Hernias flash Flashcards
What are the layers of the abdominal wall?
Skin, Subcutaneous Fat/Camper’s Fascia, Scarpa’s fascia, external oblique, internal oblique, rectus abdominus, transversus abdominus, transversalis fascia, preperitoneal Fat, peritoneum
What forms the transversus abdominus fascia?
Transversalis fascia.
What are the boundaries of the inguinal canal?
Anteriorly: aponeurosis of external oblique; Laterally: internal oblique mm.; Posteriorly: transversalis fascia and transverse abdominus; Inferiorly (floor): inguinal ligament; Superiorly (roof): internal oblique mm. and transverse abdominus mm. and aponeurosis.
What is the conjoint tendon?
Located posterior to the superficial ring, formed by transversus abdominus fascia and internal oblique aponeurosis.
What structures are found in the spermatic cord?
Vas deferens, testicular artery, pampiniform plexus, cremasteric muscle, genital branch of genitofemoral nerve.
Vas deferens - Runs anteromedial to the spermatic vessels
Hernia sac – anterormedial to cord structures
Ilioinguinal nerve runs anteriorly, outside of it, in the inguinal canal
-Cremaster muscles formed by: extension of internal oblique muscle fibers
What is the iliopubic tract?
Thickening of the transversalis fascia near the inguinal ligament.
What does the median umbilical fold (ligament) carry?
Urachus.
What do the medial umbilical folds carry?
Obliterated umbilical arteries; site of direct hernia.
What do the lateral umbilical folds cover?
Inferior epigastric vessels.
What is the risk of hernia recurrence?
Hernia width and contamination are the two most important factors.
MCC for recurrent hernia= wound infection
What is the most common type of inguinal hernia?
Indirect hernia.
What is the difference between indirect and direct inguinal hernias?
Indirect: lateral to inferior epigastrics; hernial sac within the spermatic cord; congenital: patent processus vaginalis
Hernia in <18 y/o just do high ligation of sac. MC indirect. No mesh needed
-Direct: medial to inferior epigastrics; hernial sac outside the spermatic cord; acquired: weakness in floor of inguinal canal; RF: obesity, smoking, poor nutrition, ascites, inc abdominal P, PD
Indirect hernia has a higher risk of incarceration; direct hernia has a higher recurrence rate.
What is the Lichtenstein repair?
Mesh used; conjoint tendon to inguinal ligament; reconstructs the floor.
What is the Shouldice repair?
Best tissue repair
-Open transversalis fascia from internal ring to pubic bone
-reconstructs the floor of inguinal canal via a running continuous suture stainless steel wire that incorporates 4 layers
-suture the iliopubic tract to the lateral border of rectus sheath
What is the Cooper (McVay) ligament repair used for?
Tissue repair for femoral hernias, no mesh
Open transversalis fascia - Medially sew Conjoint tendon to cooper’s ligament (pectineal ligament). - Then perform a transition stitch (last stitch laterally) connects the transversalis fascia (iliopubic tract) to the inguinal ligament (and finish repair laterally like basinni, conjoint to inguinal) - Needs relaxing incision on anterior rectus sheath extending vertically 6 cm - Use for femoral hernias
What is the most common complication following inguinal hernia repair?
Urinary retention.
What is the triangle of doom?
Medial border is vas deferens; lateral border is gonadal vessels; contains external iliac vessels.
What are the boundaries of the femoral canal?
Cooper’s ligament (posterior/inferior), inguinal ligament (anterior), iliopubic tract (superiorly), femoral vein (lateral), lacunar ligament (medially).
Femoral triangle - superiorly by inguinal ligament, medially by adductor longus, and laterally by sartorius
What is the definition of a ventral hernia?
An abdominal wall defect that can occur at various sites.
What is the Rives-Stoppa repair?
Open ventral hernia repair; mesh placed in retro-rectus above posterior sheath.
- Must be midline hernia
- Dissect the posterior rectus sheath off of rectus mm to the semilunaris line
- Posterior rectus sheath closed, mesh placed on top and secured
- Rectal muscles then approximated on top
What is the anterior component separation?
