Hernias Flashcards
What is a hernia?
Protrusion of a peritoneal sac through a musculoaponeurotic barrier.
A fascial defect.
What is the incidence of hernia?
5-10% lifetime
What are the precipitating factors for hernias?
Straining at defecation or urination (rectal cancer, colon cancer, prostatic enlargement, constipation); obesity; pregnancy; ascites; valsavagenic (coughing); COPD; abnormal congenital anatomic route
Why should hernias be repaired?
To avoid complications of incarceration and strangulation, bowel necrosis, SBO, pain
What is more dangerous: a small or large hernia defect?
Small because a tight defect is more likely to strangulate if incarcerated
What is a reducible hernia?
Ability to return the displaced organ or tissue to their usual anatomic site
What is an incarcerated hernia?
Contents swollen or fixed within the hernia sac.
May cause intestinal obstruction.
What is a strangulated hernia?
Incarcerated hernia with resulting ischemia.
Will result in signs and symptoms of ischemia and intestinal obstruction or bowel necrosis.
What is a complete hernia?
Hernia sac and its contents protrude all the way through the defect
What is an incomplete hernia?
Defect present without sac or contents protruding completely through it
What is reducing a hernia en masse?
Reducing the hernia contents and hernia sac
What is a sliding hernia?
Hernia sac partially formed by the wall of a viscus (e.g. bladder, cecum)
What is a Littre’s hernia?
Hernia involving a Meckel’s diverticulum
What is a spigelian hernia?
Hernia through the linea semilunaris (or spigelian fascia).
Also known as spontaneous lateral ventral hernia.
What is an internal hernia?
Hernia into or involving intra-abdominal structure
What is a Petersen’s hernia?
Internal herniation of small bowel through the mesenteric defect from the Roux limb after bariatric gastric bypass
What is an obturator hernia?
Hernia through obturator canal (F > M)
What is a lumbar hernia?
Petit’s hernia or Grynfeltt’s hernia
What is a Petit’s hernia?
Hernia through Petit’s triangle (inferior lumbar triangle)
What is a Grynfeltt’s hernia?
Hernia through Grynfeltt’s triangle (superior lumbar triangle)
What is a pantaloon hernia?
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
What is an incisional hernia?
Hernia through an incisional site.
Most common cause is a wound infection.
What is a ventral hernia?
Incisional hernia in the ventral abdominal wall
What is a parastomal hernia?
Hernia adjacent to an ostomy
What is a sciatic hernia?
Hernia through the sciatic foramen
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
What is an epigastric hernia?
Hernia through the linea alba above the umbilicus
What is an umbilical hernia?
Hernia through the umbilical ring, in adults associated with ascites, pregnancy, and obesity
What is an intraparietal hernia?
Hernia in which abdominal contents migrate between the layers of the abdominal wall
What is a femoral hernia?
Hernia medial to femoral vessels (under inguinal ligament)
What is a Hesselbach’s hernia?
Hernia under inguinal ligament lateral to femoral vessels
What is a Bochdalek’s hernia?
Hernia through the posterior diaphragm, usually on the left
What is a Morgagni’s hernia?
Anterior parasternal diaphragmatic hernia
What is a properitoneal hernia?
Intraparietal hernia between the peritoneum and transversalis fascia
What is a Cooper’s hernia?
Hernia through the femoral canal and tracking into the scrotum or labia majus
What is an indirect inguinal hernia?
Inguinal hernia lateral to Hesselbach’s triangle
What is a direct inguinal hernia?
Inguinal hernia within Hesselbach’s triangle
What is a hiatal hernia?
Hernia through esophageal hiatus
What is an Amyand’s hernia?
Hernia sac containing a ruptured appendix
What are the boundaries of Hesselbach’s triangle?
- Inferior epigastric vessels
- Inguinal ligament
- Lateral border of the rectus sheath
(Floor consists of internal oblique and the transversus abdominis muscle)
What is the differential diagnosis for a mass in a healed C-section incision?
Hernia, endometrioma
What is the differential diagnosis for a groin mass?
LAD, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC, undescended testicle, sarcoma, hernias, testicle torsion
What is the cause of a direct inguinal hernia?
Acquired defect from mechanical breakdown over the years
What is the incidence of direct inguinal hernia?
1% of men
What nerve runs with the spermatic cord in the inguinal canal?
Ilioinguinal nerve
What is the cause of an indirect inguinal hernia?
Patent processus vaginalis
What is the incidence of indirect inguinal hernia?
5% of men
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.
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
What is the risk of strangulation with an inguinal hernia?
Higher with indirect than direct, but highest in femoral hernia
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.
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)
What is the McVay procedure?
