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Section II General Surgery P203Surgical Recall Sixth > Hernias, C36 P209-223 > Flashcards

Hernias, C36 P209-223 Flashcards

1
Q

What is a hernia?

P209

A

(L. rupture) Protrusion of a peritoneal
sac through a musculoaponeurotic barrier
(e.g., abdominal wall); a fascial defect

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2
Q

What is the incidence?

P209

A

5%–10% lifetime; 50% are indirect
inguinal, 25% are direct inguinal, and
≈5% are femoral

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3
Q

What are the precipitating factors?

P209

A 
Increased intra-abdominal pressure:
straining at defecation or urination
(rectal cancer, colon cancer, prostatic
enlargement, constipation), obesity,
pregnancy, ascites, valsavagenic (coughing)
COPD; an abnormal congenital anatomic
route (i.e., patent processus vaginalis)
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4
Q

Why should hernias be repaired?

P209

A

To avoid complications of incarceration/

strangulation, bowel necrosis, SBO, pain

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5
Q

What is more dangerous:
a small or large hernia defect?
P209

A

Small defect is more dangerous because a
tight defect is more likely to strangulate if
incarcerated

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6
Q

Define the following descriptive terms:
Reducible
P209

A

Ability to return the displaced organ or
tissue/hernia contents to their usual
anatomic site

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7
Q

Define the following descriptive terms:
Incarcerated
P209

A

Swollen or fixed within the hernia sac (incarcerated = imprisoned); may cause intestinal obstruction (i.e., an irreducible hernia)

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8
Q

Define the following descriptive terms:
Strangulated
P210 (picture)

A 
Incarcerated hernia with resulting
ischemia; will result in signs and
symptoms of ischemia and intestinal
obstruction or bowel necrosis (Think:
strangulated = choked)
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9
Q

Define the following descriptive terms:
Complete
P210

A

Hernia sac and its contents protrude all

the way through the defect

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10
Q

Define the following descriptive terms:
Incomplete
P210

A

Defect present without sac or contents

protruding completely through it

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11
Q

What is reducing a hernia
“en masse”?
P210 (picture)

A

Reducing the hernia contents and

hernia sac

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12
Q

Define the following types of hernias:
Sliding hernia
P211 (picture)

A 
Hernia sac partially formed by the wall of
a viscus (i.e., bladder/cecum)
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13
Q

Define the following types of hernias:
Littre’s hernia
P211

A

Hernia involving a Meckel’s diverticulum

Think alphabetically: Littre’s Meckel’s = LM

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14
Q

Define the following types of hernias:
Spigelian hernia
P211

A

Hernia through the linea semilunaris
(or spigelian fascia); also known as
spontaneous lateral ventral hernia
(Think: Spigelian = Semilunaris)

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15
Q

Define the following types of hernias:
Internal hernia
P211

A

Hernia into or involving intra-abdominal

structure

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16
Q

Define the following types of hernias:
Petersen’s hernia
P211

A

Seen after bariatric gastric bypass—
internal herniation of small bowel
through the mesenteric defect from the
Roux limb

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17
Q

Define the following types of hernias:
Obturator hernia
P211

A

Hernia through obturator canal

females > males

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18
Q

Define the following types of hernias:
Lumbar hernia
P211

A

Petit’s hernia or Grynfeltt’s hernia

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19
Q

Define the following types of hernias:
Petit’s hernia
P211

A

(Rare) hernia through Petit’s triangle
(a.k.a. inferior lumbar triangle)
(Think: petite = small = inferior)

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20
Q

Define the following types of hernias:
Grynfeltt’s hernia
P211

A

Hernia through Grynfeltt-Lesshaft

triangle (superior lumbar triangle)

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21
Q

Define the following types of hernias:
Pantaloon hernia
P212 (picture)

A 
Hernia sac exists as both a direct and
indirect hernia straddling the inferior
epigastric vessels and protruding through
the floor of the canal as well as the
internal ring (two sacs separated by the
inferior epigastric vessels [the pant
crotch] like a pair of pantaloon pants)
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22
Q