Anterior Component Separation (incise external oblique)
Transversus Abdominis Repair (incise transversus abdominis)
-Posterior Component Separation (incise posterior rectus sheath)
Anterior Component separation – (open or lap)
- Mesh now always recommended to be used, either as an onlay over the fascia or sublay (retrorectus)
- Cons: Complication of large skin flap. Does not address non-midline hernia, parastomal hernia, subxiphoid, suprapubic.
- Elevate skin and SubQ from rectus sheath to anterior axillary line
- Linea semilunaris found external oblique is incised 2 cm lateral to its attachment to semilunares, from costal margin, to inguinal ligament. Can go as far as posterior axillary line
- Plane developed between external and internal oblique to posterior axillary line allows rectus muscle to be mobilized to midline
- If not sufficient; Perform a posterior component separation posterior sheath can be dissected off of rectus muscle medially, to further mobilize rectus mm. Adds additional 2-4 cm
- Should get 5 cm in upper and lower abdomen, 10 cm at waist. Add 2 cm if posterior rectus release performed
- Do no disrupt neurovascular supply located between internal oblique and transversus abdominus muscle
Posterior component separation has less wound infections compared to anterior
**external oblique aponeurosis is incised to perform compartment separation
What is the transverse abdominus release?
Transverse Abdominus Release – Uses Mesh (open or lap)
- Benefits: Avoids large subq flaps, places mesh in retrorectus when compared to anterior component separation
- Cons: less advancement of rectus mm compared to anterior component separation
- Separate posterior rectus sheath from rectus mm until you reach linea semilunaris. Be careful not to injure neurovascular bundle here
- incise posterior rectus sheath 0.5 cm medial to linea semilunaris to expose, and divide the transversus abdominus muscle
- Bluntly dissect transverse abdominus from transversalis fascia (posteriorly) all the way to psoas, costal margin, and space of Retzius
- Close transversalis fascia/peritoneum, place mesh on top on retrorectus space. Close the anterior rectus sheath
- Creates a retrorectus space for mesh placement
What are the key nerves injured in open inguinal hernia repair?
Ilioinguinal (most common; when opening external oblique), genital branch of genitofemoral, iliohypogastric.
What is the most commonly injured nerve in laparoscopic repair?
Lateral femoral cutaneous nerve; occurs from improperly placed tack laterally.
What is the Bassini repair technique?
Conjoint tendon (transversalis + internal oblique) is sutured to the inguinal ligament.
-Open the posterior wall, transversalis fascia from internal ring to pubic bone
-Internal oblique, transversus abdominus and transversalis fascia incorporated into an interrupted sutures triple layer and sewn to inguinal ligament
-External oblique then closed
-Highest rate of recurrence
What distinguishes the Shouldice repair technique?
It is similar to Bassini but performed in multiple (4) layers.
What is the Lichtenstein repair technique?
Repair with mesh, sewing the inguinal ligament to the conjoined/transversalis.
What is the plug and patch technique?
A plug is placed into the internal repair, followed by Lichtenstein on top.
What are the basics of pediatric hernia repair?
High ligation of the sac.
Delay repair until 5 y/o to see if it will close
Umbilical hernias:
-Usually congenital; contents= preperitoneal fat
-Primary repair: <1cm and pediatric patients
What are the two types of laparoscopic hernia repair?
Total Extra-Peritoneal Repair (TEP) and Trans-Abdominal Pre-Peritoneal Repair (TAPP- need to close peritoneum after mesh to prevent adhesions)
What is the main structure of fixation in laparoscopic repair?
Cooper’s ligament.
What does the Triangle of Doom contain?
Inferior to iliopubic tract/ medial to triangle of pain
Medial: vas deferens
Lateral: spermatic vessels
Inferior: peritoneal fold
Contains: external iliac artery and vein; genital branch of genitofemoral nerve
Avoid tacks lateral to vas deferent and inferior to iliopubic tract
TACS placed below coopers ligament risk injury to vessels
What does the Triangle of Pain contain?
