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Surgery Clerkship - Procedures > Hernia (Introduction and Inguinal Hernia Repair) > Flashcards

Hernia (Introduction and Inguinal Hernia Repair) Flashcards

1
Q

What is a hernia?

A

Protrusion of a peritoneal sac through a musculoaponeurotic barrier (eg., abdominal wall); a fascial defect

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2
Q

What is the incidence of hernias (overall, type)?

A

5-10% lifetime

50% indirect inguinal
25% direct inguinal
~5% femoral

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3
Q

What are the precipitating factors of a hernia?

A

Increased intra-abdominal pressure (straining at defection or urination 2/2 rectal or colon cancer, prostatic enlargement, constipation), obesity, pregnancy, ascites, valsavagenic (coughing) COPD
An abnormal congenital anatomic route

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4
Q

Why should hernias be repaire?

A

To avoid complications of incarceration/strangulation, bowel necrosis, SBO, pain

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5
Q

What is more dangerous - a small or large hernia defect?

A

Small defect, because a tight defect is more likely to strangulate if incarcerated

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6
Q

What is a reducible hernia?

A

Ability to return the displaced organ or tissue/hernia contents to their usual anatomic site

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7
Q

What is an incarcerated hernia?

A

Swollen or fixed within the hernia sac; may cause intestinal obstruction

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8
Q

What is a strangulated hernia?

A

Incarcerated hernia with resulting ischemia (signs and symptoms of ischemia and intestinal obstruction or bowel necrosis)

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9
Q

What is a complete hernia?

A

Hernia sac and its contents protrude all the way through the defect

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10
Q

What is an incomplete hernia?

A

Defect present without sac or contents protruding completely through it

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11
Q

What is reducing a hernia “en masse”?

A

Reducing the hernia contents and hernia sac

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12
Q

Define sliding hernia.

A

Hernia sac partially formed by the wall of a viscus (i.e., bladder/cecum)

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13
Q

Define Littre’s hernia.

A

Hernia involving a Meckel’s diverticulum

Think alphabetically - Littre Meckel’s = LM

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14
Q

Define Spigelian hernia.

A

Hernia through the linea semilunaris (or spigelian fascia); aka spontaneous lateral ventral hernia

Think spigelian = semilunaris

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15
Q

What is an internal hernia?

A

Hernia in or involving intra-abdominal structure

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16
Q

What is a Peterson’s hernia?

A

Seen after bariatric gastric bypass - internal herniation of small bowel through the mesenteric defect from the Roux limb

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17
Q

What is an obturator hernia?

A

Hernia through obturator canal (F>M)

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18
Q

What is a pantaloon hernia?

A

Hernia sac exists as both a direct and indirect hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring (2 sacs separated by the inferior epigastric vessels)

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19
Q

What is an incisional hernia?

A

Hernia through an incisional site; most common cause is wound infection

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20
Q

What is a ventral hernia?

A

Incisional hernia in the ventral abdominal wall

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21
Q

What is a parastomal hernia?

A

Hernia adjacent to an ostomy

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22
Q

What is Richter’s hernia?

A

Incarcerated or strangulated hernia involving only one sidewall of the bowel, which can spontaneously reduce, resulting in gangrenous bowel and perforation within the abbdomen without signs of obstruction

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23
Q

What is an epigastric hernia?

A

Hernia through the linea alba above the umbilicus

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24
Q

What is an umbilical hernia?

A

Hernia through the umbilical ring, in adults associated with ascites, pregnancy, and obesity

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25
Q

What is a femoral hernia?

A

Hernia medial to femoral vessels (under inguinal ligament)

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26
Q

What is an indirect inguinal hernia?

A

Inguinal hernia lateral to Hesselbach’s triangle

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27
Q

What is a direct inguinal hernia?

A

Inguinal hernia within Hesselbach’s trinagle

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28
Q

What is a hiatal hernia?

A

Hernia through esophageal hiatus?

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29
Q

What are the boundaries of Hesselbach’s triangle?

A

Inferior epigastric vessels (medial diagonal)
Inguinal ligament (Poupart’s)
Lateral border of the rectus sheath (lateral diagonal)
Floor: internal oblique and transversus abdominis

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30
Q

What are the layers of the abdominal wall beginning with the skin?

A 
Skin
Subcutaneous fat
Scarpa's fascia
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia
Preperitoneal fat
Peritoneum
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31
Q

DDx - groin mass?

A 
LAD
Hematoma
Seroma
Abscess
Hydrocele
Femoral artery aneurysm
EIC
Undescended testicle
Sarcoma
Hernia
Testiculra torsion
32
Q

What is a direct inguinal hernia?

A

Hernia within the floor of Hesselbach’s triangle (the hernia sac does not traverse the inguinal ring)

33
Q

Cause of direct inguinal hernia?

A

Acquired defect from mechanical breakdown over the years

34
Q

Incidence of direct inguinal hernia?

A

~1% of all men, frequency increases with age

35
Q

What nerve runs with the spermatic cord in the inguinal canal?

A

Iliinguinal nerve

36
Q

What is an indirect inguinal hernia?

A

Hernia through the internal ring of the inguinal canal, traveling down toward the external ring; it may enter the scrotum upon exiting the external ring

37
Q

What is the cause of an indirect inguinal hernia?

A

Patent processus vaginalis (i.e., congenitla)

38
Q

Incidence of indirect inguinal hernia?

A

~5% of all men

39
Q

What is the most common hernia in both men and women?

A

Indirect inguinal hernia

40
Q

When examining for an inguinal hernia, if swelling occurs below the inguinal ligament, it is possibly a ___.

A

Femoral hernia

41
Q

DDx - inguinal hernia?

