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QUESTION NOTES > HERNIAS > Flashcards

HERNIAS Flashcards

1
Q

MCC hernia recurrence

A

wound infection

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2
Q

MCC SBO (#1 and #2) in U.S.

A 
#1 = adhesions
#2 = hernia (MC worldwide)
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3
Q

Layers of anterior abdominal wall @ off midline

A

skin -> subQ -> superficial fascia -> ant rectus sheath -> muscle -> post rectus sheath -> preperitoneal fat -> peritoneum -> abd cavity

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4
Q

Layers of anterior abdominal wall @ lateral to rectus

A

skin, subQ, superficial fascia -> ext oblique -> int oblique -> trans abd -> trans fascia -> preperitoneal -> peritoneum -> cavity

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5
Q

Contents of spermatic cord

A
  • vas deferens
  • cremaster muscle
  • genital branch of GF nerve
  • pampiniform plexus
  • testicular artery
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6
Q

Inguinal ligament is an extension of…?

A

external oblique fascia

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7
Q

Median umbilical ligament was…?

A

obliterated urachus (umbilicus to bladder)

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8
Q

Medial umbilical ligaments are…?

A

obliterated umbilical arteries

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9
Q

Round ligament of liver was…?

A

umbilical vein (can recannualize)

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10
Q

Indirect inguinal hernia 2/2 …?

A

congenital patent procesalis vagenalis

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11
Q

Cremasteric muscle formed from…?

A

internal oblique muscle

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12
Q

MC injured in open inguinal hernia repair

A

ilioinguinal

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13
Q

MC injured in laparoscopic inguinal hernia repair

A

lateral femoral cutaneous nerve

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14
Q

Types of inguinal primary open repair

A
  • Bassini

- Sholdice

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15
Q

Types of inguinal mesh open repair

A
  • Lichtenstein

- Plug and patch

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16
Q

Open femoral hernia repair

A

McVay repair (Cooper’s ligament repair) - open inguinal floor

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17
Q

What is Cooper’s ligament?

A

pectineal ligament; posterior to femoral vessels (lies against bone)

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18
Q

Main structure to fix mesh for laparoscopic TEP/TAPP repair

A

Cooper’s ligament

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19
Q

What is separated for component separation?

A

external oblique fascia

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20
Q

Spigelian hernia

A

Spigelian fascia (aponeurotic layer btwn rectus muscle and semilunar line), inferior to arcuate line

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21
Q

Amyand’s hernia

A

Appendix in inguinal hernia

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22
Q

De Garengeot hernia

A

Appendix in femoral hernia

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23
Q

Littre’s hernia

A

Meckel’s diverticula in inguinal hernia

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24
Q

Canal of nuck hernia; mgmt?

A

ovary in inguinal hernia; mgmt: ligate round ligament

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25
Q

Richter’s hernia

A

part of wall of bowel herniated (not entire loop) -> can get strangulation WO obstruction

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26
Q

Obturator hernia; sign?

A

Howship-Romberg sign (medial thigh pain w/ internal rotation of hip)

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27
Q

Sciatic hernia

A

through greater sciatic foramen -> sciatica (high rate strangulation)

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28
Q

Pantaloon hernia

A

dual/saddle hernia of both direct and indirect

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29
Q

Sliding hernia

A

RP organ that forms part of hernia - cannot resect sac

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30
Q

MC organs female vs. male sliding hernia

A

Female: ovaries or fallopian tubes
Male: cecum or sigmoid

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31
Q

Corona mortis

A

aberrant obturator artery - connects obturator (br. of internal iliac) + external iliac or its br. (inferior epigastric)

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32
Q

Attaching mesh to Cooper’s during lap inguinal hernia repair… concern for?

A

Corona mortis

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33
Q

First step mgmt asymptomatic hernia in obese/smoker pt

A

weight loss, tobacco cessation before consideration of hernia repair

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34
Q

Mgmt of pt w/ uncontrolled ascites + leaky umbilical hernia

A

admission bc high risk bacterial peritonitis +/- hernia rupture; bed rest + IV Abx + diuresis + hernia repair this admission

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35
Q

MC hernia in females

A

indirect inguinal hernia

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36
Q

Petit hernia

A

@ inferior lumbar triangle:

  • iliac crest (inferior)
  • external oblique (anterior)
  • lat dorsi (posterior)
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37
Q

Grynfeltt-Lesshalf hernia

A

@ superior lumbar triangle:

  • quadratus lumborum (medial)
  • internal oblique (lateral)
  • 12th rib (superior)
  • transversalis fascia (floor)
  • external oblique (roof)
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38
Q

How much overlap for laparoscopic ventral hernia repair with intraperitoneal mesh?

