HERNIAS Flashcards
Femoral Nerve
Motor and sensory to thigh (quads)
Genitofemoral nerve
Motor–cremasteric muscle Sensory–genital region
Lateral femoral cutaneous nerves
Skin to lateral portion of thigh (often sacrificed)
Hesselbach’s Triangle
Medial: rectus sheath Inferior: inguinal ligament Superolateral: inferior epigastric vessels
Hernia Dx
Bulge in inguinal region Minor pain or vague discomfort or extreme pain (incarceration) Paresthesias if inguinal nerves are compressed
Reducing a hernia
Gentle continuous pressure on the hernial mass toward the inguinal ring in the Trendelenburg position
Radiology
Only used in ambiguous diagnosis NOT FIRST LINE US (pretty good)
Hernia Severity
Reducible –> Incarcerated –> Strangulated
Indirect inguinal hernia
Congenital lesion Bowel, omentum, other abdominal organs protrude through abdominal ring with patent processus vaginalis Indirect hernia cannot develop if processus vaginalis does not remain patent Most common type of hernia
Direct inguinal hernia
Proceeds directly through posterior inguinal wall Acquired lesions Older males Pressure and tension on muscles and fascia
Femoral Hernias
Mass below the inguinal ligament More common in females than males
RFs for inguinal hernias
Family history (8x more likely) Connective tissue disorders Smoking Coughing COPD Obesity Straining Pregnancy Ascites Prematurity, low birth weight Heavy listing
Does wearing a truss cure a hernia?
No
When to surgically repair a hernia
If they are symptomatic
When to repair emergently
Strangulation of hernia -Fever, leukocytosis, hemodynamic instability -Hernia bulge is warm and tender -Overlying skin may be erythematous or discolored -Sx of bowel obstruction
Bassini Repair
Original procedure Used for indirect and small direct hernias Closing the area with the patient’s own tissue Higher rates of recurrence
McVay (Cooper’s ligament) Repair
Inguinal and femoral hernia repairs
Shouldice (Canadian) Repair
Most commonly used Reduced recurrence rate Using patient’s own tissue to close defect Genitoformoral nerve is divided; loss of sensation on scrotum/mons pubis and labia majora
The Operation
Incision: 2 finger breadths above inguinal ligament Dissect through subcutaneous and external oblique fascia Mobilize spermatic cord Divide/separate cremasteric muscle fibers from underlying cord structures Dissect hernia sac from cord structures; open Suture ligate neck of sac at level of internal ring
Which procedures use the patient’s own tissue?
Bassini McVay Shouldice
Lichtenstein (tension-free) Repair
Very common Mesh patch is sutured over defect with a slit to allow passage of the spermatic cord Laparoscopic > Open Recurrence rate is even lower Preferred method
Which procedure cannot be used if suspected/known strangulated or incarcerated hernia?
TEPA –Opt for TAPP instead
What are the three issues with laparoscopic hernia repair?
Triangle of doom Triangle of pain Circle of death
Triangle of doom
Medial border: vas deferens Lateral border: vessels of spermatic cord Posterior border: peritoneal edge Contents: external iliac vessels, deep circumflex iliac vein, femoral nerve, genital branch of genitofemoral nerve