A 
LAD
Psoas abscess
Ectopic testis
Hydrocele of the cord
Saphenous varix
Lipoma
Varicocele
Testicular torsion
Femoral artery aneurysm
Abscess
42
Q

Compare the risk of strangulation among direct, indirect, and femoral hernias.

A

Femoral>indirect>direct

43
Q

Indications for laparoscopic inguinal hernia repair?

A

Bilateral inguinal hernias
Recurring hernia
Need to resume full activity ASAP

44
Q

Why should all abdominal hernias be repaired? What are exceptions to this?

A

Avoid the risk of intestinal obstruction and strangulation; umbilical hernias in patients younger than 2-5 years old (may close by themselves) and esophageal sliding hiatal hernias (not true hernias).

45
Q

All hernias that become ___ need emergency surgery to prevent strangulation.

A

Irreducible

46
Q

What is the treatment for an indirect inguinal hernia?

A

Emergent herniorrhaphy if strangulation is suspected or acute incarceration is present; otherwise, elective is indicated to prevent chance of incarceration/strangulation

47
Q

Define the following inguinal hernia repair procedure - Bassini

A

Sutures approximate reflection of inguinal ligament (Poupart’s) to the transversus abdominis aponeurosis/conjoint tendon

48
Q

Define the following inguinal hernia repair procedure - McVay

A

Cooper’s ligament sutured to transversus abdominis aponeurosis/conjoint tendon

49
Q

Define the following inguinal hernia repair procedure - Lichtenstein

A

“Tension-free repair” using mesh

50
Q

Define the following inguinal hernia repair procedure - plug and patch

A

Placing a plug of mesh in hernia defect and then overlaying a patch of mesh over the inguinal floor (requires few if any sutures in the mesh)

51
Q

Define the following inguinal hernia repair procedure - high ligation

A

Ligation and transection of indirect hernia sac without repair of inguinal floor (used only in children)

52
Q

Define the following inguinal hernia repair procedure - TAPP procedure

A

TransAbdominal PrePeritoneal inguinal hernia repair

53
Q

Define the following inguinal hernia repair procedure - TEPA procedure

A

Totally ExtraPeritoneal Approach

54
Q

What is the first identifiable subcutaneous named layer (inguinal hernia procedure)?

A

Scarpa’a fascia (thin in adults)

55
Q

What is the name of the subcutaneous vein that is ligated (inguinal hernia procedure)?

A

Superficial epigastric vein

56
Q

What happens if you cut the ilioinguinal nerve (inguinal hernia procedure)?

A

Numbness of inner thigh or lateral crotum; usually resolves in 6 months

57
Q

From what abdominal muscle layer is the cremaster muscle derived (inguinal hernia procedure)?

A

Internal oblique muscle

58
Q

From what abdominal muscle layer is the inguinal (aka Poupart’s) ligament derivd (inguinal hernia procedure)?

A

External oblique muscle aponeurosis

59
Q

To what does the inguinal ligament attach (inguinal hernia procedure)?

A

Anterior-superior iliac spine to the pubic subercle

60
Q

What nerve travels on the spermatic cord (inguinal hernia procedure)?

A

Ilioinguinal nerve

61
Q

Why do some surgeons deliberately cut the ilioinguinal nerve (inguinal hernia procedure)?

A

First they obtain preoperative consent and cut so as to remove the risk of entrapment and post-op pain

62
Q

What is contained in the spermatic cord (6) (inguinal hernia procedure)?

A 
Cremasteric muscle fibers
Vas deferens
Testicular artery
Testicualr pampiniform venous plexus
\+/- hernia sac
Genital branch of the genitofemoral nerve
63
Q

What is the hernia sac made of (inguinal hernia procedure)?

A

Peritoneum (direct)

Patent processus vaginalis (indirect)

64
Q

What attaches the testicle to the scrotum (inguinal hernia procedure)?

A

Gubernaculum

65
Q

What is the most common organ in an inguinal hernia sac in men (inguinal hernia procedure)?

A

Small intestine

66
Q

What is the most common organ in an inguinal hernia sac in women (inguinal hernia procedure)?

A

Ovary/fallopian tube

67
Q

What lies in the inguinal canal in females instead of the vas (inguinal hernia procedure)?

A

Round ligament

68
Q

Where in the inguinal canal does the hernia sac lie in relation to other structures (inguinal hernia procedure)?

A

Anteromedially

69
Q

What is a cord lipoma (inguinal hernia procedure)?

A

Preperitoneal fat on the cord structures (pushed in by the hernia sac); not a real lipoma; remove surgically if feasible

70
Q

What is a small outpouching of testicular tissue of the testicle (inguinal hernia procedure)?

A

Testicular appendage (remove with electrocautery)

71
Q

What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy (inguinal hernia procedure)?

A

Remove the suture as soon as possible and apply pressure (i.e., do not tie the suture down!)

72
Q

What nerve is found on top of the spermatic cord (inguinal hernia procedure)?

A

Ilioinguinal nerve

73
Q

What nerve travels within the spermatic cord (inguinal hernia procedure)?

A

Genital branch of the genitofemoral nerve

74
Q

What type of hernia goes through Hesselbach’s triangle (inguinal hernia procedure)?

A

Direct hernia due to a weak abdominal floor

75
Q

What is a “relaxing incision” (inguinal hernia procedure)?

A

Incision(s) in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal ligament without tension

76
Q

What is a conjoint tendon (inguinal hernia procedure)?

A

Aponeurotic attachments of the “conjoining” of the internal oblique and transversus abdominis to the pubic tubercle

77
Q

What percentage of the strength of an inguinal floor repair does an external oblique aponeurosis represent (inguinal hernia procedure)?

Surgery Clerkship - Procedures (17 decks)

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