Define the following types of hernias:
Incisional hernia
P212

A

Hernia through an incisional site; most

common cause is a wound infection

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23
Q

Define the following types of hernias:
Ventral hernia
P212

A

Incisional hernia in the ventral abdominal

wall

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24
Q

Define the following types of hernias:
Parastomal hernia
P212

A

Hernia adjacent to an ostomy (e.g.,

colostomy)

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25
Define the following types of hernias: Sciatic hernia P212
Hernia through the sciatic foramen
26
Define the following types of hernias: Richter’s hernia P212 (picture)
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
27
Define the following types of hernias: Epigastric hernia P213
Hernia through the linea alba above the | umbilicus
28
Define the following types of hernias: Umbilical hernia P213
Hernia through the umbilical ring, in adults associated with ascites, pregnancy, and obesity
29
Define the following types of hernias: Intraparietal hernia P213
Hernia in which abdominal contents migrate between the layers of the abdominal wall
30
Define the following types of hernias: Femoral hernia P213
Hernia medial to femoral vessels (under | inguinal ligament)
31
Define the following types of hernias: Hesselbach’s hernia P213
Hernia under inguinal ligament lateral | to femoral vessels
32
Define the following types of hernias: Bochdalek’s hernia P213
Hernia through the posterior diaphragm, usually on the left (Think: Boch da lek = “back to the left” on the diaphragm)
33
Define the following types of hernias: Morgagni’s hernia P213
Anterior parasternal diaphragmatic | hernia
34
Define the following types of hernias: Properitoneal hernia P213
Intraparietal hernia between the | peritoneum and transversalis fascia
35
Define the following types of hernias: Cooper’s hernia P213
Hernia through the femoral canal and tracking into the scrotum or labia majus
36
Define the following types of hernias: Indirect inguinal P213
Inguinal hernia lateral to Hesselbach’s | triangle
37
Define the following types of hernias: Direct inguinal P213
Inguinal hernia within Hesselbach’s | triangle
38
Define the following types of hernias: Hiatal hernia P213
Hernia through esophageal hiatus
39
Define the following types of hernias: Amyand’s hernia P213
Hernia sac containing a ruptured appendix | Think: Amyand’s = Appendix
40
What are the boundaries of Hesselbach’s triangle? P214
1. Inferior epigastric vessels 2. Inguinal ligament (Poupart’s) 3. Lateral border of the rectus sheath Floor consists of internal oblique and the transversus abdominis muscle
41
What are the layers of the abdominal wall? P214
``` Skin Subcutaneous fat Scarpa’s fascia External oblique Internal oblique Transversus abdominus Transversalis fascia Preperitoneal fat Peritoneum Note: All three muscle layer aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line ```
42
What is the differential diagnosis for a mass in a healed C-section incision? P214
Hernia, ENDOMETRIOMA
43
GROIN HERNIAS What is the differential diagnosis of a groin mass? P214
Lymphadenopathy, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC, undescended testicle, sarcoma, hernias, testicle torsion
44
GROIN HERNIAS DIRECT INGUINAL HERNIA What is it? P214
Hernia within the floor of Hesselbach’s triangle, i.e., the hernia sac does not traverse the internal ring (think directly through the abdominal wall)
45
GROIN HERNIAS DIRECT INGUINAL HERNIA What is the cause? P214
Acquired defect from mechanical | breakdown over the years
46
GROIN HERNIAS DIRECT INGUINAL HERNIA What is the incidence? P214
≈1% of all men; frequency increases | with advanced age
47
``` GROIN HERNIAS DIRECT INGUINAL HERNIA What nerve runs with the spermatic cord in the inguinal canal? P214 ```
Ilioinguinal nerve
48
GROIN HERNIAS INDIRECT INGUINAL HERNIA What is it? P215 (picture)
Hernia through the internal ring of the inguinal canal, traveling down toward the external ring; it may enter the scrotum upon exiting the external ring (i.e., if complete); think of the hernia sac traveling indirectly through the abdominal wall from the internal ring to the external ring
49
GROIN HERNIAS INDIRECT INGUINAL HERNIA What is the cause? P215
