Hernias, Abdomen, and Surgical Technology Flashcards
1
Q
_____ forms the inguinal ligament (shelving edge and roof) at the inferior portion of the inguinal canal
A
External abdominal oblique fascia
2
Q
Forms cremasteric muscles
A
Internal oblique fascia
3
Q
_______ and ______ form the inguinal canal floor
A
Transversalis muscle and conjoined tendon
4
Q
The conjoined tendon is composed of _____ and _____.
A
Aponeurosis of the internal abdominal oblique and transversalis fascia
5
Q
The inguinal ligament runs from the _____ to the _____. It is _______ to the femoral vessels
A
- Anterior superior iliac spine to the pubis
- Anterior
Inguinal ligament = Poupart’s ligament
6
Q
What is the lacunar ligament?
A
Where the inguinal ligament splays out to insert onto the pubis
7
Q
Cooper’s ligament is _____ to the femoral vessels.
A
- Posterior
Cooper’s ligament = Pectinal ligament
- Lies against bone
8
Q
The vas deferens runs ____ to the cord structures
A
Medial
9
Q
Hesselbach’s Triangle borders
A
- Rectus muscle
- Inferior inguinal ligament
- Inferior epigastrics
10
Q
Direct hernias are ______ to the epigastric vessels
A
Inferior/medial
11
Q
Indirect hernias are ______ to the epigastric vessels
A
Superior/lateral
12
Q
Which is more common, direct or indirect hernias?
A
Indirect
13
Q
Cause of indirect hernias
A
Persistently patent processus vaginalis
14
Q
Direct hernias have a _____ (higher/lower) risk of incarceration and ______ (higher/lower) recurrence rate compared to indirect hernias
A
- Lower risk of incarceration
- Higher recurrence risk
15
Q
A _____ hernia contains components of both direct and indirect hernias.
A
Pantaloon hernia
16
Q
Risk factors for inguinal hernias in adults (9)
A
- Age
- Obesity
- Heavy lifting
- COPD (coughing)
- Chronic constipation
- Straining (BPH)
- Ascites
- Pregnancy
- Peritoneal dialysis
17
Q
Part of the hernia sac in sliding hernias is made up of a ______.
A
- Retroperitoneal organ
- Most common organ in women: Ovaries or fallopian tube
- Most common organ in men: Cecum or sigmoid colon
18
Q
What to do if an ovary is found within the inguinal canal
A
- Ligate the round ligament (found within the inguinal canal in women)
- Return the ovary to the peritoneum
- Perform biopsy of ovary if looks abnormal
19
Q
How to repair inguinal hernia in infants and children
A
- Perform high ligation (nearly always indirect hernias)
- Open sac prior to ligation
20
Q
Lichtenstein repair
A
- Uses mesh
- Recurrence decreased with use of mesh as this reduces tension
21
Q
Bassini repair
A
- Approximation of the conjoined tendon to the free edge of the inguinal ligament (shelving edge, inferior)
22
Q
Cooper’s ligament repair
A
Approximation of the conjoined tendon to Cooper’s ligament (pectineal ligament, inferior)
- Needs relaxing incision to the external oblique fascia
- Can be used for femoral hernia repair
23
Q
Indications for laparoscopic inguinal hernia repair
A
- Bilateral inguinal hernias
- Recurrent inguinal hernia
24
Q
Most common complication following hernia repair
A
Urinary retention
25
Wound infection rate following inguinal hernia repair
1%
26
Recurrence rate following inguinal hernia repair
2%
27
Testicular atrophy following inguinal hernia repair is usually caused by _____.
Dissection of the distal component of the hernia sac causing vessel disruption
- Thrombosis of the spermatic cord vessels
- Usually occurs with indirect hernias
28
Pain after inguinal hernia repair is usually caused by _____.
- Treatment:
- Compression of the ilioinguinal nerve
| - Tx: Local infiltration near anterior superior iliac spine (can be diagnostic and therapeutic)
29
Symptoms of ilioinguinal nerve injury and where is it most commonly injured
- Loss of cremasteric reflex
- Numbness of ipsilateral penis, scrotum and thigh
Usually injured at the external ring as the nerve runs on top of the cord (anterior)
30
Genitofemoral nerve
- Genital branch function:
- Femoral branch function:
- Genital branch function: Cremaster (motor), scrotum (sensory)
- Femoral branch function: Upper lateral thigh (sensory)
- Usually injured with laparoscopic hernia repair
31
Cord lipomas _____ (should/should not) be removed if found.
Should be removed if found
32
Femoral canal boundaries
- Cooper's ligament (pectineal, posterior)
- Inguinal ligament (anterior)
- Femoral vein (lateral)
- Lacunar ligament (medial)
33
Femoral hernia is _____ to the femoral vein and _____ to the lymphatics.
- Medial to the femoral vein
| - Lateral to the lymphatics
34
Femoral hernias pass underneath the ________
Inguinal ligament
35
Characteristic physical exam finding of a femoral hernia
Bulge on the anterior-medial thigh below the ligament
36
Femoral hernias are usually repaired through an ______ approach with a _________ repair
- Inguinal approach
| - Cooper's ligament repair
37
Umbilical hernia repairs are delayed until age ___
Age 5
*Risk of incarceration in adults, not children
38
Spigelian hernia occurs between the ________ and _______.