A

3-5cm

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39
Q

MC artery injured during inguinal herniorrhaphy

A

inferior epigastric artery (from ext iliac artery immediately superior to inguinal ligament)

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40
Q

Properties: polypropylene mesh

A

incorporates into native tissue

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41
Q

Properties: vicryl mesh

A

absorbable, often used in contaminated fields

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42
Q

Properties: PTFE

A

synthetic

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43
Q

Properties: macroporous lightweight

A

higher rate bacterial clearance than microporous heavyweight

44
Q

Properties: biologic

A

acellular collagen matrix; promotes neovascularization and native collagen deposition; can be used in contaminated fields

45
Q

Incarcerated obturator hernia and cannot reduce intra-op… next step?

A

incise obturator membrane to help reduce hernia

46
Q

Cross-linked vs. non biologic mesh

A

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

47
Q

Where is biologic mesh best placed?

A

between 2 layers of vascularized tissue that promotes fibroblast and vessel ingrowth within scaffold

48
Q

Large-pore mesh in relation to recurrence rate?

A

Large-pore = lightweight - better tissue incorporation of mesh, thought to reduce recurrence rate

49
Q

Urinary retention more prevalent in laparoscopic vs. open hernia repairs?

A

laparoscopic

50
Q

Elderly female w/ prior weight loss, no hx abdominal surgery, presenting with abd pian, N/V… think?

A

obturator hernia

51
Q

Surgical approach for mgmt of obturator hernia

A

midline laparotomy

52
Q

Howship-Romberg sign

A

ipsilateral groin pain radiating down thigh 2/2 irritation of obturator nerve (obturator hernia pt)

53
Q

Groin pain from obturator hernia relieved by…? Aggregated by…?

A

Relieved by thigh flexion - aggravated by extension, abduction, and medial rotation

54
Q

Ilioinguinal nerve innervates…

A

sensation to proximal and medial thigh, pubic region (base of penis) and upper portion of the scrotum or labia majora

55
Q

Lateral femoral cutaneous nerve innervates…

A

sensation to lateral portion of anterior thigh

56
Q

Long-term complication of inguinal hernia repair?

A

chronic pain (up to 30%, only 5% debilitating)

57
Q

If doing PD cath, but also have asymptomatic hernia… what to do?

A

PD cath + hernia repair (because with PD, will have high intraabdominal pressure)

58
Q

How soon post-op can you use PD cath? What about if concurrently fixed hernia?

A

only PD cath: 1-2 weeks post-op

PD cath + hernia repair: 4-6 weeks post-op

59
Q

Approach for femoral hernia repairs

A

McVay, open preperitoneal repair, laparoscopic extraperitoneal herniorrhaphy* (lower recurrence than open)

60
Q

Asymptomatic inguinal hernia can be managed by watchful waiting, but are likely to need operation bc… (esp in elderly)

A

progression of symptoms (MC pain; rarely obstruction)

61
Q

Two etiologies and mgmt for pubic inguinal pain syndrome (PIPS)

A

non-hernia-associated inguinal pain

  1. weakness of inguinal floor - mgmt: surgical reinforcement
  2. 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)
62
Q

Genital branch of GF nerve provides sensation to…

A

scrotum

63
Q

Location and path of aberrant right subclavian artery (ARSA)

A

orginates posteriorly, AFTER left subclavian artery, and travels posterior to esophagus to reach right thoracic outlet

64
Q

MC sxs aberrant right subclavian artery in children vs. adult

A

children: respiratory (bc trachea not rigid yet)
adult: dyphagia 2/2 esophageal compression

65
Q

What if suspect inguinal hernia but negative physical exam?

A

dx laparoscopy

66
Q

% recurrence rate of tension-free inguinal hernia w/ mesh (Lichtenstein)

A

4% (lowest recurrence rate compared to other techniques of hernia repair)

67
Q

% recurrence rate of open tissue hernia repair under tension

A

20-30% (high)

68
Q

Borders of femoral hernia

A

anterior: inguinal ligament
posterior: pectineal ligament
medial: lacunar ligament
lateral: femoral vein

69
Q

Femoral hernia pain worse with…?

A

external rotation of hip

70
Q

Have to divide what ligament to fully reduce herniated bowel of femoral hernia?

A

inguinal ligament

71
Q

Where is bulge of femoral hernia?

A

anterior-medial thigh

72
Q

Bulge on valsalva in postpartum female… think? Tx?

A

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)

73
Q

Bulge at groin + pain @ medial rotation and extension of hip joint… think?

A

Obturator hernia

74
Q

Bulge at groin + pain at external rotation of hip… think?

