Hernias, abdomen and surgical technology

Question 1

Abdominal wall anatomy
1) Inguinal canal: what forms the
a- floor
b- anterior wall
c- posterior wall 
d- roof
2) what forms the cremasteric muscles
3) what is the lacunar ligament
4) what is Cooper's ligament
5) where does the Vas deferens run
6) structures in inguinal canal

Answer 1

1) a- inguinal ligament
b- aponeurosis of external oblique muscle
c- transversalis fascia/muscle and conjoined tendon (aponeurosis of internal oblique and transversalis)
d-external oblique, transversalis fascia
2) internal oblique muscle
3) where inguinal ligament splays out to insert in the pubis
4) pectineal ligament, posterior to femoral vessels, lies against bone
5) medial to cord structures
6) spermatic cord (men) vs round ligament (women), genitofemoral and ileoinguinal nerve

Question 2

1) borders of Hesselbach’s triangle and what hernias are within it?
2) location of direct vs. indirect inguinal hernias
3) MC hernia and embryologic cause
4) which hernias have a lower risk of incarceration but a higher recurrence risk: direct or indirect
5) What is a pantaloon hernia

Answer 2

1) rectus muscle is media, inferior epigastric is lateral and inguinal ligament is inferior. Direct hernias are in the triangle.
2) direct are inferomedial to epigastrics (in the triangle); indirect are superolateral to epigastrics
3) indirect. from patent processus vaginalis
4) Direct henias (rare in females) have lower risk of incarceration and higher recurrance rates
5) both direct and indirect components

Question 3

Hernias
1) risk factors for inguinal hernia in adults
2) when does a hernia need emergent repair
3) sliding hernias- definition
a- MC types in males
b- in females

Answer 3

1) age, obesity, heavy lifting, COPD (coughing), chronic constipation, straining (BPH), ascites, pregnancy, peritoneal dialysis
2) if it’s incarcerated
3) retroperitoneal organ makes up part of hernia sac
a- males- cecum or sigmoid MC
b- females- ovaries or fallopian tubes MC

Question 4

Hernias
1) rx of Sliding hernia with ovary in canal
2) rx of hernias in infants and children and which type is MC
3) type of repairs
a- Describe Lichtenstein repair and advantage of this technique
b- Describe Bassini repair
c- Cooper’s ligament repair and what type of hernia can it also repair
d- Laparoscopic hernia repair- indications for use

Answer 4

1) ligate the round ligament, return ovary to peritoneum and perform bx if looks abnormal
2) just do high ligation (nearly always indirect), open sac prior to ligation
3) a- uses mesh= decreased recurrence 2/2 decreased tension
b- approximation of conjoined tendon and transversalis fascia (superior) to free edge of inguinal ligament (inferior)
c-approximation of the conjoined tendon and transversalis fascia (superior) to cooper’s ligament (pectineal ligament, inferior), needs relaxing incision in external abdominal oblique fascia. Can use for femoral hernia
c- use for bilateral or recurrent inguinal herna

Question 5

Inguinal Hernia repair complications

1) MC early complications
2) wound infection rate
3) recurrence rate
4) causes of testicular atrophy and what type of hernia is it seen most often with
5) cause of pain after hernia repair and rx
6) effects of damage to ilioinguinal nerve and where is it MC damaged
7) rx of Cord lipoma
8) effects of genitofemoral nerve injury

Answer 5

1) urinary retention; 2) 1%; 3) 2%
4) usually 2/2 dissection of distal component of hernia sac-> vessel disrution-> thrombosis of spermatic cord veins
- seen more with indirect hernias
5) compression of ilioinguinal nerve. rx- local infiltration can be diagnostic and therapeutic
6) loss of cremasteric reflex, numbness on ipsilateral penis, scrotum and thigh. usually injured at external ring
7) remove it
8) genital branch-> cremaster (motor) and scrotum (sensory); femoral branch- upper lateral thigh (sensory). Usually injured with laparoscopic surgery.

Question 6

Femoral Hernia

1) MC in what sex
2) femoral canal boundaries
3) high risk of incarceration- what might you have to do to reduce the bowel
4) location of hernia/where does buldge appear
5) rx

Answer 6

1) males, although incidence higher in females compared to inguinal hernias
2) Cooper’s ligament (posterior), inguinal ligament (anterior), femoral vein (lateral) and Poupart’s ligament (medial)
3) medial to femoral vein and lateral to lymphatics (in empty space) NAVEL, bulge of anterior-medial thigh, below the ligament
4) inguinal approach with COoper’s ligament repair

Question 7

Umbilical Hernias

1) what race has increased incidence
2) when to repair and why

Answer 7

1) African americans

2) delay until 5yo. often close on own and risk of incarceration in adults, not children

Question 8

1) Spigelian Hernia-where go they occur?
2) Sciatic Hernia- where does it occur
3) Incisional hernia-MCC
4) which are most likely to recur
5) which have high rate of strangulation

Answer 8

1) lateral border of rectus muscle, adjacent to the linea semilunaris, almost always inferior to the smicircularis. Occurs bw the internal oblique and insertion of the external oblique aponeurosis into rectus sheath
2) posterior pelvis- herniation through the greater sciatic foramen
3) inadequate closure
4) incisional hernias
5) sciatic hernias

