HERNIAS Flashcards
MCC hernia recurrence
wound infection
MCC SBO (#1 and #2) in U.S.
#1 = adhesions #2 = hernia (MC worldwide)
Layers of anterior abdominal wall @ off midline
skin -> subQ -> superficial fascia -> ant rectus sheath -> muscle -> post rectus sheath -> preperitoneal fat -> peritoneum -> abd cavity
Layers of anterior abdominal wall @ lateral to rectus
skin, subQ, superficial fascia -> ext oblique -> int oblique -> trans abd -> trans fascia -> preperitoneal -> peritoneum -> cavity
Contents of spermatic cord
- vas deferens
- cremaster muscle
- genital branch of GF nerve
- pampiniform plexus
- testicular artery
Inguinal ligament is an extension of…?
external oblique fascia
Median umbilical ligament was…?
obliterated urachus (umbilicus to bladder)
Medial umbilical ligaments are…?
obliterated umbilical arteries
Round ligament of liver was…?
umbilical vein (can recannualize)
Indirect inguinal hernia 2/2 …?
congenital patent procesalis vagenalis
Cremasteric muscle formed from…?
internal oblique muscle
MC injured in open inguinal hernia repair
ilioinguinal
MC injured in laparoscopic inguinal hernia repair
lateral femoral cutaneous nerve
Types of inguinal primary open repair
- Bassini
- Sholdice
Types of inguinal mesh open repair
- Lichtenstein
- Plug and patch
Open femoral hernia repair
McVay repair (Cooper’s ligament repair) - open inguinal floor
What is Cooper’s ligament?
pectineal ligament; posterior to femoral vessels (lies against bone)
Main structure to fix mesh for laparoscopic TEP/TAPP repair
Cooper’s ligament
What is separated for component separation?
external oblique fascia
Spigelian hernia
Spigelian fascia (aponeurotic layer btwn rectus muscle and semilunar line), inferior to arcuate line
Amyand’s hernia
Appendix in inguinal hernia
De Garengeot hernia
Appendix in femoral hernia
Littre’s hernia
Meckel’s diverticula in inguinal hernia
Canal of nuck hernia; mgmt?
ovary in inguinal hernia; mgmt: ligate round ligament
Richter’s hernia
part of wall of bowel herniated (not entire loop) -> can get strangulation WO obstruction
Obturator hernia; sign?
Howship-Romberg sign (medial thigh pain w/ internal rotation of hip)
Sciatic hernia
through greater sciatic foramen -> sciatica (high rate strangulation)
Pantaloon hernia
dual/saddle hernia of both direct and indirect
Sliding hernia
RP organ that forms part of hernia - cannot resect sac
MC organs female vs. male sliding hernia
Female: ovaries or fallopian tubes
Male: cecum or sigmoid
Corona mortis
aberrant obturator artery - connects obturator (br. of internal iliac) + external iliac or its br. (inferior epigastric)
Attaching mesh to Cooper’s during lap inguinal hernia repair… concern for?
Corona mortis
First step mgmt asymptomatic hernia in obese/smoker pt
weight loss, tobacco cessation before consideration of hernia repair
Mgmt of pt w/ uncontrolled ascites + leaky umbilical hernia
admission bc high risk bacterial peritonitis +/- hernia rupture; bed rest + IV Abx + diuresis + hernia repair this admission
MC hernia in females
indirect inguinal hernia
Petit hernia
@ inferior lumbar triangle:
- iliac crest (inferior)
- external oblique (anterior)
- lat dorsi (posterior)
Grynfeltt-Lesshalf hernia
@ superior lumbar triangle:
- quadratus lumborum (medial)
- internal oblique (lateral)
- 12th rib (superior)
- transversalis fascia (floor)
- external oblique (roof)
How much overlap for laparoscopic ventral hernia repair with intraperitoneal mesh?