A

Femoral hernia

75
Q

Hannington-Kidd sign

A

Loss of adductor reflex in presence of positive patellar reflex 2/2 obturator nerve compression (by hernia) leading to adductor muscle weakness

76
Q

What approach is recommended for femoral hernias?

A

Inguinal (McVay)

77
Q

What approach is recommended for obturator hernia if have SBO?

A

Laparotomy

78
Q

If femoral hernia is difficult to reduce intra-op, then can do what to increase exposure?

A

Divide inguinal ligament (femoral canal is just posterior)

79
Q

Which type of hernia has highest risk strangulation?

A

Femoral hernia (15-20%)

80
Q

Why is surgical correction necessary for type II, III, and IV hiatal hernias?

A

Risk of volvulus (but remember, in elderly and asymptomatic, greater risk to operate, so will observe these)

81
Q

Which method of repairing parastomal hernia has been proven effective?

A

Repair with mesh

82
Q

When would you do stomal relocation for parastomal hernia?

A

If also have skin excoriation (bc also will have risk of incisional hernia at old stoma site)

83
Q

Borders of femoral hernia

A

Anterior: inguinal ligament (often divided during repair)
Posterior: pectineal ligament
Lateral: femoral vein
Medial: lacunar ligament

84
Q

Borders of obturator hernia

A

Lateral: hip-joint
Medial: pubic arch
Superior: superior pubic ramis
Inferior: adductor magnus

85
Q

Indirect inguinal hernia due to…

A

Patent processus vaginalis

86
Q

Direct inguinal hernia is due to…

A

Weakness of the conjoint tendon (which forms the posterior wall of the inguinal canal)

87
Q

Component separation repairs includes… (what steps?)

A
  • 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
88
Q

Pathophys of development ischemic orchid is as Cx from hernia repair

A

Due to venous congestion from paminiform plexus thrombosis or ligation of testicular artery during repair

89
Q

Unilateral tender, swollen testicle post-hernia repair… think? How to avoid?

A

Ischemic orchitis. Minimize risk by avoiding excessive dissection of spermatic cord.

90
Q

Mgmt ischemic orchitis after hernia repair

A

NSAID + pain control (may last up to 12-weeks)

91
Q

Where is the mesh placed in Rives-Stoppa-Wantz repair?

A

Between rectus muscle and posterior sheath (retrorectus position - sublay)

92
Q

Triple neurectomy includes what nerves?

A
  • genitofemoral
  • iliohypogastric
  • ilioinguinal
93
Q

Inguinal nerve block is done where?

A

1-cm medial to the ASIS, 2-cm up

94
Q

If strangulated hernia, can you fix laparoscopically?

A

NO

95
Q

Absolute C/I laparoscopic hernia repairs

A
  • inability to tolerate insuffulation/pneumoperitoneum (COPD, CHF)
  • active infection
  • strangulated hernia
96
Q

Pt w/ ascites + leaking umbilical hernia… mgmt?

A

Emergent repair (high risk peritonitis and death)

97
Q

Pt with ascites + umbilical hernia (asymptomatic - no skin changes, no leak), mgmt…?

A

Ascites control (diuretics) vs. TIPS for refractory ascites -> followed by elective repair

98
Q

Where should tacks be place laparoscopically for inguinal hernia repair?

A

Superior to inguinal ligament + lateral to inferior epigastric artery

99
Q

Internal inguinal ring formed by…

A

Internal oblique muscle (superficial component) and transversal is fascia (courage of ring)

100
Q

Borders of internal inguinal ring

A

Medial: transversalis fascia + inferior epigastric vessels
Inferior: iliopubic tract
Anterior: transversus abdominis arch

101
Q

External inguinal ring is formed by…?

A

Medial fibers of external oblique aponeurosis divide into medial and lateral crura to form ext. inguinal ring

102
Q

Conjoined tendon is formed by…?

A

Internal oblique + transverse abdominis muscles joining together

103
Q

Petersen hernia, mgmt?

A

Internal hernia that can occur in potential space posterior to a gastroJ.
Mgmt: closure of space between Roux-limb and transverse colon mesenteries

104
Q

When do primary repair vs. mesh repair for umbilical hernia?

A

Primary if <2cm.
Laparoscopic mesh preferred (associated with lower risk recurrence, decreased recovery time, pain, and wound infection compared to open).

105
Q

% recurrence rate of Lichtenstein repair

A

1.2-4%

106
Q

Choice operation for recurrent inguinal hernia (failed open with mesh)

A

Endoscopic (TEP) - less postop pain, faster healing time, less chronic pain than open Lichtenstein

QUESTION NOTES (28 decks)

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