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surgery (britney) > Hernias > Flashcards

Hernias Flashcards

1
Q

What is a Hernia?

A

A hernia occurs when an organ or fatty tissue pushes through a weakness in the surrounding muscle or fascia wall.

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2
Q

How are Hernias Classified?

A

Hernias are classified by:

(1) Degree of complication:
1. Reducible
2. Irreducible
3. Obstructed
4. Strangulated
5. Inflamed
6. Occult (Inguinal)

(2) Anatomical location:
1. Epigastric
2. Umbilical
3. Spigelian
4. Diaphragmatic
5. Lumbar
6. Inguinal
7. Femoral
8. Obturator
9. Perineal
10. Sciatic

(3) Contents of Hernia:
1. Richter’s hernia
2. Sliding hernia
3. Maydl’s hernia
4. Littre’s hernia
5. Omentocele
6. Enterocele
7. Cystocele

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3
Q

What is a Femoral hernia?

A

Herniation of abdominal contents through the femoral ring into the femoral canal

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4
Q

Describe the location, boundaries and contents of the femoral canal

A

The femoral canal lies in the medial border of the femoral sheath.

It is bordered by:FLIP
F - Femoral vein (laterally)
L - Lacunar ligament (medially)
I - Inguinal ligament (anteriorly)
P - Pectineal ligament (posteriorly)

Contains: Fat, Lymphatic vessels, Cloquet’s node (AKA: Rosenmuller’s node)

The entrance of the femoral canal is the femoral ring, through which bowel can sometimes enter causing a femoral hernia.

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5
Q

What are the borders & contents of the femoral triangle?

A

The femoral traingle is bordered by the: SAIL
* **S **- Sartorius muscle (laterally)
* A - Adductor longus muscle (medially)
* IL - Inguinal Ligament (superiorly)

And it contains: NAVY-C
* N - Femoral Nerve
* A - Femoral Artery
* Y - Y fronts (i.e., midline)
* C - Femoral Canal

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6
Q

What are the borders of the inguinal canal?

A
  1. Superior border / Roof: Internal oblique muscle , Transversus abdominus muscles & Transverse fascia
  2. Inferior border / Floor: Inguinal ligament, Lacunar ligament (medially)
  3. Anterior border: external oblique aponeurosis muscle & reinforced laterally by the internal oblique muscle
  4. Posterior border: Transverse fascia & reinforced medially by the conjoint tendon
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7
Q

What are the contents of the Inguinal canal?

A

Both males & females have:
* Blood vessels
* Lymphatic vessels
* ilioinguinal nerve
* Genitofemoral nerve

Males:
* Spermatic cord, which contains:
- Vas deferens
- Testicular, deferential & cremasteric arteries
- Genital branch of the femoral nerve
- Testicular nerves
- Pampiniform plexus
- Tunica vaginalis
- Lymphatic vessels

  • External spermatic fascia, which covers the spermatic cord and testes

Females: Round ligament of the uterus

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8
Q

What are the 3 complications of hernias and explain them

A
  1. Incarceration: bowel is trapped in herniated position (irreducible). Can → Strangulation & Obstruction. Sx: tenderness, irreducibility, no impulse on coughing, recent increase in size of swelling
  2. Strangulation: base of the hernia becomes so tight that it cuts off blood supply → ischemia, pain & tenderness. This is a surgical emergency. Bowel will die within hours if not corrected by surgery.
  3. Obstruction: hernia causes a blockage in the passage of feces, fluids and gas, through the bowel. Sx: vomiting, generalized abdominal pain, absolute constipation, step ladder peristalsis
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9
Q

What is an Inguinal Hernia?

A

An inguinal hernia is a weakness or decfect in the lower abdominal wall that allows passage of abdominal contents into the inguinal region.

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10
Q

What are the caues of an inguinal hernia?

A
  1. Processus vaginalis fails to close
  2. Connective tissue disorders like:
    * Prune bell disorder (congenital)
    * Smoking (aquired, weakness of abdominal muscles due to decreased elastin)
  3. Abdominal wall injury
  4. Postappendicectomy: injury to the ilioinguinal nerve causes denervation of the right transversus abdominis muscle → formation of a “ U “ shaped ring
  5. In elderly patients it’s precipitated by:
    * Benign prostatic hypertrophy (BPH) due to difficulty passing urine
    * Chronic constipation or left colon malignancy
    * Chronic cough or a disease that causes a a chronic cough like chronic bronchitis
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11
Q

how do you defferentiate a direct and a indirect inguinal hernia?

A
  1. Direct inguinal hernia: hernia bulges through the Hesselbach’s triangle , then the inguinal canal and finally through the superficial inguinal ring, where a bulge is seen in the groin. It is irreducible when pressure is applied to the deep inguinal ring
  2. Indirect inguinal hernia: hernia bulges through both the internal inguinal ring and superficial inguinal ring. Can bulge into the scrotum. It is reducible when pressure is applied to the deep inguinal ring.
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12
Q

Where is the Deep inguinal ring?

