Hernias Flashcards
What is the floor of the inguinal canal that prevents all hernias there?
Transversalis fascia
What on bloody hell is the iliopubic tract?
It’s the backside of the inguinal ligament.
Exactly the same. It’s just that they HAD TO name is something freaking different just because you’re looking at it from the inside
Borders of the hasselbach triangle?
Medially: rectus muscle
Superiorly: epigastric vessels
Inferiorly: inguinal ligament/iliopubic tract
What is conjoined in the conjoined tendon?
Fusion of the transversis abdominis and the internal oblique
Inguinal canal as a long box with six sides.
What/where are the internal ring vs external ring?
Superior wall
Inferior wall
Floor (posterior wall)
Roof (anterior wall)
External ring is towards to scrotum. Internal ring is the opening of the processus vaginalis
Superior wall: conjoined tendon
Roof (Anterior wall): external oblique aponeurosis
Floor (posterior wall): transversalis fascia
Inferior wall: inguinal ligament/lacunar ligament (provides the shelving edge)
Describe the bassini repair. What are the 3 layes you incorporate into the repair?
You have to incise the transversalis fascia. Then you incorporate:
1) Conjoined tendon superiorly
2) Transversalis fascia and 3) inguinal ligament inferiorly
Describe the McVay repair
Make the relaxing incision on top of the rectus medially.
Then suture the conjoined tendon (transversus abdominis aponeurosis) superiorly to the Cooper’s ligament (posterior aspect of the superior ramus of pubic symphysis) medially
Lateral to the femoral canal you suture the conjoined tendon to the inguinal ligament
During a laparoscopic inguinal hernia repair, placing tacks in the triangle bordered by bad deferens and spermatic vessels will result in what?
Bleeding. Triangle of doom.
Do not place tacks below the inguinal ligament during lap repair.
Spermatic vessels come from lateral to medial horizontally.
Bad deferens comes from below to up
Femoral vessels lie between these two
Where is the triangle of pain?
Below the inguinal ligament, lateral to the spermatic vessels
Repair of choice for uncomplicated femoral hernia?
Open preperitoneal mesh repair
Hat is the recurrence rate for incisional hernia repair without mesh?
Up to 50%
With mesh: 1-9%
Describe the component separation
Divide the external oblique just beyond the semilunar line
Allows for the sliding of the fascia towards the midline
3 months after a lap inguinal, pt has persistent groin pain exacerbated by physical activity. what to do next and why?
MRI first to rule out non-neuropathic pain such as hernia recurrence or meshomas.
if (+) neuropathic pain, then rx is percutaneous nerve ablation. inguinal nerve block is diagnostic but also only temporary
Inguinal hernia. What are the borders of the mesh placement to minimize recurrence and pain?
Use a large mesh (7x15cm), to extend 3-4cm above hasselbach triangle, 2cm medial to the public tubercle and 5-6cm lateral to the internal ring
Which part of component separation is a major source of mortality and morbidity?
Creation of large lipocutaneous flap. Wound issues
When you do a McVay, what do you cut for the relaxing incision?
External oblique aponeurosis and the anterior rectus sheath
How do you obtain access to the femoral space from the anterior approach?
By opening the posterior inguinal wall
Rate of strangulation for asymptomatic reducible femoral hernia?
For emergency surgery, rate of bowel resection and mortality for femoral hernia?
Up to 45%
25% bowel resection
10% mortality
What’s in the medial and lateral umbilical folds?
Medial: umbilical artery remnant
Lateral: epigastric vessels
In the pediatric population, umbilical hernia over what cm has relatively low chance of closing on its own?
Over 1.5cm
For recurrent hernia, between laparoscopic and open:
- recurrence rate
- PT’s return to normal activities
- operative time
- complication rate
- post-op pain
- no difference in recurrence rate
- open has slower return to normal activities
- laparoscopic may take longer
- no difference in complication rate
- open has more pain
Where is the spigelian hernia?
Lateral edge of the rectus sheath and the semilunar line at the level of the arcuate line
In general who has higher recurrence after ventral hernia repair males or females?
Males
Does umbilical hernias have a sex preference?
Females (3) > males (1)
Recurrence rate of umbilical hernia suture repair
5-10%
What are the two possible sites for lumbar hernias? What are their boundaries?
Which one is more common?
Superior lumbar triangle (Grynfeltt-Lesshaft): lateral edge of quadratus lumborum, costal margin, posterior edge of internal oblique
Inferior lumbar triangle (Petit): lateral edge of lat dorsi, posterior edge of the external oblique, superior to iliac crest
Superior is more common
What is a Gilbert repair and how is the recurrence rate compared to Lichtenstein?
It’s a plug and patch repair
Similar outcomes and recurrence rate as Lichtenstein (onlay)
What is a stoppa-reves repair?
Involves infraunbilical midline incision to put an inguinal mesh preperitoneally
Recommended method of midline closure according STITCH trial
What suture?
How far from the edge?
How far apart?
2-0 PDS 5mm apart, 5mm from edge
Most common nerve injured during lap inguinal hernia repair?
They don’t give you lateral femoral cutaneous as an option
Genitofemoral
What is a cross-linked mesh? is it better?
attribute used to describe BIOLOGIC meshes. Cross-linking appears to increase durability, tensile strength, and resistance to bacterial contamination. There is no evidence, though, that cross-linking or non–cross-linking is superior to the other.
SESAP
60yo BMI40 COPD Diabetic smoker comes to you for a repair of ventral hernia that’s 50 x 25cm. what’s the highest risk factor for recurrence?
2 highest risk factors: hernia width + infection/contamination
COPD, BMI, smoking are all less of risk factors compared to those 2
sesap
T/F: asymptomatic type III paraesophageal hernias can be watched
true. mortality from emergency surgery for these is only ~5% and mortality risk for elective surgery ~1.5%. the need for emergency surgery is also only about ~1.5%
SESAP
for paraesophageal hernia repair, compare thoracic vs laparoscopic approaches:
- length of stay
- risk of PE
- need for mechanical ventilation
- thoracic had longer length of stay, higher PE, higher need for mech ventilation
SESAP
watchful waiting for hernias:
false. repair will be needed in 65-75% of the patients
true. you can’t do watch and wait for females. urgent hernia repair needed in almost 20% of females
false. rate of acute incarceration is actually low. 2%
