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Intuitive CAST > Hernia - Inguinal & ventral > Flashcards

Hernia - Inguinal & ventral Flashcards

1
Q

What is a hernia - where do they typically occur

A

Abnormal protrusion of an organ or tissue through a defect in its surrounding walls - anterior abdominal wall

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2
Q

What is a ventral hernia

A

Protrusion through the anterior abdominal wall fascia. Occur only at sites which aponeurosis and fascia are not covered by striated muscle.

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3
Q

What are the 4 pairs of muscles that make up the abdominal wall?

A

External oblique
Internal oblique
Tranversus abdominus
Recuts abdominus

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4
Q

What is aponeurosis

A

A type of deep fascia in the form of a sheet of pearly-white fibrous tissue

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5
Q

where are the external oblique muscles located? How do the fibers travel

A

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.

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6
Q

Linea Alba

A

midline fibrous band joining both sides of the abd. wall

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7
Q

Anterior rectus sheath - where is it located and what does it enclose?

A

Medial extension of the external oblique aponeurosis. Encloses the rectus abdominis muscles.

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8
Q

Aponeurosis of the external obliques

A
  • Inserts on the linea semilunaris
  • contributes to the anterior rectus sheath
  • inserts on the linea alba
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9
Q

Where are the internal oblique locted

A

deep to the external oblique

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10
Q

How do the fibers travel - internal oblique

A

Extend superiorly and medially - opposite the external oblique

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11
Q

Aponeurosis of the internal oblique

A

-inserts on the linea semilunaris
- contributes to the anterior and posterior recuts sheath
- inserts on the linea alba

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12
Q

Transversus abdominus

A

deepest lateral muscle layer of the abdominal wall

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13
Q

How do the fibers travel - Transversus abdominis

A

Horizontal direction
- inserts on the linea semilunaris
- contributes to the posterior recuts sheath
- inserts on the linea alba

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14
Q

Rectus Abdominus

A

Medial muscle of the anterior abdominal wall. Deep to the anterior rectus sheath, on either side of the linea alba.

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15
Q

How do the fibers of the rectus abdominus run

A

longitudinally and down the entire length of the abdominal wall from the xiphoid to pubic symphysis

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16
Q

Tendinous intersections

A

3 transverse bands of collagen fibers that seperate the rectus abdominis muscle. Resulting in the look of 6 pack abs.

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17
Q

Linea semilunaris

A

Curved tendinous line one on either side of the rectus abdominis.

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18
Q

Arcuate Line

A

demacrates lower limit of the posterior recuts sheath

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19
Q

Posterior Rectus sheath - where is it located

A

Deep to the rectus abdominis (only above the arcuate line)

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20
Q

Transversalis fascia - what is it & where is it located.

A

the connective tissue layer that underlies the abdominal wall musculature, located inferior to the arcuate line

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21
Q

Arcuate line - what is it, where is it located

A

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.

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22
Q

Why is the arcuate line a weak spot?

A

the absence of the posterior recuts sheath below the arcuate line

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23
Q

Where do the Inferior epigastric vessels enter the rectus abdominis

A

At the level of the arcuate line

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24
Q
A
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25
Q

What is a TAPP hernia repair

A

Transabdominal Pre-peritoneal

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26
Q

What is a TAR hernia repair

A

Transversus Abdominus Release

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27
Q

What is the peritoneum, what and where is it located

A

Serous membrane that forms the lining of the abdominal cavity. Deep to the tranversalis fascia

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28
Q

What is the omentum - & where is it located

A

Large flat adipose tissue layer sitting on the surface of the intra-peritoneal organs. Deep to the peritoneum

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29
Q

What/where is the falciform ligament

A

Attached to the anterior side of the liver. Separates the right & left lobes of the liver. Anchors the liver to the abdomen

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30
Q

What is a common reason the falciform ligament is taken down?

A

to ensure the mesh lays flat during an intraperitoneal only mesh ventral hernia (IPOM)

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31
Q

What is an IPOM hernia repair

A

Intraperitoneal onlay mesh (IPOM)

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32
Q

How may the falciform ligament be used in a hernia repair

A

used as a natural patch for holes in the facial layer

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33
Q

When is a hernia classified as reducible

A

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

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34
Q

What is an incarcerated/irreducible hernia

A

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

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35
Q

Strangulated Hernia

A

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

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36
Q

symptoms of strangulated hernia’s

A

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

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37
Q

Hernia mass contents

A

Covering tissue (skin, subcutaneous tissues) peritoneal sac, and any contained viscera

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38
Q

Fascial defect of the hernia

A

where the hernia protrudes from - a break in the fascia

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39
Q

neck of the hernia

A

innermost musculoaponeurotic layer

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40
Q

Causes of hernia - ventral

A

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

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41
Q

activites that can increase pressure on abd. wall

A

Straining on the toilet
persistent cough
being overweight or obese
pregnancy
abd. fluid
lifting heavy items
physical exertion

42
Q

activities that can weaken tissue

A

peritoneal dialysis
poor nutrition
smoking
diabetes

43
Q

Diagnosis of hernia

A

Review med. history
Physical exam - determine stage
ultrasound - view contents
CT scan - view contents
MRI - view contents
Blood work - infection or shock

44
Q

Why do an ultrasound or blood test

A

to study the contents of the hernia or check for infection or shock

45
Q

Types of Hernias - Ventral

A

Umbilical
Epigastric
Incisional
Spigelian

46
Q

Umbilical hernia

A

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

47
Q

Epigastric Hernia

A

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

48
Q

Incisional Hernia

A

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.