A

Midway point between the anterior superior illiac spine & Pubic tubercle

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13
Q

What are the boundaries of the Hesselbach’s Triangle (AKA: Inguinal Triangle) ?

A

The Hesselbach’s Triangle is bounded by: RIP
* R - Rectus abdominis muscle (medially)
* I - Inferior epigastric vessels (laterally)
* P - Poupart’s ligament / Inguinal ligament (Inferiorly)

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14
Q

How do you classify inguinal hernias?

A

by:
1. Extent:
(1) Incomplete
(2) Complete

  1. Anatomy:
    (1) Indirect inguinal hernia
    (2) Direct inguinal hernia
  2. Gilbert classification
  3. NYHUS classification
  4. Bendavid classification
  5. European Hernia Society (EHS) classification
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15
Q

What is meant by an incomplete inguinal hernia

A

An incomplete iguinal hernia could be one of two things:

A Bubonocele: where the hernia sac is confinied to the inguinal canal

                             OR

A Funicular: where the hernia sac has crossed the superficial inguinal ring but hasnt descended to the bottom of the scrotum.

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16
Q

What is meant by a complete inguinal hernia?

A

A complete inguinal hernia is where the hernia sac has descended to the bottom of the scrotum.

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17
Q

What are the symptoms of a inguinal hernia?

A

Adults:
* Swelling in the groin
- better seen while coughing or on standing
- disappears on lying down but better seen while, straining, walking, caughing

  • Dragging pain in the umbilical region indicates omentocele (reason: the omentum is attached to the stomach above and supplied by T10)
  • Sudden severe pain in the hernia, vomiting & irreducibility suggest obstruction.

Infants: swelling appears when the child cries and is often translucent.

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18
Q

The clinical examination of an inguinal hernia in adults includes?

A
  1. Inspection
  2. Palpation
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19
Q

In what position should you inspect a patient with an inguinal hernia?

A

Inspection should be done in the standing position and both sides of the groin should be checked.

A Direct inguinal hernia pops out as soon as the patient stands and is often bilateral.

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20
Q

On inspection:
1. where is the swelling?
2. where does it extend to?
3. what’s the measurement
4. what is the texture & quality of the skin over the swelling?
5. describe the shape of swelling?
6. are there any scars?

A
  1. swelling in the inguinal region
  2. extending to the root of scrotum
  3. measursing about 6 x 3 cm
  4. The skin over the surface of swelling is smooth and normal
  5. and it is pyriform in shape
  6. no scars are present ( a scar indicates a recurrent hernia. A ragged scar indicates an infection)
21
Q

What should you do during palpation of an inguinal hernia?

A
  1. Palpate the swelling
  2. Ask the patient to cough, while palpating the root of scrotum
  3. While the patient is standing, Get above the swelling
  4. Check for reducibility
  5. External ring invagination test
  6. Internal / Deep ring occlusion test
  7. Leg raising test
  8. Per-rectal exam
22
Q
  1. Palpate the swelling
A
  • Firm and granular = Omentocoele
  • Soft and gurgles = Enterocoele
23
Q
  1. Ask the patient to cough, while palpating the root of scrotum
A

An expansile impulse on cough

24
Q

an expansile impulse on coughing also could suggest?

A
  • Meningocoele
  • Dermoid cyst with intracranial communication
  • Laryngocoele
  • Lymphatic cyst in children
  • Empyema necessitatis
25
Q

While the patient is standing, Get above the swelling test

A

Get above the swelling test: palapate the root of the scrotum, feeling for the spermatic cord. This cannot be felt in a complete indirect inguinal hernia, so getting above the swelling is impossible

26
Q

Why is getting above the swelling test done?

A

To differentiate between a scrotal swelling from a inguinoscrotal swelling

27
Q
  1. Check for reducibility
A

To check for Reducibility ask the patient to lie down, If:

  • the swelling becomes smaller or disappears, then it’s a hernia, NOT a hydrocoele
  • reduction is difficult, either ask the patient to reduce it or flex and medially rotate the hips (i.e., Taxis method). No reduction = irreducible hernia

A hydrocoele is irreducible.

28
Q
  1. External ring invagination test
A

In males: at the root of the scrotum, gather the skin and lif it up, then with the other finger press into the external ring. If your finger goes:

  • oblique and laterally = indirect inguinal hernia
  • backwards hitting the superior ramus of the pubic bone = Direct inguinal hernia

Next ask the patient to cough, impulses touches the:
* pulp of finger in direct hernia
* finger tip in indirect inguinal hernia

29
Q

Why is the External ring invagination test not done in females?

A

the labial skin is thick and not lax

30
Q
  1. Internal / Deep inguinal ring occlusion test
A

Occlude the deep inguinal ring with the thumb and ask the patient to cough. If:

impulse and swelling are seen, it’s a direct inguinal hernia because it occurs in the Hesselbach’s triangle (medial to the deep inguinal ring).

swelling is not seen, its a indirect inguinal hernia

31
Q

What position can the deep inguinal occlusion test be done?

