Hernias Flashcards
Approx. 75% of abdominal wall hernias occur where?
groin
Lifetime risk of inguinal hernias in men vs women?
men 27% women 3%
Most common subtype of groin hernia in men and women?
indirect inguinal hernia
Most common hernia in women?
indirect inguinal hernia
70% of femoral hernia repairs reported in women, however inguinal hernias are;
5x more common
The incidence of inguinal hernias has a bimodal age distribution;
before 1st year of age >40
The deep internal inguinal ring is a defect in what?
tranversalis fascia
The superficial external inguinal ring is a defect in what?
external oblique aponeurosis
This is the point at which the spermatic cord crosses the external oblique aponeuoosis;
superficial external inguinal ring
What are the boundaries of the inguinal canal?
A–> EO aponeurosis P–> tranversalis fascia, TO S–> IO I–> Inguinal (Poupart’s) ligament
Contents of the spermatic cord?
vas deferens testicular A ductus deferens A cremasteric A pampiniform plexus genital branch of genitofemoral N PSNS/SNS nerves lymphatics
What is the lacunar ligament?
triangular fanning of inguinal ligament as it joins pubic tubercle
What is Cooper’s (pectineal) ligament?
lateral portion of lacunar ligament that’s fused to periosteum of pubic tubercle
What two muscles make up the conjoint tendon?
IO + TA aponeurosis (they insert on pubic tubercle)
What’s an indirect hernia?
protrusion lateral to inferior epigastric vessels through deep inguinal ring
What’s a direct inguinal hernia?
protrude medial to inferior epigastric vessels within Hasselbach’s triangle
What are borders of Hasselbachs triangle?
inguinal ligament inferiorly
lateral edges of rectus sheath medially
inferior epigastric vessels superolaterally
Femoral hernias protrude thru the femoral ring, what are the borders?
iliopubic tract and inguinal ligament anteriorly
Cooper’s ligament posteriorly
lacunar ligament medially
femoral vein laterally
This classifies hernias based on location, size and type:
Nyhus classification
Inferior epigastric artery supplies what m?
rectus abdominus
Inferior epigastrics are derived from?
external iliac artery
Inferior epigastric vessels anastomose with what?
superior epigastric vessels which come off the internal mammary A
What 4 nerves are of interest during hernia repairs?
ilioinguinal N
iliohypogastric N
lateral femoral cutaneous N
genitofemoral N
What’s the course of the ilioinguinal nerve?
comes out medial to ASIS
enters inguinal canal
exits thru superifical inguinal ring
What does ilioinguinal nerve supply?
skin of upper/medial thigh
base of penis & upper scrotum
What does ilioinguinal nerve innervate in females?
mons pubis
labia majus
Course of iliohypogastric N?
comes off of T12-L1
course between IO and TA (supplies both)
This nerve arises from L1-L2, courses along the retroperitoneum and then pierces the psoas:
genitofemoral
Genital branch of genitofemoral nerve supplies what?
ipsilateral scrotum and cremaster M
Femoral branch of genitofemoral N supplies what?
skin of upper anterior thigh
Genital branch of genitofemoral N supplies what in females?
mons pubis
labia majus
This N passes inferior to inguinal ligament where it divides to supply the lateral thigh:
lateral femoral cutaneous N
What is the triangle of doom?
space seen in laparoscopic hernia repair
bordered medially by vas
bordered laterally by vessels of spermatic cord
What do we worry about with the triangle of doom?
external iliac vessels
deep circumflex iliac vein
femoral N
genital branch of genitofemoral N
What nerves do we find in the triangle of pain?
lateral femoral cutaneous
femoral branch of genitofemoral
femoral
Best characterized risk factor for development of inguinal hernias is?
weakness in abdominal wall muscles
Inguinal hernias can be congenital or acquires, most adults hernias are acquired, while in this population they tend to be congenital:
pediatric
Why do pre-term babies have a high incidence of congenital inguinal hernias?