Between the muscle fibers of the internal oblique muscle and insertion of the external oblique aponeurosis into the rectus sheath
39
Spigelian hernias are found at the lateral border of the _____, adjacent to the _______.
- Lateral border of rectus muscle
- Adjacent to the linea semilunaris
*Almost always inferior to the semicircularis
40
Obturator hernia can present as a _____ or ______
- Tender medial thigh mass
- SBO
*Found in anterior pelvis
41
What is Howship-Romberg sign? What type of hernia is it seen in?
- Inner thigh pain with internal rotation
| - Obturator hernia
42
Treatment of an obturator hernia
Tx: operative reduction, may need mesh, check other side for similar defect
43
Sciatic hernia is caused by herniation through the ______.
- Through the greater sciatic foramen
| * Found in posterior pelvis. High rate of strangulation
44
Most common cause of incisional hernias
Inadequate closure
45
Posterior rectus sheath is absent below the ______.
Semicircularis (absent below umbilicus)
*The posterior aponeurosis of the internal oblique and transversalis moves anterior below the umbilicus
46
Most common cause of rectus sheath hematoma
Trauma - epigastric vessel injury
47
Rectus sheath hematomas usually present as a _______.
| Treatment:
- Painful abdominal wall mass
| - Tx: usually non-operative, surgery if expanding
48
What is Fothergill's sign?
Abdominal wall mass is more prominent and painful with flexion of the rectus muscle. Seen in rectus sheath hematoma
49
Desmoid tumor usually present as _______. Can be seen in _____ syndrome.
- Painless mass
- Gardner's syndrome
* More common in women
* Usually benign, but locally invasive
50
Treatment of desmoid tumors
Tx: Wide local excision if possible
- If involving significant small bowel mesentery, excision may not be indicated as often it is not completely resectable
Medical Tx: Sulindac and Tamoxifen
51
Most sensitive test for retroperitoneal fibrosis
- IVP (intravenous pyelogram): shows constricted ureters
| * retroperitoneal fibrosis can occur with hypersensitivity to methysergide
52
Symptoms and treatment of retroperitoneal fibrosis
- Symptoms: usually related to trapped ureters and lymphatic obstruction
- Tx: Steriods, nephrostomy if infection is present, surgery if renal function becomes compromised (free up ureters and wrap in omentum)
53
Mesenteric tumors
- Tumors closer to the root are more likely to be _____ (malignant/benign)
- More peripheral tumors are more likely to be ______ (malignant/benign)
- Tumors closer to the root are more likely to be malignant
| - More peripheral tumors are more likely to be benign
54
Most common malignant mesenteric tumor
Liposarcoma
55
Diagnosis and treatment of mesenteric tumors
Dx: Abdominal CT
Tx: Resection
56
Most common malignant retroperitoneal tumor
- Lymphoma
| * 2nd most common: liposarcoma
57
Retroperitoneal sarcoma
- ___% resectable
- ___% recurrence rate
- ___% 5-year survival rate
- < 25 % resectable
- 40 % recurrence rate
- 10 % 5-year survival rate
* Mets go to the lungs
* Tumors have pseudocapsule, but can't shell out because this would leave residual tumor
58
Most common omental solid tumor
Metastatic disease
*Primary solid omental tumors are rare, 1/3 are malignant
59
Omental cyst symptoms
Usually asymptomatic, but can undergo torsion
60
Omental tumor diagnosis and treatment
Dx: No biopsy, can have significant bleeding
Tx: Resection
61
Blood is absorbed through _______ in the peritoneum
Fenestrated lymphatic channels
62
Removed during peritoneal dialysis (4)
NH3, Ca, Fe, and lead are removed
*most drugs are not removed
63
Mechanism of peritoneal dialysis: movement of fluid into the peritoneal cavity can occur with administration of _______.
Hypertonic intra-peritoneal saline load
*can cause hypotension
64
Cardiopulmonary dysfunction can occur with intra-abdominal pressure > ____
> 20
65
Increased intra-abdominal pressure causes increased (8)
- MAP
- PA pressure
- HR
- SVR
- CVP
- Mean airway pressure
- Peak inspiratory pressure
- CO2
66
Increased intra-abdominal pressure causes decreased (4)
- pH
- Venous return (IVC compression)
- Cardiac output
- Renal flow secondary to decreased cardiac output
67
CO2 embolus presentation and treatment
- Sudden rise in ETCO2, followed by a drop then hypotension
| - Tx: Head down, turn patient on left, can try to aspirate CO2 through CVL, prolonged CPR
68
Harmonic scalpel mechanism of action
Disrupts protein H bonds causing coagulation
69
Ultrasound
- Lower frequencies show ____ (superficial/deep) structures
- Higher frequencies show ____ (superficial/deep) structures
- Lower frequencies show deep structures
| - Higher frequencies show superficial structures
70
Argon beam causes ____ (deep/superficial) coagulation
Superficial coagulation
*Is non-contact, so good for hemostasis of the liver and spleen
71
Fibroblast ingrowth can be seen in ______ (Gore-Tex / Dacron)
Gore-Tex (PTFE) cannot get fibroblast ingrowth
Dacron (polypropylene) allows fibroblast ingrowth
72
Incidence of vascular or bowel injury with Veress needle or trocar
0.1 %