3-5cm
MC artery injured during inguinal herniorrhaphy
inferior epigastric artery (from ext iliac artery immediately superior to inguinal ligament)
Properties: polypropylene mesh
incorporates into native tissue
Properties: vicryl mesh
absorbable, often used in contaminated fields
Properties: PTFE
synthetic
Properties: macroporous lightweight
higher rate bacterial clearance than microporous heavyweight
Properties: biologic
acellular collagen matrix; promotes neovascularization and native collagen deposition; can be used in contaminated fields
Incarcerated obturator hernia and cannot reduce intra-op… next step?
incise obturator membrane to help reduce hernia
Cross-linked vs. non biologic mesh
X-linked: less prone to degradation in vivo by collangenases; also delays cellular infiltration and neovasc in short-term
Non-x-linked: promote early vasc and cellular ingrowth
Where is biologic mesh best placed?
between 2 layers of vascularized tissue that promotes fibroblast and vessel ingrowth within scaffold
Large-pore mesh in relation to recurrence rate?
Large-pore = lightweight - better tissue incorporation of mesh, thought to reduce recurrence rate
Urinary retention more prevalent in laparoscopic vs. open hernia repairs?
laparoscopic
Elderly female w/ prior weight loss, no hx abdominal surgery, presenting with abd pian, N/V… think?
obturator hernia
Surgical approach for mgmt of obturator hernia
midline laparotomy
Howship-Romberg sign
ipsilateral groin pain radiating down thigh 2/2 irritation of obturator nerve (obturator hernia pt)
Groin pain from obturator hernia relieved by…? Aggregated by…?
Relieved by thigh flexion - aggravated by extension, abduction, and medial rotation
Ilioinguinal nerve innervates…
sensation to proximal and medial thigh, pubic region (base of penis) and upper portion of the scrotum or labia majora
Lateral femoral cutaneous nerve innervates…
sensation to lateral portion of anterior thigh
Long-term complication of inguinal hernia repair?
chronic pain (up to 30%, only 5% debilitating)
If doing PD cath, but also have asymptomatic hernia… what to do?
PD cath + hernia repair (because with PD, will have high intraabdominal pressure)
How soon post-op can you use PD cath? What about if concurrently fixed hernia?
only PD cath: 1-2 weeks post-op
PD cath + hernia repair: 4-6 weeks post-op
Approach for femoral hernia repairs
McVay, open preperitoneal repair, laparoscopic extraperitoneal herniorrhaphy* (lower recurrence than open)
Asymptomatic inguinal hernia can be managed by watchful waiting, but are likely to need operation bc… (esp in elderly)
progression of symptoms (MC pain; rarely obstruction)
Two etiologies and mgmt for pubic inguinal pain syndrome (PIPS)
non-hernia-associated inguinal pain
- weakness of inguinal floor - mgmt: surgical reinforcement
- inflammation/injury at pubic tubercle and associated musculotendinous insertions - confirmed with MRI - mgmt: physical therapy (if fails, then surgery to off-load tension on pubic tubercle)
Genital branch of GF nerve provides sensation to…
scrotum
Location and path of aberrant right subclavian artery (ARSA)
orginates posteriorly, AFTER left subclavian artery, and travels posterior to esophagus to reach right thoracic outlet
MC sxs aberrant right subclavian artery in children vs. adult
children: respiratory (bc trachea not rigid yet)
adult: dyphagia 2/2 esophageal compression
What if suspect inguinal hernia but negative physical exam?
dx laparoscopy
% recurrence rate of tension-free inguinal hernia w/ mesh (Lichtenstein)
4% (lowest recurrence rate compared to other techniques of hernia repair)
% recurrence rate of open tissue hernia repair under tension
20-30% (high)
Borders of femoral hernia
anterior: inguinal ligament
posterior: pectineal ligament
medial: lacunar ligament
lateral: femoral vein
Femoral hernia pain worse with…?
external rotation of hip
Have to divide what ligament to fully reduce herniated bowel of femoral hernia?
inguinal ligament
Where is bulge of femoral hernia?
anterior-medial thigh
Bulge on valsalva in postpartum female… think? Tx?
Diastasis recti (seen in postpartum females or pts after weight loss) - fascia intact
Tx: abdominal wall strengthening (if op-repair desired, then placating of broad midline aponeurosis)
Bulge at groin + pain @ medial rotation and extension of hip joint… think?
Obturator hernia
Bulge at groin + pain at external rotation of hip… think?
Femoral hernia
Hannington-Kidd sign
Loss of adductor reflex in presence of positive patellar reflex 2/2 obturator nerve compression (by hernia) leading to adductor muscle weakness
What approach is recommended for femoral hernias?