failure of processus vaginalis to close
Does genetics play a role in development of inguinal hernias?
positive family hx associated with 8-fold lifetime incidence of inguinal hernias
How does COPD increase risk of direct inguinal hernias?
repeated episodes of increased intra-abdominal pressures
What role does collagen play in inguinal hernia development?
pts tend to have decreased ratios of type I to type III collagen
(type III collagen does not contribute to wound tensile strength as well as type I)
With a pt with suspected hernia, if they have change in bowel or bladder habits, what type of hernia do we suspect?
sliding hernia with a bowel or bladder component
On physical exam how do we examine pts for hernias?
ideally standing position
groin and scrotum exposed
Where do we palpate for femoral hernias?
below inguinal ligament
lateral to pubic tubercle
What’s a femoral pseudohernia?
if a thin pt has a prominent fat pad
erroneously think it’s a femoral hernia
Surgical treatment is definitive treatment for inguinal hernias, but what about asymptomatic hernia pts?
a non operative approach is safe for minimally symptomatic inguinal hernia pts
does not increase risk of developing hernia complications
complication rates between immediate and delayed tension free repairs ae the same
For femoral and symptomatic inguinal hernias, there is a higher complication risk, thus;
surgical repair performed earlier for these pts
Antibiotics before elective open surgical inguinal hernia repair?
no universal guidelines established for or against
however, routinely given peri-operatively
What do we term a hernia sac that fails to reduce?
incarceration
With respect to hernias, when we have compromise of intestinal contents, we are worried about;
strangulation
surgical emergency
Clinical signs of strangulation of hernia include what?
fever
leukocytosis
hemodynamic instability
(bulge is warm/tender with erythema or discoloration)
In open inguinal hernia repairs, when do we opt for tensions free tissue repairs vs prosthetic material ?
when there is contamination or strangulation
When do we use local anesthesia for an open inguinal hernia repair?
as a loco-regional ilio-inguinal nerve block
What’s your incision for an open approach?
2 figerbreadths infero-medial to ASIS
extended 6-8 cm medially
As we dissect the skin and subcutaneous tissue in an open inguinal hernia repair, what layer do we dissect before seeing the external oblique?
scarpa’s fascia
Describe steps of an open inguinal hernia approach:
incision made infero medially to ASIS, extended medially
dissection begins on skin, down to subQ fat, thru camper’s, scarpa’s to expose external oblique apo
incision made on external oblique apo
scissors used to excise the aponeurosis, opening the external ring
flaps of external oblique elevated
internal oblique fibers bluntly dissected off EO
shelving edge of inguinal ligament seen after dissecting inferior flap
iliohypogastric and ilioinguinal nerves identified
pubic tubercle identified, cord structures elevated with a penrose
For an indirect hernia, where do we usually find the hernia in relation to the spermatic cord?
anterolateral
How do we identify the hernia sac during an open repair?
at the leading edge of the sac, the two layers of peritoenum will fold upon themselves, and reveal a white edge
During open hernia repair, injury to what cord structure can result in testicular atrophy and ischemia?
pampiniphom venous plexus
Where do we find the genital branch of the genitofemoral nerve in the cord structures?
on the infero-lateral surface of the cord
Most common synthetic prosthesis used in hernia repairs?
polypropolene & polyester
Describe polypropolene and polyester meshes;
permanent & hydrophobic
promote local inflammatory response
cell infiltration and scarring
contraction in size
Difference in using lightweight mesh vs heavy weight mesh in hernia repair?
less pain with lightweight mesh
When do we use biologic meshes?
contaminated cases
high infection risk
Xenograft vs allograft biological mesh material for hernia repairs?
xenografts assc. with lower recurrence rate
The most common complications of inguinal hernia repairs?
bleeding
seroma
wound infection
urinary retention
ileus
injury to nearby structures
Common medical issues associated with hernia recurrence?
malnutrition
immunosuppression
DM
steroid use
smoking
What are some technical causes of hernia recurrence?
