Hernias Flashcards
1
Q
What is a hernia?
A
Protrusion of a peritoneal sac through a musculoaponeurotic barrier.
A fascial defect.
2
Q
What is the incidence of hernia?
A
5-10% lifetime
3
Q
What are the precipitating factors for hernias?
A
Straining at defecation or urination (rectal cancer, colon cancer, prostatic enlargement, constipation); obesity; pregnancy; ascites; valsavagenic (coughing); COPD; abnormal congenital anatomic route
4
Q
Why should hernias be repaired?
A
To avoid complications of incarceration and strangulation, bowel necrosis, SBO, pain
5
Q
What is more dangerous: a small or large hernia defect?
A
Small because a tight defect is more likely to strangulate if incarcerated
6
Q
What is a reducible hernia?
A
Ability to return the displaced organ or tissue to their usual anatomic site
7
Q
What is an incarcerated hernia?
A
Contents swollen or fixed within the hernia sac.
May cause intestinal obstruction.
8
Q
What is a strangulated hernia?
A
Incarcerated hernia with resulting ischemia.
Will result in signs and symptoms of ischemia and intestinal obstruction or bowel necrosis.
9
Q
What is a complete hernia?
A
Hernia sac and its contents protrude all the way through the defect
10
Q
What is an incomplete hernia?
A
Defect present without sac or contents protruding completely through it
11
Q
What is reducing a hernia en masse?
A
Reducing the hernia contents and hernia sac
12
Q
What is a sliding hernia?
A
Hernia sac partially formed by the wall of a viscus (e.g. bladder, cecum)
13
Q
What is a Littre’s hernia?
A
Hernia involving a Meckel’s diverticulum
14
Q
What is a spigelian hernia?
A
Hernia through the linea semilunaris (or spigelian fascia).
Also known as spontaneous lateral ventral hernia.
15
Q
What is an internal hernia?
A
Hernia into or involving intra-abdominal structure
16
Q
What is a Petersen’s hernia?
A
Internal herniation of small bowel through the mesenteric defect from the Roux limb after bariatric gastric bypass
17
Q
What is an obturator hernia?
A
Hernia through obturator canal (F > M)
18
Q
What is a lumbar hernia?
A
Petit’s hernia or Grynfeltt’s hernia
19
Q
What is a Petit’s hernia?
A
Hernia through Petit’s triangle (inferior lumbar triangle)
20
Q
What is a Grynfeltt’s hernia?
A
Hernia through Grynfeltt’s triangle (superior lumbar triangle)
21
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
22
Q
What is an incisional hernia?
A
Hernia through an incisional site.
Most common cause is a wound infection.
23
Q
What is a ventral hernia?
A
Incisional hernia in the ventral abdominal wall
24
Q
What is a parastomal hernia?
A
Hernia adjacent to an ostomy
25
What is a sciatic hernia?
Hernia through the sciatic foramen
26
What is a Richter's hernia?
Incarcerated or strangulated hernia involving only one sidewall of the bowel, which can spontaneously reduce, resulting in gangrenous bowel and perforation within the abdomen without signs of obstruction
27
What is an epigastric hernia?
Hernia through the linea alba above the umbilicus
28
What is an umbilical hernia?
Hernia through the umbilical ring, in adults associated with ascites, pregnancy, and obesity
29
What is an intraparietal hernia?
Hernia in which abdominal contents migrate between the layers of the abdominal wall
30
What is a femoral hernia?
Hernia medial to femoral vessels (under inguinal ligament)
31
What is a Hesselbach's hernia?
Hernia under inguinal ligament lateral to femoral vessels
32
What is a Bochdalek's hernia?
Hernia through the posterior diaphragm, usually on the left
33
What is a Morgagni's hernia?
Anterior parasternal diaphragmatic hernia
34
What is a properitoneal hernia?
Intraparietal hernia between the peritoneum and transversalis fascia
35
What is a Cooper's hernia?
Hernia through the femoral canal and tracking into the scrotum or labia majus
36
What is an indirect inguinal hernia?
Inguinal hernia lateral to Hesselbach's triangle
37
What is a direct inguinal hernia?