Inguinal (McVay)
What approach is recommended for obturator hernia if have SBO?
Laparotomy
If femoral hernia is difficult to reduce intra-op, then can do what to increase exposure?
Divide inguinal ligament (femoral canal is just posterior)
Which type of hernia has highest risk strangulation?
Femoral hernia (15-20%)
Why is surgical correction necessary for type II, III, and IV hiatal hernias?
Risk of volvulus (but remember, in elderly and asymptomatic, greater risk to operate, so will observe these)
Which method of repairing parastomal hernia has been proven effective?
Repair with mesh
When would you do stomal relocation for parastomal hernia?
If also have skin excoriation (bc also will have risk of incisional hernia at old stoma site)
Borders of femoral hernia
Anterior: inguinal ligament (often divided during repair)
Posterior: pectineal ligament
Lateral: femoral vein
Medial: lacunar ligament
Borders of obturator hernia
Lateral: hip-joint
Medial: pubic arch
Superior: superior pubic ramis
Inferior: adductor magnus
Indirect inguinal hernia due to…
Patent processus vaginalis
Direct inguinal hernia is due to…
Weakness of the conjoint tendon (which forms the posterior wall of the inguinal canal)
Component separation repairs includes… (what steps?)
- longitudinal incision made in aponeurosis of ext. oblique muscle ~2-cm lateral to rectus sheath, overlapping hernia defect caudally and extending 5-7cm cranial to the costal margin
- additional length can be gained by incising posterior rectus sheath
- ext. oblique muscle is separate from internal oblique muscles as far laterally as possible
Pathophys of development ischemic orchid is as Cx from hernia repair
Due to venous congestion from paminiform plexus thrombosis or ligation of testicular artery during repair
Unilateral tender, swollen testicle post-hernia repair… think? How to avoid?
Ischemic orchitis. Minimize risk by avoiding excessive dissection of spermatic cord.
Mgmt ischemic orchitis after hernia repair
NSAID + pain control (may last up to 12-weeks)
Where is the mesh placed in Rives-Stoppa-Wantz repair?
Between rectus muscle and posterior sheath (retrorectus position - sublay)
Triple neurectomy includes what nerves?
- genitofemoral
- iliohypogastric
- ilioinguinal
Inguinal nerve block is done where?
1-cm medial to the ASIS, 2-cm up
If strangulated hernia, can you fix laparoscopically?
NO
Absolute C/I laparoscopic hernia repairs
- inability to tolerate insuffulation/pneumoperitoneum (COPD, CHF)
- active infection
- strangulated hernia
Pt w/ ascites + leaking umbilical hernia… mgmt?
Emergent repair (high risk peritonitis and death)
Pt with ascites + umbilical hernia (asymptomatic - no skin changes, no leak), mgmt…?
Ascites control (diuretics) vs. TIPS for refractory ascites -> followed by elective repair
Where should tacks be place laparoscopically for inguinal hernia repair?
Superior to inguinal ligament + lateral to inferior epigastric artery
Internal inguinal ring formed by…
Internal oblique muscle (superficial component) and transversal is fascia (courage of ring)
Borders of internal inguinal ring
Medial: transversalis fascia + inferior epigastric vessels
Inferior: iliopubic tract
Anterior: transversus abdominis arch
External inguinal ring is formed by…?
Medial fibers of external oblique aponeurosis divide into medial and lateral crura to form ext. inguinal ring
Conjoined tendon is formed by…?
Internal oblique + transverse abdominis muscles joining together
Petersen hernia, mgmt?
Internal hernia that can occur in potential space posterior to a gastroJ.
Mgmt: closure of space between Roux-limb and transverse colon mesenteries
When do primary repair vs. mesh repair for umbilical hernia?
Primary if <2cm.
Laparoscopic mesh preferred (associated with lower risk recurrence, decreased recovery time, pain, and wound infection compared to open).
% recurrence rate of Lichtenstein repair
1.2-4%
Choice operation for recurrent inguinal hernia (failed open with mesh)
Endoscopic (TEP) - less postop pain, faster healing time, less chronic pain than open Lichtenstein