improper mesh size
tissue infection
ischemia
tension in the reconstruction
When a hernia recurrence has occured, and needs re-operation, how do we proceed?
through a virgin plane
after an initial anterior approach, a posterior lap approach may be more suitable and vice versa
What are the three different types of pain commonly seen after hernia repair?
somatic (nociceptive)*
neuropathic
visceral
How do we treat somatic post-hernia pain?
usually a result of anatomic trauma and inflammation
reproduced with abd. muscle contraction
Tx–> rest, NSAIDs, reassurance
resolves spontaneously in most cases
What causes neuropathic post-op hernia pain?
direct nerve damage or entrapment
Describe visceral post-op hernia pain;
pain via afferent autonomic fibers
poorly localized
can occur after ejaculation (due to SNS plexus injury)
How do we treat chronic inguinoydnia refractory to medical therapy?
triple neuro-ectomy of ilioinguinal, iliohypogastric, genitofermoral nerves
What two nerves are at greatest risk of injury durion open anterior repairs?
ilioinguinal
iliohypogastric
What two nerves are at greatest risk of injury in the posterior laparoscopic approach?
lateral femoral cutaneous
genitoferomal
What’s meralgia paresthetica?
entrapment of lateral femoral cutaneous nerve
paresthesias of lateral thigh
What is osteitis pubis?
inflammation of pubic symphysis
pubc symphysis pain with thigh adduction
avoid the pubic periosteum when tacking mesh
How long does it take for osteitis pubis to resolve regardless of treatment?
at least 6 months
Ischemic orchitis usually caused by injury to what cord structure?
pampiniform venous plexus
When do we see ischemic orchitis in hernia repairs?
damage to pampiniform plexus
within 1 week of repair (enlarged, indurated, painful testes)
Risk of ischemic orchitis with primary hernia repairs?
<1 %
In ischemic orchitis, US is used to demonstrate testicular blood flow, when do we perform orchiectomy?
incase of necrosis
Tx for ischemic orchitis?
reassurance
NSAIDs
comfort measures
Analog of the spermatic cord in females?
round ligament of uterus
Does injury to artery of round ligament in females during hernia repair cause any problems?
no
Most common cause of urinary retention after hernia repair is?
general anesthesia
This type of hernia repair is associated with higher rates of ileus:
laparoscopic
What organs are at risk of injury during laparoscopic hernia repairs?
small bowel
colon
bladder
If a bladder injury is made during hernia repair how is it addressed?
cystostomy is repaired in several layers
Foley for 1-2 weeks
cystogram before Foley removed
Severe vascular injuries during hernia repair occur due to damage of what vessels?
iliac or femoral vessels
(either by sutures in anterior approach or trocar and direct dissection in laparoscopic approach)
Most common injured vessels in laparoscopic approach include?
inferior epigastrics
external iliacs
If the inferior epigastrics are injured during hernia repair what do we do?
can be ligated
During vascular hernia repair injuries, why is bleeding not apparent until pneumoperitoneum released?
if the tissue pressure exerted by pneumoperitoneum is greater than the injured vessel’s hydrostatic intraluminal pressure, wont’ be apparent until pneumoperitoneum is released
Why is the presentation of an inferior epigastric vein injury often delayed?
pneumoperitoneum needs to be released
it usually exerts a greater pressure on vessel hydrostatic pressure
Injury to the inferior epigastric vein can result in what?
a rectus sheath hematoma
What is a seroma?
loculated fluid collection
commonly seen within 1 week of synthetic repairs
How do we treat seromas?
reassurance and warm compresses
To avoid secondary infection of seromas, we?
avoid aspirating them unless they cause discomfort or restrict activity
Most common tissue repair hernia technique performed?
shouldice
Recurrence rate of shouldice repair is?