Patent processus vaginalis (i.e., congenital)
50
GROIN HERNIAS INDIRECT INGUINAL HERNIA What is the incidence? P215
≈5% of all men; most common hernia in | both men and women
51
``` GROIN HERNIAS INDIRECT INGUINAL HERNIA How is an inguinal hernia diagnosed? P215 ```
Relies mainly on history and physical exam with index finger invaginated into the external ring and palpation of hernia; examine the patient standing up if diagnosis is not obvious (Note: if swelling occurs below the inguinal ligament, it is possibly a femoral hernia)
52
``` GROIN HERNIAS INDIRECT INGUINAL HERNIA What is the differential diagnosis of an inguinal hernia? P215 ```
Lymphadenopathy, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess
53
GROIN HERNIAS INDIRECT INGUINAL HERNIA What is the risk of strangulation? P215
Higher with indirect than direct inguinal | hernia, but highest in femoral hernias
54
GROIN HERNIAS INDIRECT INGUINAL HERNIA What is the treatment? P216
Emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present; otherwise, elective herniorrhaphy is indicated to prevent the chance of incarceration/strangulation
55
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: Bassini P216
``` Sutures approximate reflection of inguinal ligament (Poupart’s) to the transversus abdominis aponeurosis/ conjoint tendon ```
56
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: McVay P216
Cooper’s ligament sutured to transversus | abdominis aponeurosis/conjoint tendon
57
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: Lichtenstein P216
“Tension-free repair” using mesh
58
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: Shouldice P216
Imbrication of the floor of the inguinal | canal (a.k.a. “Canadian repair”)
59
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: Plug and patch P216
Placing a plug of mesh in hernia defect and then overlaying a patch of mesh over inguinal floor (requires few if any sutures in mesh!)
60
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: High ligation P216
Ligation and transection of indirect hernia sac without repair of inguinal floor (used only in children)
61
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: TAPP procedure P216
TransAbdominal PrePeritoneal inguinal | hernia repair
62
GROIN HERNIAS INGUINAL HERNIA REPAIRS Define the following procedures: TEPA procedure P216
Totally ExtraPeritoneal Approach
63
``` GROIN HERNIAS INGUINAL HERNIA REPAIRS What are the indications for laparoscopic inguinal hernia repair? P216 ```
1. Bilateral inguinal hernias 2. Recurring hernia 3. Need to resume full activity as soon as possible
64
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is the first identifiable subcutaneous named layer? P216 ```
Scarpa’s fascia (thin in adults)
65
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is the name of the subcutaneous vein that is ligated? P217 ```
Superficial epigastric vein
66
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What happens if you cut the ilioinguinal nerve? P217 ```
Numbness of inner thigh or lateral | scrotum; usually goes away in 6 months
67
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS From what abdominal muscle layer is the cremaster muscle derived? P217 ```
Internal oblique muscle
68
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS From what abdominal muscle layer is the inguinal ligament (a.k.a. Poupart’s ligament) derived? P217 ```
External oblique muscle aponeurosis
69
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS To what does the inguinal (Poupart’s) ligament attach? P217 ```
Anterior superior iliac spine to the pubic | tubercle
70
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS Which nerve travels on the spermatic cord? P217 ```
Ilioinguinal nerve
71
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS Why do some surgeons deliberately cut the ilioinguinal nerve? P217 ```
First they obtain preoperative consent and cut so as to remove the risk of entrapment and postoperative pain
72
GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is in the spermatic cord (6)? P217
1. Cremasteric muscle fibers 2. Vas deferens 3. Testicular artery 4. Testicular pampiniform venous plexus 5. ± hernia sac 6. Genital branch of the genitofemoral nerve
73
GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is the hernia sac made of? P217