Inguinal hernia within Hesselbach's triangle
38
What is a hiatal hernia?
Hernia through esophageal hiatus
39
What is an Amyand's hernia?
Hernia sac containing a ruptured appendix
40
What are the boundaries of Hesselbach's triangle?
1. Inferior epigastric vessels
2. Inguinal ligament
3. Lateral border of the rectus sheath
(Floor consists of internal oblique and the transversus abdominis muscle)
41
What is the differential diagnosis for a mass in a healed C-section incision?
Hernia, endometrioma
42
What is the differential diagnosis for a groin mass?
LAD, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC, undescended testicle, sarcoma, hernias, testicle torsion
43
What is the cause of a direct inguinal hernia?
Acquired defect from mechanical breakdown over the years
44
What is the incidence of direct inguinal hernia?
1% of men
45
What nerve runs with the spermatic cord in the inguinal canal?
Ilioinguinal nerve
46
What is the cause of an indirect inguinal hernia?
Patent processus vaginalis
47
What is the incidence of indirect inguinal hernia?
5% of men
48
How is an inguinal hernia diagnosed?
Relies mainly on H&P with index finger invaginated into the external ring and palpation of hernia.
Examine the patient standing up if diagnosis is not obvious.
49
What is the differential diagnosis of an inguinal hernia?
LAD, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess
50
What is the risk of strangulation with an inguinal hernia?
Higher with indirect than direct, but highest in femoral hernia
51
What is the treatment for an inguinal hernia?
Emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present.
Otherwise, elective herniorrhaphy is indicated to prevent the chance of incarceration or strangulation.
52
What is the Bassini procedure?
Inguinal hernia repair in which sutures approximate reflection of inguinal ligament (Poupart's) to the transversus abdominis aponeurosis (conjoint tendon)
53
What is the McVay procedure?
Inguinal hernia repair in which Cooper's ligament is sutured to tranversus abdominis aponeurosis (conjoint tendon)
54
What is the Lichtenstein procedure?
Inguinal hernia repair using mesh (tension-free repair)
55
What is the Shouldice procedure?
Inguinal hernia repair in which the floor of the inguinal canal in imbricated
56
What is the plug and pouch procedure?
Inguinal hernia repair in which a plug of mesh is placed in the hernia defect and then a patch of mesh is laid over the inguinal floor
57
What is the high ligation procedure?
Ligation and transection of indirect hernia sac without repair of inguinal floor
58
What is the TAPP procedure?
TransAbdominal PrePeritoneal inguinal hernia repair
59
What is the TEPA procedure?
Totally ExtraPeritoneal Approach
60
What are the indications for laparoscopic inguinal hernia repair?
1. Bilateral inguinal hernias
2. Recurring hernia
3. Need to resume full activity as soon as possible
61
What is the first identifiable subcutaneous named layer of the abdomen?
Scarpa's fascia
62
What is the name of the subcutaneous vein that is ligated in an inguinal hernia repair?
Superficial epigastric vein
63
What happens if you cut the ilioinguinal nerve?
Numbness of inner thigh or lateral scrotum.
| Usually goes away in 6 months.
64
From what abdominal muscle layer is the cremaster muscle derived?
Internal oblique muscle
65
From what abdominal muscle layer is the inguinal ligament derived?
External oblique muscle aponeurosis
66
To what does the inguinal ligament attach?
Anterior superior iliac spin to the pubic tubercle
67
Why do some surgeons deliberately cut the ilioinguinal nerve?
First they obtain preoperative consent and cut so as to remove the risk of entrapment and postoperative pain
68
What is in the spermatic cord?
1. Cremasteric muscle fibers
2. Vas deferens
3. Testicular artery
4. Testicular pampiniform venous plexus
5. +/- hernia sac
6. Genital branch of the genitofemoral nerve
69
What is the hernia sac made of?
Peritoneum (direct) or a patent processus vaginalis (indirect)
70
What is the most common organ in an inguinal hernia sac in men?
Small intestine
71
What is the most common organ in an inguinal hernia sac in women?
Ovary/fallopian tube
72
What lies in the inguinal canal in the female instead of the vas deferens?