1% in experienced hands
Compared to open tissue based repairs, mesh repair is associated with what?
lower recurrence rate
shorter hospital stay
Abdominal wall hernais commonly occur at sites where?
the aponeurosis and fascia are not covered by striated muscle
Common hernia sites include? (sites where the aponeurosis and fascia are not covered by fascia)
inguinal, femoral, umbilical areas, linea alba, semi-lunar lines, sites of prior incisions
What’s a reducible hernia?
contents can be replaced within surrounding musculature
When a hernia cannot be reduced, it’s?
incarcerated
This type of hernia has a compromised blood supply to its contents;
strangulated hernia
With this type of hernia, part of bowel wall becomes trapped, usually anti-mesenteric side of small bowel, with intact intestinal lumen;
Richter’s
Can you have strangulation of hernia contents without obstruction?
yes, in a richter’s hernia
small bowel wall trapped in defect, usually anti-mesenteric side, with patent small bowel lumen
Internal vs external hernia?
ex–> protrusion through all layers of abdominal wall
in–> protrustion through a defect in the peritoneal cavity
Inguinal hernias classified as direct vs indirect, what’s the path of an indirect inguinal hernia?
sac passes from internal ring to external ring to the scrotum
Whats the path of a direct inguinal hernia?
protrudes outward and forward
medial to internal ring and inferior epigastrics
What’s a pantaloon hernia?
hernia with both direct and indirect components
75% of hernias occur in inguinal region, and 2/3 are?
indirect
Femoral hernias make up what % of all groin hernias?
3%
Regardless of gender, what’s the most common type of hernia?
indirect inguinal hernia
Indirect inguinal and femoral hernias most commonly occur on what side?
right side
due to slower descent of right testicle and delayed closure of processus vaginalis during development
Why are femoral hernias more common on the right side?
due to tamponading effect of sigmoid colon on left femoral canal
Most common serious complication of hernias?
strangulation
happens in 1-3% of hernias
Why is it recommended that all femoral hernias be repaired at time of discovery?
have highest rates of strangulation at 15-20%
Most superficial of lateral abdominal wall muscles?
external oblique
oriented inferiorally & medially
The inguinal ligament (Poupart’s) is the inferior aspect of what?
external oblique aponeurosis
What is the lacunar ligament?
medial fanning of inguinal ligament (Pouparts) which inserts into pubis
Spermatic cord exits through the external inguinal ring which is an opening in what?
external oblique aponeurosis
Middle layer of abdominal wall encases what muscle?
internal oblique m
This muscle is the superior border of inguinal canal;
internal oblique m
What makes up the conjoint tendor?
internal oblique muscle fibers + tranverse abdominis aponeurosis
Conjoint tendon is present in what % of pts?
5-10 %
The internal oblique muscle gives rise to what testicular structure?
cremasteric fibers
What’s the pectineal (Coopers) ligament?
formed by the periosteum and aponeurotic tissues along superior pubic ramus
Why is cooper’s ligament an important landmark?
important achoring structure
What does the inguinal canal contain in men vs women:
m–>spermatic cord
w–> round ligament of uterus
What are the four borders of the inguinal canal?
anteriorly–> external o. aponeurosis
posteriorly–> tranverse abdominis m./tranversalis fascia
roof–> internal o. m. & tranversus abd. m
floor–> inguinal ligament & lacunar
Borders of Hasselbach’s triangle?
medial border–> rectus sheath
supero-lateral border–> inferior epigastrics
inferior border–> inguinal ligament
What type of hernia’s occur within Hasselbach’s triangle?
DIRECT
(indirect occur lateral to it)
The ilioinguinal nerves lies where in the spermatic cord?
anterior
Genital branch of genitofemoral nerve innervates what muscle?
cremaster m
lateral side of scrotum and labia
The genitofemoral nerve divides into the two branches where?
anterior surface of psoas
Inferior epigastric artery and vein are branches off what?
external iliacs
The inferior epigastric vessels course medial to what?
internal inguinal ring
Borders of femoral canal?
medially–> lacunar ligament
laterally–> femoral vein
anteriorly–> inguinal ligament
posteriorly–> pectineal ligament
Femoral hernias tend to occur medial to what vessels?