Lateral to triangle of doom
Superior: iliopubic tract
Medial: spermatic vessels
Lateral: peritoneal fold
- Tacs below the iliopubic tract can cause injury to nerves
- Nerves from lateral to medial; Lateral femoral cutaneous, anterior femoral cutaneous nerve, femoral nerve, femoral branch of the genitofemoral nerve, and genital branch of the genitofemoral nerve
- TACS placed lateral to the deep ring in laparoscopic hernia repair risk injury to lateral femoral cutaneous n
Who is at risk for femoral hernias?
Females and the elderly.
Where is the defect located in a femoral hernia?
Below the inguinal ligament, medial to the femoral vein.
Bulge on anterior-medial thigh
What is the open repair technique for femoral hernias?
McVay (Cooper’s) Repair
-Open inguinal floor, close femoral space by suturing Conjoint tendon to Cooper’s Ligament
High risk for incarceration: may need to divide the inguinal ligament to reduce the bowel
Femoral hernia – can be repaired suprainguinal with cooper ligament repair or infrainguinal incision directly over the hernia with plug mesh
What is the difference between incarceration and strangulation in hernias?
Incarceration: not able to reduce, can lead to obstruction and strangulation; should be repaired emergently
Strangulation: compromised blood supply; skin changes, severe tenderness, and pain.
Dusky bowl intraop.
What are the risk factors for ventral/incisional hernias?
Wound infection, obesity, COPD, smoking (discontinue prior to elective repair).
What are the types of mesh placement for hernia repair?
Underlay, inlay (highest recurrence), onlay.
What type of mesh should be chosen for hernia repair?
Macroporous mesh; biologic mesh if contamination is present.
Biologic mesh IS NOT proven to have less infection or higher recurrence rates than synthetic, only believed to be
*If performed hernia repair and accidentally get into bowel, but no gross spillage: can still use synthetic mesh
*Synthetic mesh should be used for clean and clean/contaminated cases
*Biologic mesh for contaminated or dirty
What is the optimal suture closure method for large ventral hernias?
5-7mm bites with absorbable suture.
What is a Spigelian hernia?
Occurs at the junction of the semilunaris and arcuate line, leading to an intramuscular hernia.
Spigelian – Occur below the arcuate line!! Between internal oblique muscle and external oblique aponeurosis insertion into rectus sheath
What is an Amyand hernia?
An appendix found in the inguinal hernia sac; primary repair in appendicitis.
What is a Littre’s hernia?
Meckel’s diverticulum found in the inguinal hernia sac.
What is a Pantaloon hernia?
Both indirect and direct hernia.
What is a sliding hernia?
A retroperitoneal structure makes up a portion of the sac; do not open the sac.
Female: ovaries or Fallopian tubes
Male: cecum or sigmoid
Can also involve bladder
What is a Richter’s hernia?
Part of the wall of the bowel is present in the hernia sac; strangulation without obstruction.
What should be done if you cannot find the hernia during inguinal repair?
Open the floor and look for a femoral hernia.
What is the recommended approach for massive ascites and umbilical hernia?
TIPS first to control ascites before considering repair.
Large arterial bleeding during laparoscopic inguinal hernia repair when tacking mesh to cooper’s ligament?
Consider corona mortis (branch between obturator and external iliac artery); found at lacunar ligament
What does significant medial thigh pain with internal rotation of the hip indicate?
Obturator hernia; Howship Romberg sign.
What should be done for a wound infection with purulent fluid around mesh after inguinal hernia repair?
Mesh explantation.
What should be done if the inguinal hernia sac cannot be reduced?
Ligate the proximal portion that will reduce into the abdominal cavity; keep distal portion open to reduce chances of hydrocele.
Where is the anesthetic administered for ilioinguinal/iliohypogastric block?
2 cm cephalad and 2 cm medial to the anterior superior iliac spine (ASIS).
Severe comorbid and needs hernia repair – under local. Inject lateral to ASIS to block ilioinguinal
What does the ilioinguinal nerve supply?
Branch of the first lumbar nerve (L1), runs anterior to the transversalis fascia. Skin over the groin, medial thigh, penis/scrotum in men, and mons pubis/labia majora in women.