Peritoneum (direct) or a patent processus | vaginalis (indirect)
74
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What attaches the testicle to the scrotum? P217 ```
Gubernaculum
75
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is the most common organ in an inguinal hernia sac in men? P217 ```
Small intestine
76
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is the most common organ in an inguinal hernia sac in women? P217 ```
Ovary/fallopian tube
77
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What lies in the inguinal canal in the female instead of the VAS? P218 ```
Round ligament
78
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS Where in the inguinal canal does the hernia sac lie in relation to the other structures? P218 ```
Anteromedially
79
GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is a “cord lipoma”? P218
Preperitoneal fat on the cord structures (pushed in by the hernia sac); not a real lipoma; remove surgically, if feasible
80
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is a small outpouching of testicular tissue off of the testicle? P218 ```
``` Testicular appendage (a.k.a. the appendix testes); remove with electrocautery ```
81
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy? P218 ```
Remove the suture as soon as possible and apply pressure (i.e., do not tie the suture down!)
82
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What nerve is found on top of the spermatic cord? P218 ```
Ilioinguinal nerve
83
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What nerve travels within the spermatic cord? P218 ```
Genital branch of the genitofemoral | nerve
84
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What are the borders of Hesselbach’s triangle? P218 (picture) ```
1. Epigastric vessels 2. Inguinal ligament 3. Lateral border of the rectus
85
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What type of hernia goes through Hesselbach’s triangle? P219 ```
Direct hernia due to a weak abdominal | floor
86
GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is a “relaxing incision”? P219
Incision(s) in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal ligament without tension
87
GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What is the conjoint tendon? P219
Aponeurotic attachments of the “conjoining” of the internal oblique and transversus abdominis to the pubic tubercle
88
GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS Define inguinal anatomy P219 (picture)
1. Inguinal ligament (Poupart’s ligament) 2. Transversus aponeurosis 3. Conjoint tendon
89
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS How tight should the new internal inguinal ring be? P219 ```
Should allow entrance of the tip of a Kelly clamp but not a finger (the new external inguinal ring should not be tight and should allow entrance of a finger)
90
``` GROIN HERNIAS CLASSIC INTRAOPERATIVE INGUINAL HERNIA QUESTIONS What percentage of the strength of an inguinal floor repair does the external oblique aponeurosis represent? P219 ```
ZERO
91
GROIN HERNIAS FEMORAL HERNIA What is it? P219
Hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels (Think: FM radio, or Femoral hernia = Medial)
92
``` GROIN HERNIAS FEMORAL HERNIA What are the boundaries of the femoral canal? P220 ```
1. Cooper’s ligament posteriorly 2. Inguinal ligament anteriorly 3. Femoral vein laterally 4. Lacunar ligament medially
93
``` GROIN HERNIAS FEMORAL HERNIA What factors are associated with femoral hernias? P220 ```
Women, pregnancy, and exertion
94
``` GROIN HERNIAS FEMORAL HERNIA What percentage of all hernias are femoral? P220 ```
5%
95
``` GROIN HERNIAS FEMORAL HERNIA What percentage of patients with a femoral hernia are female? P220 ```
85%!
96
GROIN HERNIAS FEMORAL HERNIA What are the complications? P220
Approximately one third incarcerate | due to narrow, unforgiving neck
97
``` GROIN HERNIAS FEMORAL HERNIA What is the most common hernia in women? P220 ```
Indirect inguinal hernia
98
``` GROIN HERNIAS FEMORAL HERNIA What is the repair of a femoral hernia? P220 ```
McVay (Cooper’s ligament repair), mesh | plug repair
99
``` HERNIA REVIEW QUESTIONS Should elective TURP or elective herniorrhaphy be performed first? P220 ```
TURP
100