Inguinal hernia repair in which Cooper’s ligament is sutured to tranversus abdominis aponeurosis (conjoint tendon)
What is the Lichtenstein procedure?
Inguinal hernia repair using mesh (tension-free repair)
What is the Shouldice procedure?
Inguinal hernia repair in which the floor of the inguinal canal in imbricated
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
What is the high ligation procedure?
Ligation and transection of indirect hernia sac without repair of inguinal floor
What is the TAPP procedure?
TransAbdominal PrePeritoneal inguinal hernia repair
What is the TEPA procedure?
Totally ExtraPeritoneal Approach
What are the indications for laparoscopic inguinal hernia repair?
- Bilateral inguinal hernias
- Recurring hernia
- Need to resume full activity as soon as possible
What is the first identifiable subcutaneous named layer of the abdomen?
Scarpa’s fascia
What is the name of the subcutaneous vein that is ligated in an inguinal hernia repair?
Superficial epigastric vein
What happens if you cut the ilioinguinal nerve?
Numbness of inner thigh or lateral scrotum.
Usually goes away in 6 months.
From what abdominal muscle layer is the cremaster muscle derived?
Internal oblique muscle
From what abdominal muscle layer is the inguinal ligament derived?
External oblique muscle aponeurosis
To what does the inguinal ligament attach?
Anterior superior iliac spin to the pubic tubercle
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
What is in the spermatic cord?
- Cremasteric muscle fibers
- Vas deferens
- Testicular artery
- Testicular pampiniform venous plexus
- +/- hernia sac
- Genital branch of the genitofemoral nerve
What is the hernia sac made of?
Peritoneum (direct) or a patent processus vaginalis (indirect)
What is the most common organ in an inguinal hernia sac in men?
Small intestine
What is the most common organ in an inguinal hernia sac in women?
Ovary/fallopian tube
What lies in the inguinal canal in the female instead of the vas deferens?
Round ligament
Where is the inguinal canal does the hernia sac lie in relation to the other structures?
Anteromedially
What is a cord lipoma?
Preperitoneal fat on the cord structures (pushed in by the hernia sac).
Not a real lipoma.
What is a small outpouching of testicular tissue off of the testicle?
Testicular appendage
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
What nerve travels within the spermatic cord?
Genital branch of the genitofemoral nerve
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
What is the conjoint tendon?
Aponeurotic attachments of the conjoining of the internal oblique and transversus abdominis to the pubic tubercle
What are the boundaries of the femoral canal?
- Cooper’s ligament posteriorly
- Inguinal ligament anteriorly
- Femoral vein laterally
- Lacunar ligament medially
What factors are associated with femoral hernias?
Women, pregnancy, and exertion
What percentage of all hernias are femoral?
5%
What percentage of patients with a femoral hernia are female?
85%
What are the complications with a femoral hernia?
Approximately one third incarcerate
What is the most common hernia in women?
Indirect inguinal hernia
What is the repair of a femoral hernia?
McVay (Cooper’s ligament repair), mesh plug repair
Which type of esophageal hiatal hernia is associated with GER?
Sliding esophageal hiatal hernia
Classically, how can an incarcerated hernia be reduced in the ER?
- Apply ice to incarcerated hernia
- Sedate
- Use the Trendelenburg position for inguinal hernias
- Apply steady gentle manual pressure
- Admit and observe for signs of necrotic bowel after reduction
- Perform surgical herniorrhaphy
What is appropriate if you cannot reduce an incarcerated hernia with steady, gentle compression?
Go directly to OR for repair
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.
What is the Howship-Romberg sign?
Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia
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
What must you do before leaving the OR after an inguinal hernia repair?
Pull the testicle back down to the scrotum
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.
What is the incidence of sliding esophageal hiatal hernias?
> 90% of all hiatal hernias
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
How is a sliding esophageal hiatal hernia diagnosed?
UGI series, manometry, EGD with biopsy for esophagitis
What are the complications of a sliding esophageal hiatal hernia?
Reflux, esophagitis, Barrett’s esophagus, esophageal cancer, stricture formation, aspiration pneumonia, ulceration, bleeding
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)
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.
What is the incidence of paraesophageal hiatal hernias?
What are the symptoms of paraesophageal hiatal hernia?
Dysphagia, stasis gastric ulcer, strangulation
What are the complications with a paraesophageal hiatal hernia?
Hemorrhage, incarceration, obstruction, strangulation
What is the treatment for a paraesophageal hiatal hernia?
Surgical, because of the frequency and severity of potential complications
What is a type III hiatal hernia?
Combined type I and II
What is a type IV hiatal hernia?
Organ (e.g. spleen, colon) +/- stomach in the chest cavity