Question 9

Obturator hernia

1) location
2) Howship-ROmberg Sign
3) who is at risk
4) rx

Answer 9

1) anterior pelvis. present as tender medial thigh mass or SBO
2) inner thigh pain with internal rotation
3) elderly women, previous pregnancy, bowel gas below superior pubic ramus
4) operative reduction, may need mesh, check other side for similar defects

Question 10

Rectus Sheath Hematoma

1) difference bw anterior and posterior rectus sheath
2) MCC of hematoma
3) presentation
4) rx

Answer 10

1) anterior sheath is complete, posterior is absent beowe the semicirularis (umbilicus). The posterior aponeurosis of the internal oblique and transversalis aponeruosis move more anterior below the umbilicus
2) trauma, epigastric vessel injury
3) painful abdominal mass, more prominent and painful with flexion of the rectus muscle (Fothergill’s sign)
4) nonop usual. surgery if expanding.

Question 11

Desmoid tumors

1) MC sex
2) benign or malignant
3) what syndrome are they associated with
4) rx

Answer 11

1) women
2) benign but locally invasive; inc recurrences
3) gardner’s
4) wide local excision if possible. if involving significant small bowel mesentery, excision may not be indicated (often not completely resectable). Medical rx- sulindac and tamoxifen

Question 12

Retroperitoneal fibrosis

1) cause
2) most sensitive test to dx
3) symptoms
4) rx

Answer 12

1) can occur with hypersensitivity to methysergide
2) IVP- showes constricted ureters
3) related to trapped ureters and lymphatic obstruction
4) steroids, nephrostomy if infection is present. surgery if renal fnc becomes compromised (free up ureters and wrap in omentum)

Question 13

Mesenteric tumors

1) location of malignant tumors
2) location of benign tumors
3) MC malignant tumors
4) Dx
5) rx

Answer 13

Of primary tumors, most are cystic

1) closer to root of mesentery
2) more peripheral
3) liposarcoma is #1, leiomyosarcoma
4) abdominal CT
5) resection

Question 14

Retroperitoneal tumors

1) ages affected
2) malignant or benign
3) MC malignant RP tumors
4) RP sarcoma: a-% resectable, b-% local recurrence, c-5YS, d-where mets go

Answer 14

1) 15% in children, others in 50s-60s
2) Malignant> benign
3) #1 lymphoma, #2 liposarcoma
4) a- <25%; b-40%, c-10% -5YS; d-lung

Question 15

Omental tumors

1) MC omental solid tumor
2) rx of omental mets
3) rx of primary solid omental tumors

Answer 15

1) mets
2) omentectomy of some CA (ie-ovarian, colon)
3) no bx- can bleed. resect. only 1/3 are malignant

Question 16

Peritoneal membrane

1) how is blood absorbed?
2) Peritoneal dialysis: a- are drugs removed with it? b- what elements are removed
3) when can fluid move into the peritoneal cavity?

Answer 16

1) via fenestrated lymphatic channels in the peritoneum.
2) a- most are not removed; b- NH3, Ca, Fe and lead are removed
3) with hypertonic intra-peritoneal saline load (mechanism of PD), Can cause hypotension

Question 17

CO2 Pneumoperitoneum

1) side effect at intra-abdominal pressure >20
2) what lowers the pressure necessary to cause compromise
3) what vent setting worsens effects of pneumoperitoneum
4) rx of CO2 embolus
5) are the following increased or decreased with CO2 pneumoperitoneum: MAP, Pulmonary artery pressure, pH, venous return, cardiac output, HR, Renal flow, SVR, CVP, mean airway pressure, peak inspiratory pressure, CO2

Answer 17

1) cardiopulmonary dysfunction
2) hypovolemia
3) PEEP
4) head down, turn pt to the left (sudden rise in ETCO2 and hypotension), can try to aspirate CO2 through central line, prolonged CPR
5) Increased: MAP, pulmonary artery pressure, HR, SVR, CVP, mean airway pressure and peak inspiratory pressure, CO2

Decreased: pH, venous return (IVC compression), cardiac output, renal flow

Question 18

Surgical Technology

1) harmonic- a- how does it work; what vessels is it cost-effective for
2) ultrasound- a-what does shadowing indicate, b- what does enhancement indicate
3) ultrasound duplex- what frequency are deep vs superficial structures

Answer 18

1) disrupts protein H-bonds, causes coagulation. Cost-effective for medium vessels (ie- short gastrics)
2) a- dark area posterior to object=mass;
b- brighter area posterior to object indicates fluid-filled cyst
3) a- lower frequencies are deep structures, b- higher frequencies are superficial structures

Question 19

1) How does the argon beam work and what is it good for

2) how does the laser work and what to use it for

Answer 19

1) energy transferred across argon gas-> superficial coagulation. Non-contact. good for hemostasis of liver and spleen
2) Laser- return of electrons to ground state-> release of energy as heat-> coagulates and vaporizes. Use for condyloma acuminata (wear mask)

Question 20

1) difference between Gore-Tex (PTFE) and Dacron (polypropylene) mesh
2) incidence of vascular or bowel injury with veress needle or trocar

Answer 20

1_ Gore-Tex- cannot get fibroblast ingrowth. Dacron- allows fibroblast ingrowth
2) 0.1%