``` HERNIA REVIEW QUESTIONS Which type of esophageal hiatal hernia is associated with GE reflux? P220 ```
Sliding esophageal hiatal hernia
101
``` HERNIA REVIEW QUESTIONS Classically, how can an incarcerated hernia be reduced in the ER? P220 ```
1. Apply ice to incarcerated hernia 2. Sedate 3. Use the Trendelenburg position for inguinal hernias 4. Apply steady gentle manual pressure 5. Admit and observe for signs of necrotic bowel after reduction 6. Perform surgical herniorrhaphy ASAP
102
``` HERNIA REVIEW QUESTIONS What is appropriate if you cannot reduce an incarcerated hernia with steady, gentle compression? P221 ```
Go directly to O.R. for repair
103
``` HERNIA REVIEW QUESTIONS What is the major difference in repairing a pediatric indirect inguinal hernia and an adult inguinal hernia? P221 ```
In babies and children it is rarely necessary to repair the inguinal floor; repair with “high ligation” of the hernia sac
104
HERNIA REVIEW QUESTIONS What is the Howship-Romberg sign? P221
Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia
105
HERNIA REVIEW QUESTIONS What is the “silk glove” sign? P221
Inguinal hernia sac in an infant/toddler feels like a finger of a silk glove when rolled under the examining finger
106
``` HERNIA REVIEW QUESTIONS What must you do before leaving the O.R. after an inguinal hernia repair? P221 ```
Pull the testicle back down to the | scrotum
107
ESOPHAGEAL HIATAL HERNIAS Define type I and type II hiatal hernias. P221
Type I  = sliding | Type II  = paraesophageal
108
ESOPHAGEAL HIATAL HERNIAS SLIDING ESOPHAGEAL HIATAL HERNIA What is it? P221 (picture)
Both the stomach and GE junction herniate into the thorax via the esophageal hiatus; also known as type I hiatal hernia
109
ESOPHAGEAL HIATAL HERNIAS SLIDING ESOPHAGEAL HIATAL HERNIA What is the incidence? P222
>90% of all hiatal hernias
110
ESOPHAGEAL HIATAL HERNIAS SLIDING ESOPHAGEAL HIATAL HERNIA What are the symptoms? P222
``` Most patients are asymptomatic, but the condition can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration ```
111
ESOPHAGEAL HIATAL HERNIAS SLIDING ESOPHAGEAL HIATAL HERNIA How is it diagnosed? P222
UGI series, manometry, esophagogastroduodenoscopy (EGD) with biopsy for esophagitis
112
ESOPHAGEAL HIATAL HERNIAS SLIDING ESOPHAGEAL HIATAL HERNIA What are the complications? P222
Reflux → esophagitis → Barrett’s esophagus → cancer and stricture formation; aspiration pneumonia; it can also result in UGI bleeding from esophageal ulcerations
113
ESOPHAGEAL HIATAL HERNIAS SLIDING ESOPHAGEAL HIATAL HERNIA What is the treatment? P222
``` 85% of cases treated medically with antacids, H(2) blockers/PPIs, head elevation after meals, small meals, and no food prior to sleeping; 15% of cases require surgery for persistent symptoms despite adequate medical treatment ```
114
ESOPHAGEAL HIATAL HERNIAS SLIDING ESOPHAGEAL HIATAL HERNIA What is the surgical treatment? P222
Laparoscopic Nissen fundoplication (LAP NISSEN) involves wrapping the fundus around the LES and suturing it in place
115
ESOPHAGEAL HIATAL HERNIAS PARAESOPHAGEAL HIATAL HERNIA What is it? P222 (picture)
``` Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the gastroesophageal junction; also known as type II hiatal hernia ```
116
ESOPHAGEAL HIATAL HERNIAS PARAESOPHAGEAL HIATAL HERNIA What is the incidence? P223
<5% of all hiatal hernias (rare)
117
ESOPHAGEAL HIATAL HERNIAS PARAESOPHAGEAL HIATAL HERNIA What are the symptoms? P223
Derived from mechanical obstruction; dysphagia, stasis gastric ulcer, and strangulation; many cases are asymptomatic and not associated with reflux because of a relatively normal position of the GE junction
118
ESOPHAGEAL HIATAL HERNIAS PARAESOPHAGEAL HIATAL HERNIA What are the complications? P223
Hemorrhage, incarceration, obstruction, | and strangulation
119
ESOPHAGEAL HIATAL HERNIAS PARAESOPHAGEAL HIATAL HERNIA What is the treatment? P223
Surgical, because of frequency and | severity of potential complications
120
ESOPHAGEAL HIATAL HERNIAS PARAESOPHAGEAL HIATAL HERNIA What is a type III hiatal hernia? P223
Combined type I and type II
121
ESOPHAGEAL HIATAL HERNIAS PARAESOPHAGEAL HIATAL HERNIA What is a type IV hiatal hernia? P223
Organ (e.g., colon or spleen) +/- | stomach in the chest cavity

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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