Round ligament
73
Where is the inguinal canal does the hernia sac lie in relation to the other structures?
Anteromedially
74
What is a cord lipoma?
Preperitoneal fat on the cord structures (pushed in by the hernia sac).
Not a real lipoma.
75
What is a small outpouching of testicular tissue off of the testicle?
Testicular appendage
76
What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?
Remove the suture as soon as possible and apply pressure
77
What nerve travels within the spermatic cord?
Genital branch of the genitofemoral nerve
78
What is a relaxing incision?
Incision in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal ligament without tension
79
What is the conjoint tendon?
Aponeurotic attachments of the conjoining of the internal oblique and transversus abdominis to the pubic tubercle
80
What are the boundaries of the femoral canal?
1. Cooper's ligament posteriorly
2. Inguinal ligament anteriorly
3. Femoral vein laterally
4. Lacunar ligament medially
81
What factors are associated with femoral hernias?
Women, pregnancy, and exertion
82
What percentage of all hernias are femoral?
5%
83
What percentage of patients with a femoral hernia are female?
85%
84
What are the complications with a femoral hernia?
Approximately one third incarcerate
85
What is the most common hernia in women?
Indirect inguinal hernia
86
What is the repair of a femoral hernia?
McVay (Cooper's ligament repair), mesh plug repair
87
Which type of esophageal hiatal hernia is associated with GER?
Sliding esophageal hiatal hernia
88
Classically, how can an incarcerated hernia be reduced in the ER?
1. Apply ice to incarcerated hernia
2. Sedate
3. Use the Trendelenburg position for inguinal hernias
4. Apply steady gentle manual pressure
5. Admit and observe for signs of necrotic bowel after reduction
6. Perform surgical herniorrhaphy
89
What is appropriate if you cannot reduce an incarcerated hernia with steady, gentle compression?
Go directly to OR for repair
90
What is the major difference in repairing a pediatric indirect inguinal hernia and an adult inguinal hernia?
In babies and children, it is rarely necessary to repair the inguinal floor.
Repair with high ligation of the hernia sac.
91
What is the Howship-Romberg sign?
Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia
92
What is the silk glove sign?
Inguinal hernia sac in an infant/toddler feels like a finger of a silk glove when rolled under the examining finger
93
What must you do before leaving the OR after an inguinal hernia repair?
Pull the testicle back down to the scrotum
94
What is a sliding esophageal hiatal hernia?
Both the stomach and GE junction herniate into the thorax via the esophageal hiatus.
Also known as type I hiatal hernia.
95
What is the incidence of sliding esophageal hiatal hernias?
> 90% of all hiatal hernias
96
What are the symptoms of a sliding esophageal hiatal hernia?
Most patients are asymptomatic, but the condition can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration
97
How is a sliding esophageal hiatal hernia diagnosed?
UGI series, manometry, EGD with biopsy for esophagitis
98
What are the complications of a sliding esophageal hiatal hernia?
Reflux, esophagitis, Barrett's esophagus, esophageal cancer, stricture formation, aspiration pneumonia, ulceration, bleeding
99
What is the treatment for a sliding esophageal hiatal hernia?
85% treated medically (antacids, H2 blockers, PPIs, head elevation after meals, small meals, no food prior to sleeping)
Surgical: Laparoscopic Nissen fundoplication (involves wrapping the fundus around the LES and suturing it in place)
100
What is a paraesophageal hiatal hernia?
Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the GE junction.
Also known as type II hiatal hernia.
101
What is the incidence of paraesophageal hiatal hernias?
< 5% of hiatal hernias
102
What are the symptoms of paraesophageal hiatal hernia?
Dysphagia, stasis gastric ulcer, strangulation
103
What are the complications with a paraesophageal hiatal hernia?
Hemorrhage, incarceration, obstruction, strangulation
104
What is the treatment for a paraesophageal hiatal hernia?
Surgical, because of the frequency and severity of potential complications
105
What is a type III hiatal hernia?
Combined type I and II
106
What is a type IV hiatal hernia?
Organ (e.g. spleen, colon) +/- stomach in the chest cavity