49
Q

Spigelian Hernia

A

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

50
Q

Another name for inguinal ligament

A

Poupart’s ligament

51
Q

Pubic Tubercle

A

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

52
Q

Inguinal ligament (Poupart’s ligament)

A

spans from the ASIS to pubic tubercle.

The medial half of the inguinal ligament is curled inwardly, forming a trough

53
Q

what is another name for Cooper’s ligament

A

Pectineal ligament

54
Q

Cooper’s ligament

A

fibrous extension of the inguinal ligament. Travels posteriorly along the superior edge of the suprapubic ramus

55
Q

What is coopers ligament used for in a hernia repair

A

useful to anchor suture to

56
Q

Inguinal canal

A

a passage through the lower abdominal wall and is about 4cm long. There are 2, 1 on each side of the lower abd.

57
Q

Inguinal canal boundaries

A

Posterior wall: transversalis fascia
Inferior boundary: inguinal ligament
Superior boundary: Transversus Abd. & internal oblique
Anterior wall: External oblique

58
Q

Superficial ring

A

lies at the pubic tubercle

59
Q

Deep ring

A

at the midpoint of the inguinal ligament

60
Q

What does the inguinal canal contain in males

A

Spermatic cord: Vas deferens and testicular vessels

61
Q

Vas Deference

A

the duct that transports sperm from the epididymis to ampulla for ejaculation

62
Q

What does the inguinal canal contain in women

A

Round ligament

63
Q

Round ligament

A

supports the uterus within the pelvic cavity and travels through the inguinal canal to the labia majora

64
Q

Indirect hernia

A

Occurs when abdominal contents protrude through the deep ring of the inguinal canal

Lateral to the inferior epigastric vessels

65
Q

Spermatic cord

A

passes through the inguinal canal and connects to the testicles.

Carries sperm from the testicles to the penis

66
Q

Inguinal region

A

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

67
Q

ASIS

A

Anterior superior Iliac spine

68
Q

3 umbilical folds

A

Median umbilical fold
Medial umbilical folds
lateral umbilical folds

69
Q

Where are the umbilical folds located and how are they used?

A

On the posterior surface of the anterior abd. wall

They are used as surgical landmarks

70
Q

What does the median umbilical fold contain?

A

the Urachus: an embryonic remnant of the allantoic duct

71
Q

What do the medial umbilical folds contain

A

remnant of the umbilical artery. They also suspend the bladder with the urachus

72
Q

what do the lateral umbilicus folds contain

A

inferior epigastric vessels

73
Q

Vessels of the inguinal region

A

Inferior epigastric vessels
testicular vessels
external iliac vessels

74
Q

Hesselbach’s triangle

A

an area of potential weakness in the anterior abd. wall. A hernia through hesselbach’s triangle is referred to as a direct hernia

75
Q

Boarders of hesselbach’s triangle

A

Lateral border of the rectus abdominis
inferior epigastric vessels
Inguinal ligament

76
Q

Triangle of doom

A

an area that contains the external iliac vessels

77
Q

Boarders of the triangle of doom

A

Deep ring
Vas deferens
testicular vessels

78
Q

Triangle of Pain

A

an area with a high concentration of nerves

79
Q

Borders of the triangle of pain

A

Deep ring
inguinal ligament
testicular vessels

80
Q

What are the nerves that are contained within the triangle of pain

A

Lateral femoral cutaneous nerve
genitofemoral nerve
femoral nerve

81
Q

Lateral femoral cutaneous nerve

A

provides sensory innervation to the anterior skin of the thigh

82
Q

Genitofemoral nerve

A

provides sensory and motor innervation to the scrotum and cremaster muscles in males, as well as labia majora and mons pubis in females

83
Q

femoral nerve

A

provides motor and sensory innervation to the anterior compartment of the thighs as well as sensory branches to the hip joint

84
Q

Signs and symptoms of an inguinal hernia

A

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

85
Q

how to distinguish between a direct and indirect hernia

A

based off of the inferior epigastric vessels

Direct - medial
indirect - lateral

86
Q

Indirect hernia

A

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

87
Q

Direct hernia - caused by?

A

caused by a weakness in the muscles of the abd. wall that develops over time or are due to straining or heavy lifting

88
Q

Direct hernia

A

Medial to the inferior epigastric vessels

abdominal contents protrude through a weak spot in the transversalis fascia

Less common than indirect hernia

89
Q

Causes of a hernia - inguinal

A

Faliure of abd. wall closure during embryonic development. - More common in males

weakness in abd. wall caused by strain

90
Q

incidence of hernia in men vs women

A

men are 25x more likely to have an inguinal hernia

indirect hernias are at a ratio of 2:1

91
Q

Robotic inguinal hernia repair

A

TAPP (Transabdominal preperitoneal) is the simplest and most common robotic repair

TAPP is a 3 are procedure

92
Q

TAPP patient positioning and prep

A

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

93
Q

TAPP port placement - LEFT

A
94
Q

TAPP Inguinal repair instruments

A
95
Q

TAPP advanced instrumentation

A

Force bipolar
- dual grip technology
- bipolar functionality

96
Q

TAPP Procedure steps

A
  1. lysis of adhesions
  2. Creation of the peritoneal flap and mesh pocket dissection
  3. Mesh fixation
  4. closure of the peritoneum
  5. bilateral hernia repair
97
Q

Lysis of Adhesions

A

For pelvic access - take-down abdominal adhesions. Reduce Hernia contents if possible.

98
Q

Creating of the peritoneal flap and mesh pocket dissection

A

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

99
Q

Mesh fixation

A

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

100
Q

Closure of the peritoneum

A

close the peritoneum using a running stitch of barbed,self-locking suture

101
Q
A

Intuitive CAST (8 decks)

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