessels
failure of embryonic closure
abd. contents protrude through the deep inguinal ring
Direct hernia - caused by?
caused by a weakness in the muscles of the abd. wall that develops over time or are due to straining or heavy lifting
Direct hernia
Medial to the inferior epigastric vessels
abdominal contents protrude through a weak spot in the transversalis fascia
Less common than indirect hernia
Causes of a hernia - inguinal
Faliure of abd. wall closure during embryonic development. - More common in males
weakness in abd. wall caused by strain
incidence of hernia in men vs women
men are 25x more likely to have an inguinal hernia
indirect hernias are at a ratio of 2:1
Robotic inguinal hernia repair
TAPP (Transabdominal preperitoneal) is the simplest and most common robotic repair
TAPP is a 3 are procedure
TAPP patient positioning and prep
Supine
Tuck arms and pad pressure points and bony prominences
secure patient to table
insufflate up to 12mmHg
15 degrees trend
set table to lowest limit
TAPP port placement - LEFT
TAPP Inguinal repair instruments
TAPP advanced instrumentation
Force bipolar
- dual grip technology
- bipolar functionality
TAPP Procedure steps
- lysis of adhesions
- Creation of the peritoneal flap and mesh pocket dissection
- Mesh fixation
- closure of the peritoneum
- bilateral hernia repair
Lysis of Adhesions
For pelvic access - take-down abdominal adhesions. Reduce Hernia contents if possible.
Creating of the peritoneal flap and mesh pocket dissection
measure and mark a point superior to the hernia defect using two lengths of the cadiere forceps to approx. a 4-5cm distance.
Incise peritoneum to create flap
perform: medial, lateral, and central dissection
Mesh fixation
Insert the mesh
secure the mesh with interrupted sutures
consider placing one suture into coopers ligament
avoid nerves and vasculature
self fixing mesh my be used
Closure of the peritoneum
close the peritoneum using a running stitch of barbed,self-locking suture
