Hernia Management Flashcards
What is a hernia?
Anytime fatty tissue pushes through the abdominal wall
Waht are the possible complications of Hernias?
Progression to bowel or small/med organ herniation, ischemia, necrosis, death, etc
Who is more likely to develop a hernia?
Males are more succeptible to hernias due to their anatomy.
What are the layers of the inguinal canal?
Transversallis Fascia-floor
Transverse Abdominis-floor
Internal Oblique-floor
External Oblique-shelving edge
What is a Direct inguinal Hernia?
Passes through the weakess of Hasselbach’s triangle
(Rectus abdominis, med to inferior epigastric vessels
Superior to inguinal ligament)
Med to inferior epigastrics
lies within inguinal canal
adjacent to spermatic cord
What is a Femoral Hernia?
Passes through femoral space (inguinal ligament above, cooper's lig below, lacunar lig, fem vessels laterally) Passes through the femoral space below the inguinal ligament maintain index of suspicion
Different types of Inguinal Hernia Repair?
Bassini
Shouldice
McVay
Don’t use prosthetic reinforcement!
Why would we do a tissue repair?
No mesh available
Infected field and risk of infection
What is the Lichtenstein Mesh Repair
Mesh reconstruction of inguinal floor Tension free Lowest incidence of recurrence Risk of prosthetic mesh infection (Standard hernia repair)
What is the Pre-Peritoneal Mesh Repair?
Mechanically more sound repair
Eliminates need to reconstruct internal ring
Theoretically more durable
Open vs laparoscopic
Pro/Cons of Labparoscopic repair?
Low pain
Low infection and hematoma
Rapid recovery
Comparable recovery vs open mesh
Technically difficult
Longer operation
Higher Hospital cost
What is the TransAbdominal Preperitoneal Lap. Ing. Hernia Repair
Lap Entry Incision of Peritoneum Dissection of Pre-Peritoneal space Placement of mesh Closure of peritoneal flap
What is the total Extraperitoneal Preperitoneal Lap. Ing. Hernia Repair
Entry into rectus sheath
Dissection of pre-peritoneal space
Placement of mesh
Avoid Peritoneal entry/injury
What are the indications for Laparoscopic Repair?
Bilateral Ing. Hernia
Comorbid UImbilical Hernia
Earlier Return to work
When is watchful waitign a satisfactory alternative to surgery?
Pt is unfit for surgery
What are the different Abdominal Hernia Types?
Umbilical, Incisional, Epigastric, Spigelian
What is an umbilical hernia?
Occurs at the umbilical stalk, Congenital in infants (regress) Acquired in Adults (Progress and enlarge) Primary repair if 1-2cm Mesh reinforcement for 1-2+cm defects
What is an Inciisional hernia?
Failure of Fascia Healing
20-30% incidence in laparotomy incision
Risk factors for incisional hernia?
Wound infection Lifting and straining Obesity Age Male Sleep apnea Emphysema
What is an eigastric hernia?
Occur between umbilicus and rib cage
Small but painful
Difficult to ID when asleep
Repaired to alleviate pain
What is an Spigelian hernia?
Vascular perforations of inferior semilunar line
What are ways of repairing abdominal wall hernias?
Primary Repair
Mesh Reinforced repair
Component Separation
What is primary repair of abdominal wall hernias?
Suture repair of defect Re-approximated transeversely Small defects Ok with contaminated fields high recurrence
What is mesh reinforced repair of abdominal wall hernias?
Contra-indicated in infected fields.
lower recurrence rate
variety of types of mesh available
Need explanation for infection
What is the most robust, gold standard placement of mesh?
Retrorectus (dissect into back of muscle belly)
What is the most common mesh placement in laparoscopic techniques?
Underlay
What is the clinical presentation of hernias?
Palpate + Valsalva
Can you reduce it?
Note prior incisions
Can present with bowel obstruction.
What is the difference between Reducible and Incarcerated hernias?
Reducible can be returned to the abdominal cavity
Incarcerated hernias cannot be returned.
What are signs of a Strangulated hernia?
Compromised blood flow
tissue death
Redness, Warmth, etc
What is the Bassini repair of Inguinal hernias?
single layer reconstruction of the inguinal floor
What is the Shouldice repair of Inguinal hernias?
4 layer reconstruction of the inguinal floor
What is the McVay repair of Inguinal hernias?
Inguinal floor brought to Cooper’s ligament