Ilioinguinal nerve (located anterior to cord) injury L1 – MC w/ open inguinal hernia repair.
- Loss of cremasteric reflex, sensory to ipsilateral base of penis, upper scrotum and medial thigh.
- Passes through inguinal canal and superficial ring but NOT internal ring, it penetrates internal oblique and joins cord distal to deep ring
What is the traditional approach to the ilioinguinal nerve during hernia repair?
It is protected; however, neurectomy may avoid chronic groin pain postoperatively.
What does the iliohypogastric nerve supply?
Iliohypogastric nerve: from superior branch of L1, skin of the suprapubic region and posterolateral aspect of gluteal region
Iliohypogastric nerves – runs on the internal oblique, provides sensation to the pubis
Rectus sheath:
Ends: arcuate line (third of distance between umbilicus and pubis symphysis)
-Bloody supply to the rectus: inferior and Superior Epigastrics
Hesselbach’s Triangle Anatomy
-Inferior Border: Inguinal Ligament (extension of the external oblique fascia)
-Medial Border: Rectus
-Lateral Border: Epigastrics
-Hernia in Hesselbach’s triangle = Direct Hernia
Abdominal wall defect in Omphalocele? Gastroschisis?
-Omphalocele: through the umbilical stalk
-Gastroschisis: Inferior/Right of the umbilicus
-When does the midgut herniate? And what does it return?
-Herniates at 6 weeks
-Returns at 10 weeks
What are the embryological structures that are at or go through umbilicus?
-Omphalomesenteric duct (Vitelline duct) -> becomes Meckel’s Diverticulum
-Median umbilical ligament -> urachus
-Medial umbilical ligaments -> obliterated umbilical arteries
-Round ligament of liver (ligamentum teres) -> obliterated umbilical vein
Watchful waiting in minimally symptomatic hernia
Watchful waiting (in minimally symptomatic hernia in MALES only) – OK to do if patient prefers
- 64% of men who used watchful waiting required repair by 10 years
- No difference in overall survival
- No difference in requiring bowel resection
- No significant risk of bowel strangulation
- This should not be considered in females. Females are higher risk in incarceration and strangulation
Open vs laparoscopic techniques
- Meta-analyses show no difference in recurrence rates
- Laparoscopic has slightly lower rates of groin pain, numbness, and quicker return to normal activities
- Laparoscopic may have slightly higher peri-op complications
- Higher risk of surgical site infection with open repair
Prior prostate or pelvic surgery, or radiation complicates laparoscopic, go open with these
Laparoscopic hernia repair
- indicated for BL or recurrent hernias
- Has a quicker return to work and recovery and decreased pain vs open repair but has longer operative times and more complications
- avoid placing tacs lateral to inferior epigastric vessels
Rectus sheath hematoma
MC epigastric artery
Above arcuate line – will not cross midline
Below arcuate line – crosses midline more severe bleeding
Fothergill sign is palpable mass that is unchanged with flexion
Non op 1st. refractory embolization, if refractory ligation
Petit Hernia
bounded by latissimus dorsi, iliac crest, external oblique muscle (inferior lumbar triangle)
Grynfeltt hernia
-More common than petit
-bounded by quadratus lumborum, internal oblique and the 12th rib (superior lumbar triangle)
Genitofemoral nerve:
Genitofemoral nerve:
- Genital branch: cremaster (motor) and lower scrotum (sensory).
o It DOES go through deep and superficial ring
- Femoral branch: middle anterior thigh sensory
Lateral femoral cutaneous
MC nerve injured with lap inguinal hernia repairlateral thigh sensory
Mesh overlap
≥ 2 cm overlap for open repair of < 1-cm hernias
≥ 3-cm overlap for open repair of 1-4-cm hernias
≥ 5-cm overlap for open repair of > 4-cm hernias
≥ 5-cm overlap for all laparoscopic ventral hernia repairs
Ventral hernia repair
- 3 main meshes – polypropylene, PTFE, and polyester
- Umbilical hernia only some argue < 2 cm defect no mesh. Anything bigger needs mesh
- ALL incisional hernias need mesh