A

can be done while the patient is standing or in the supine position

32
Q
  1. Leg raising test
A

Ask the patient to raise both legs extended, Malgaigne’s bulgings above the medial half of inguinal ligament, indicates weakness of the oblique muscles and its an absolute indication for a Hernioplasty.

33
Q
  1. Per- rectal exam
A

Do a per rectal exam to rule out protate enlargement

34
Q
  1. Respiratory exam
A

to rule out Chronic bronchitis, Tuberculosis

35
Q

How do you examin for an inguinal hernia in children?

A

Gornall’s test, where you gently compress the abdomen, while holding the child’s back with the other hand. Bulge = hernia

when the child strains, examin the root scrotum for any thickening, this indicates a hernia sac

36
Q

What are the differential diagnosis for a lump in the inguinal region?

A
  • Femoral hernia: swelling is below the inguinal ligament, at the top of the thigh
  • Vaginal hydrocoele
  • Undescended / ectopic testes: swelling in the inguinal region but scrotum is empty
  • Saphena varix: dilation of the saphenous vein at junction with the femoral vein. The swelling disappears on elevation of the leg

** Femoral aneurysm**

  • Lipoma of cord: soft lobulated irreducible swelling in the inguinal region
  • Inguinal lymphadenitis: pain and nodular swelling below the inguinal ligament , which is irreducible and there’s some sort of infection in the lower limb
  • Abscess
  • Kidney transplant
37
Q

How do you diagnose a hernia?

A

It’s a clinical diagnosis. however to confirm dignosis for:

early cases → Ultrasound (however it’s user dependent)

large hernias → CT is ideal

an athlete → MRI (because it can also rule out muscle sprain or other orthopedic disorders)

38
Q

What are the 3 types of hernia repair operations?

A
  1. Herniotomy
  2. Hernioplasty
  3. Herniorrhaphy
39
Q

What is a Herniotomy?

A

Excision of the sac alone. Done in children 14 -16 years old.

40
Q

What is a Hernioplasty

A

A Hernioplasty refers to strenghtening of the posterior wall of the inguinal canal by placing a mesh over it.

41
Q

What are the 2 types of Hernioplasty?

A

1) Lichtenstein repair (AKA: Polyprophylene mesh repair)

2) Prolene nylon darning (AKA: Handmade mesh repair)

42
Q

Explain the Lichtenstein repair

A
  • A 8 x 16 cm Polyprophylene mesh is tailored to the patient’s needs by:
  • cutting the corners to give it a round shape
  • for males: you place a slit in the upper 2/3rd and lower 1/3rds on the lateral border to allow the spermatic cord to pass through.

Place the mesh medially on top of the pubic tubercle, and place a few interrupted sutures to anchor it over the transversalis fascia on top of the pupic symphysis. Avoid the pubic bone to prevent osteitis. Next you overlap the slit ends around the spermatic cord and suture the inferior end to the inguinal and lacunar ligaments and superior end to the conjoined tendon

43
Q

Explain the Prolene nylon darning?

A

The conjoined tendon is sutured to inguinal ligament in a criss-cross manner with a prolene suture.

44
Q

What are the advantages of a Polyprophylene mesh?

A
  • High tensile strength
  • Bicompatible
  • Nonabsorbable
  • Encourages rapid ingrowth of connective tissue
  • Cheaper
  • Flexible for any anatomical placement
45
Q

What is a Biological mesh?

A

sterilized sheets of connective tissue derived from either: human or animal dermis OR porcine intestinal submucosa

46
Q

What are the advantages and disadvantege of a biological mesh?

A

These are uncommon:
* Chronic inflammtion
* Foreign body reaction
* Infection
* Stiffness and fibrosis

And can be used in the presence of an infection.

Disadvantage: they are very expensive

47
Q

What are the 2 types of Herniorrhaphy?

A

1) Bassini’s herniorrhaphy (but the Modified Bassini’s repair is what’s done today)

2) Shouldice repair

48
Q

Explain the Modified Bassini’s Heniorrhaphy

A

The Modified Bassini’s Heniorrhaphy is a tension repair. The conjoined tendon is sutured to the inguinal ligament using an interrupted suture with a non-absorbable material like nylon, thick silk or polyprophylene.

49
Q

Explain the Shouldice repair

A

The Shouldice repair is done in 3 layers:

1st layer: the upper and lower flaps of the transversalis fascia are sutured together in a double-breasted fashion.

2nd layer: the conjoined tendon is sutured to the inguinal ligament

3rd layer: the upper half of the external oblique aponeurosis is sutured to the inguinal ligament.

Non-absorbable suture material is used: 34 guage stainless steel wire, polyamide or polprophylene

surgery (britney) (5 decks)

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