Hernias Flashcards
Where is a femoral hernia
Medial to femoral vessels, under the inguinal ligament
What does TEPA procedure stand for
Totally ExtraPeritoneal Approach
To what does the inguinal ligament attach?
ASIS to the pubic tubercle
What are the borders of hesselbach’s triangle
Epigastric vessels
Inguinal ligament
Lateral border of the rectus
What is the most common organ in an inguinal hernia sac in women
Ovary/fallopian tube
Risk of strangulation in groin hernias from most likely to least
Femoral
Indirect
Direct
Medial border of femoral canal
Lacunar ligament
What lies in the inguinal canal in females instead of the VAS?
Round ligament
What does TAPP procedure stand for
TransAbdominal PrePeritoneal inguinal hernia repair
What is the difference between complete and incomplete hernia
Incompete = defect present without sac or contents protruding completely through it
Complete = hernia sac and its contents protrude all the way through the defect
A hernia is a protrusion of a _______ through a ______
Peritoneal sac
Musculoaponuerotic barrier
What is an umbilical hernia
Hernia through the umbilical RING
What is an umbilical hernia associated with in adults
Ascites, pregnancy, and obesity
Which is more dangerous: a small or large hernia defect
Small
Tight defect = more likely to strangulate if incarcerated
Most common hernia in women
Indirect
What is the repair of a femoral hernia?
McVay, mesh plug repair
Risk factors associated with femoral hernia
Women
Preggos
Exertion
Where is a hiatal hernia
Hernia through esophageal hiatus
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
Name the layers of the abdominal wall from superficial to deep
Skin ➡️ subcuntaneous fat ➡️ Scarpa’s fascia ➡️ External oblique ➡️ Internal oblique ➡️ Transversus abdominus ➡️ Transversalis fascia ➡️ Preperitoneal fat ➡️ Peritoneum
What is a ventral hernia
Primary hernias with no associated prior incision and are located anywhere along the midline above or below the umbilicus
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 the most common cause of incisional hernia
Wound infection
What is Peterson’s hernia
Seen after bariatric gastric bypass-internal herniation of small bowel through the mesenteric defect from the Roux limb
What is a “cord lipoma”
Preperitoneal fat on the cord structures (pushed in by the hernia sac); not a real lipoma
What is an obturator hernia
Hernia through obturator canal
Where in the inguinal canal does the hernia sac lie in relation to the other structures?
Anteromedially
What nerve runs with the spermatic cord in the inguinal canal?
Ilioinguinal nerve
What is a conjoint tendon?
Aponeurotic attachments of the “conjoining” of the internal oblique and transversus abdominis to the pubic tubercle
What is a pantaloon hernia
Hernia sac exists as both a direct and indirect hernia straddling the inferior epigastric vessels and prodtruding through the floor of the canal as well as the internal ring
(Two sacs separated by the inferior epigastric artery)
What is the first identifiable subcutaneous named layer?
Scarpa’s fascia
Describe McVay procedure
Cooper’s ligament sutured to transversus abdominis aponeurosis
Posterior border of femoral canal
Cooper’s ligament
What is a small outpouching of testicular tissue off the testicle?
Testicular appendage
How tight should the nre internal inguinal ring be?
Should allow entrance of the tip of a kelly clamp but not a finger
What are the indications for laparoscopic inguinal hernia repair
- Bilateral inguinal hernias
- Recurring hernia
- Need to resume full activity as soon as possible
Why do we repair hernias
To avoid complications of incarceration/strangulation, bowel necrosis, SBO, pain
What is an internal hernia
Hernia in or involving intra-abdominal structure
From what abdominal muscle layer is the inguinal ligament derived?
External oblique muscle aponeurosis
What is a “relaxing incision”
Incisions in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal liagment without tension
Symptoms that the hernia is strangulated
Intractable nausea/vomiting Severe pain Tachycardia Fever Focal peritonitis Leukocytosis Acidosis Obstruction on imaging
What nerve travels within the spermatic cord
Genital branch of the genitofemoral nerve
What is the differential diagnosis of an inguinal hernia?
Lymphadenopathy
Psoas abscess
Ectopic testis
Hydrocele of the cord
Saphenous varix
Lipoma
Baricocele
Testicular torsion
Femoral artery aneurysm
Abscess
How often do femoral hernias incarcerate?
1/3
What is Littre’s hernia
Hernia involving a Meckel’s diverticulum
What is a sliding hernia
Hernia sac partially formed by the wall of a viscus (bladder, cecum)
Describe the Lichtenstein procedure
“Tension-free repair” using mesh
Lateral border of femoral canal
Femoral vein
Most common hernia in men
Indirect inguinal
What is an epigastric hernia (location specifically)
Hernia through the linea alba above the umbilicus
Why do some surgeons deliverately cut the ilioinguinal nerve?
To remove the risk of entrapment and postoperative pain
What are the boundaries of Hasselbach’s triangle
Inferior epigastric vessels
Inguinal ligament (Poupart’s)
Lateral border of the rectus sheath
Floor consists of internal oblique and the transversus abdominis muscle
What attaches the testicle to the scrotum
Gubernaculum
What happens if you cut the ilioinguinal nerve
Numbness of inner thigh or lateral scrotum, usually goes away in 6 months
What percentage of patients with a femoral hernia are female?
85%
Which nerve travels on the spermatic cord
Ilioinguinal nerve
Non-reducible hernia =
Incarcerated
What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?
Remove the suture ASAP and apply pressure
What is a femoral hernia
Hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels
What is the name of the surgery for hernia repair
Herniorrhaphy
Incarcerated hernia with resulting ischemia =
Strangulated
Describe High ligation
Ligation and transection of indirect hernia sacwithout repair of inguinal floor (used only in children)
Describe the Bassini procedure
Sutures approximate reflection of inguinal ligament to the transversus abdominis aponeurosis
Where is a direct hernia
Inguinal hernia within Hasselbach’s triangle
What is the hernia sac made of
Peritoneum (direct)
Patent processus vaginalis (indirect)
What is the name of the subcutaneous vein that is ligated?
Superficial epigastric vein
What is a spigelian hernia
Hernia through the linea semilunaris
Also known as spontaneous lateral ventral hernia
Describe “plug and patch” procedure
Placing a plug of mesh in hernia defect and then overlaying a patch of mesh over inguinal floor
Anterior border of femoral canal
Inguinal liagment
What is the nerve found on top of the spermatic cord
Ilioinguinal nerve
What is a hernia adjacent to an -ostomy called?
Parastromal hernia
What are the boundaries of the femoral canal?
- Cooper’s ligament - posterior
- Inguinal ligament - anterior
- Femoral vein - lateral
- Lacunar ligament - medial
What is a ventral hernia
Incisional hernia in the ventral abdominal wall
Where is an indirect hernia
Inguinal hernia lateral to hasselbach’s triangle
From what abdominal muscle layer is the cremaster muscle derived?
Internal oblique muscle
Precipitating factors for hernia
Increased intra-abdominal pressure:
Straining at defecation/urination, obesity, pregnancy, ascites, valsavagenic COPD, abnormal congenital anatomic route
What is reducing a hernia “en masse”
Reducing the hernia contents and hernia sac
What is the most common organ in an inguinal hernia sac in men
Small intenstin