femoral vessels
What are the technical aspects of an open inguinal hernia repair?
curvilinear incision made slightly above inguinal ligament halfway between ASIS & pubic tubercle
carry dissection thru subQ tissues and scarpa’s
external oblique fascia identified
external oblique fascia incised at superficial inguinal ring
nerves identified
spermatic cord mobilized at pubic tubercle
cremasteric fibers separated from cord
hernia sac dissected off cord structures and dissected at level of internal inguinal ring
sac opened and examined if large
In an indrect hernia, the hernia sac is found where?
anterior superior to cord structure
What is a sliding hernia?
hernia containing piece of organ, usually colon or bladder
When do we do a tissue repair for henria repairs?
in strangulated hernias where bowel resection is necessary and mesh prostheses are contraindicated
What are the different types of henria tissue repairs?
McVay
Shouldice
Bassini
Shouldice repair?
multilayer imbricated repair of posterior wall of inguinal canal with running suture
This tissue based repair reconstructs the posterior wall of inguinal canal by superimposing running suture lines progressing from more deep to superficial;
Shouldice repair
Shouldice repair?
reconstructing posterior wall in multiple layers, deep to superficial, continuous running sutures
tranversus abdominis aponeurotic arch secured to iliopubic tract
IO and TA muscles sutured to inguinal ligament
What is a Bassini repair?
suturing tranverse abdominus and internal oblique or conjoint tendon to the inguinal ligament
With this tissue based repair, a relaxing incision usually needed;
McVay
McVay repair is particularly suited for what type of repair?
strangulated femoral hernias
Lichtenstein repair?
tension-free hernia repair using mesh
In Lichtenstein’s repair, where do you suture the mesh?
monofilament, non-absorbable suture used to secure mesh at pubic tubercle
medially–> aponeurotic pubic bone tissue
superiorly–> tranverse abdominus or conjoint tendon
inferiorly–>iliopubic tract or shelving edge of inguinal ligament
the tails created by suture slit are sutured together around spermatic cord forming new internal ring
Gilbert’s repair?
adapting principles of tension free repair + cone shaped plug of polyprop mesh
Difference between TEP and TAPP?
sequence of gaining access to the preperitoneal space
TEP–> dissection begins in preperitoneal space using baloon dissector
TAPP–>preperitoneal space is accessed after initially entering the preperitoneal cavity
Contraindications for laparoscopic hernia repair?
no absolute contraindications except pts inability to tolerate general anesthesia
How do you perform a TEP?
infraumbilical incision made
anterior rectus sheath incised, space created beneath rectus
dissecting balloon inserted posterior to rectus, advanced to pubic symphysis, then inflated
space insufflated and additional trocars placed
How to do a TAPP?
infraumbilical incision is made to gain access to peritoneal cavity directly
2- 5 mm ports placed lateral to inferior epigastrics at level of umbilicus
peritoneal flap created on anterior abdominal wall, extending from median umbilical wall to ASIS
Borders of femoral canal?
ilipubic tract superior
cooper’s ligament inferiorly
femoral vein laterally
lacunar ligament medially
Recurrence of femoral hernia after repair?
2%
(recurrent femoral hernias have a recurrence of 10%)
What’s a sliding hernia?
when an internal organ comprises a portion of the wall of hernia sac
Most common organs involved in sliding hernia?
colon vs bladder
Risk of surgical site infection after open inguinal hernia repair?
1-2%
Linea alba is stretched resulting in bulging at medial edges of rectus muscles;
rectus diastasis
Whats the arcuate line?
3-6 cm below umbilicus
point at which posterior rectus sheath is absent
What happens above vs below the arcuate line?
above arcuate line; external oblique, internal oblique and tranversus abdominus all contribute to anterior and posterior rectus sheath equally
below arcuate line; aponeurosis of external, internal, tranversus abdominus muscles all pass anterior to rectus muscle, posterior rectus fused to tranversalis fascia only
Superior and inferior epigastrics anastomose where?
near umbilicus
In lateral abdominal wall anatomy, the neurovascular bundle is found between what muscle layers?
between tranverse abdominis and internal oblique
More than 50% of obturator hernias present with what?
small bowel obstruction
Whats the treatment for a pt who presents with obturator hernia and small bowel obstruction?
urgen surgery (lap vs open) given high risk of ischemia
This is the only open non-mesh repair that be used for repair of either inguinal or femoral hernias:
McVay
For laparoscopic hernia repairs with intraperitoneal placement of mesh, how much do we have mesh overlap?
3-5 cm overlap between fascia and abdominal wall
What types of meshes can be used in contaminated fields?
vicyrl mesh–> absorbable, thus no prosthetic material long-term
biologic mesh–> acellular collagen matrix that promotes neovascularization and collagen deposition
Difference between polypropolene mesh and PTFE?
polypropolene mesh—> incorporated into native tissue
PTFE–> does not incorporate into tissues
In women of childbearing age, who are pregnant, who need a hernia repair, what do we do?
usually wait post-partum
most will not need any surgical intervention
do not use mesh in women of child-bearing age because the mesh cannot stretch to accomodate gravid uterus
Course of genitofemoral nerve?
starts from lumbar plexus
pierces psoas then divides into genital/femoral branches
genital branch exits via deep inguinal ring with spermatic cord
Where do Spigelian hernias occur?
between rectus abdominus medially and semilunar line laterally thru traversus abominus aponeurosis
What’s the Howship-Romberg sing?
adduction and medial rotation of the thigh which helps identify an obturator hernia
What’s the optimal way to repair a parastomal hernia?
covert the parastomal hernia to an incisional hernia by reversing ostomy
Primary repair of incisional hernias can be performed when the defect is how big?
less than 2-3 cm
defects >2-3 cm require mesh (b/c of high recurrence rate if done primarily)
This type of mesh is hydrophobic and macroporous and allows for ingrowth of native fibroblasts and incorporation into surround fascia;
polypropolene mesh
WHy do we not place polypropolene meshes intraperitoneal directly apposed to the bowel?
high rates of enterocutaneous fistulae formation
This is a hydrophobic, heavyweight, macroporous mesh;
polyester mesh
What is PTFE mesh?
single sheet mesh
visceral side is microporous
abdominal wall side is macroporous (promotes tissue growth)
impermeable to fluids
some tissue ingrowth seen
PTFE is not incorporated into native tisues
when infected, PTFE needs to be removed
What’s a composite mesh?
combines polypropolene + PTFE
PTFE serves as a protective barrier against bowel
polypropolene faces superficially and gets incorporated into fascial tissue
What are biologic meshes?
acellular collagen matrices
provide a matrix for neovascularization and native collagen deposition
advantageous in infected/contaminated cases
What is the onlay mesh repair technique for ventral hernia repairs?
primary closure of fascial defect
mesh placed over anterior rectus fascia
advntage; mesh placed outside abd cavity, no interaction with abdominal viscera
disadvantage; have to dissec thru subQ, seroma formation, superficial location of mesh if you get insional infection
What is an interposition synthetic repair or inlay mesh?
mesh secured to fascial edges without overlap
has high rates of recurrence, due to mesh pulling away from fascial edges bc of increased intra-abdominal pressure
Where do most Spigelian hernias occur?
lateral rectus and semilunar line
at or below arcuate line (absence of a posterior rectus fascia contributes to this weakness)
Pain in antero-medial thigh relieved by thigh flexion?
howship romberg sign–> obturator hernia
Almost 50% of pts with that type of hernia present with partial or complete SBO?
obturator
What’s Grynfeldt lumbar hernia?
protrusion thru superior lumbar trinagle;
12th rib, paraspinal muscles, IO muscle
What’s Petit’s triangle?
inferior lumbar triangle;
iliac crest
lattissimus dorsi
EO muscle
How do we repair lumbar hernias?
usually with mesh
bony landmarks make it difficult to repair primarily with sutures
