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Hernias flash Flashcards

1
Q

What are the layers of the abdominal wall?

A

Skin, Subcutaneous Fat/Camper’s Fascia, Scarpa’s fascia, external oblique, internal oblique, rectus abdominus, transversus abdominus, transversalis fascia, preperitoneal Fat, peritoneum

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2
Q

What forms the transversus abdominus fascia?

A

Transversalis fascia.

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3
Q

What are the boundaries of the inguinal canal?

A

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.

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4
Q

What is the conjoint tendon?

A

Located posterior to the superficial ring, formed by transversus abdominus fascia and internal oblique aponeurosis.

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5
Q

What structures are found in the spermatic cord?

A

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

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6
Q

What is the iliopubic tract?

A

Thickening of the transversalis fascia near the inguinal ligament.

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7
Q

What does the median umbilical fold (ligament) carry?

A

Urachus.

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8
Q

What do the medial umbilical folds carry?

A

Obliterated umbilical arteries; site of direct hernia.

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9
Q

What do the lateral umbilical folds cover?

A

Inferior epigastric vessels.

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10
Q

What is the risk of hernia recurrence?

A

Hernia width and contamination are the two most important factors.

MCC for recurrent hernia= wound infection

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11
Q

What is the most common type of inguinal hernia?

A

Indirect hernia.

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12
Q

What is the difference between indirect and direct inguinal hernias?

A

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.

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13
Q

What is the Lichtenstein repair?

A

Mesh used; conjoint tendon to inguinal ligament; reconstructs the floor.

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14
Q

What is the Shouldice repair?

A

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

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15
Q

What is the Cooper (McVay) ligament repair used for?

A

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
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16
Q

What is the most common complication following inguinal hernia repair?

A

Urinary retention.

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17
Q

What is the triangle of doom?

A

Medial border is vas deferens; lateral border is gonadal vessels; contains external iliac vessels.

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18
Q

What are the boundaries of the femoral canal?

A

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

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19
Q

What is the definition of a ventral hernia?

A

An abdominal wall defect that can occur at various sites.

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20
Q

What is the Rives-Stoppa repair?

A

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
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21
Q

What is the anterior component separation?

A

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

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22
Q

What is the transverse abdominus release?

A

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

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23
Q

What are the key nerves injured in open inguinal hernia repair?

A

Ilioinguinal (most common; when opening external oblique), genital branch of genitofemoral, iliohypogastric.

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24
Q

What is the most commonly injured nerve in laparoscopic repair?

A

Lateral femoral cutaneous nerve; occurs from improperly placed tack laterally.

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25
Q

What is the Bassini repair technique?

A

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

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26
Q

What distinguishes the Shouldice repair technique?

A

It is similar to Bassini but performed in multiple (4) layers.

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27
Q

What is the Lichtenstein repair technique?

A

Repair with mesh, sewing the inguinal ligament to the conjoined/transversalis.

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28
Q

What is the plug and patch technique?

A

A plug is placed into the internal repair, followed by Lichtenstein on top.

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29
Q

What are the basics of pediatric hernia repair?

A

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

30
Q

What are the two types of laparoscopic hernia repair?

A

Total Extra-Peritoneal Repair (TEP) and Trans-Abdominal Pre-Peritoneal Repair (TAPP- need to close peritoneum after mesh to prevent adhesions)

31
Q

What is the main structure of fixation in laparoscopic repair?

A

Cooper’s ligament.

32
Q

What does the Triangle of Doom contain?

A

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

33
Q

What does the Triangle of Pain contain?

A

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
34
Q

Who is at risk for femoral hernias?

A

Females and the elderly.

35
Q

Where is the defect located in a femoral hernia?

A

Below the inguinal ligament, medial to the femoral vein.

Bulge on anterior-medial thigh

36
Q

What is the open repair technique for femoral hernias?

A

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

37
Q

What is the difference between incarceration and strangulation in hernias?

A

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.

38
Q

What are the risk factors for ventral/incisional hernias?

A

Wound infection, obesity, COPD, smoking (discontinue prior to elective repair).

39
Q

What are the types of mesh placement for hernia repair?

A

Underlay, inlay (highest recurrence), onlay.

40
Q

What type of mesh should be chosen for hernia repair?

A

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

41
Q

What is the optimal suture closure method for large ventral hernias?

A

5-7mm bites with absorbable suture.

42
Q

What is a Spigelian hernia?

A

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

43
Q

What is an Amyand hernia?

A

An appendix found in the inguinal hernia sac; primary repair in appendicitis.

44
Q

What is a Littre’s hernia?

A

Meckel’s diverticulum found in the inguinal hernia sac.

45
Q

What is a Pantaloon hernia?

A

Both indirect and direct hernia.

46
Q

What is a sliding hernia?

A

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

47
Q

What is a Richter’s hernia?

A

Part of the wall of the bowel is present in the hernia sac; strangulation without obstruction.

48
Q

What should be done if you cannot find the hernia during inguinal repair?

A

Open the floor and look for a femoral hernia.

49
Q

What is the recommended approach for massive ascites and umbilical hernia?

A

TIPS first to control ascites before considering repair.

50
Q

Large arterial bleeding during laparoscopic inguinal hernia repair when tacking mesh to cooper’s ligament?

A

Consider corona mortis (branch between obturator and external iliac artery); found at lacunar ligament

51
Q

What does significant medial thigh pain with internal rotation of the hip indicate?

A

Obturator hernia; Howship Romberg sign.

52
Q

What should be done for a wound infection with purulent fluid around mesh after inguinal hernia repair?

A

Mesh explantation.

53
Q

What should be done if the inguinal hernia sac cannot be reduced?

A

Ligate the proximal portion that will reduce into the abdominal cavity; keep distal portion open to reduce chances of hydrocele.

54
Q

Where is the anesthetic administered for ilioinguinal/iliohypogastric block?

A

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

55
Q

What does the ilioinguinal nerve supply?

A

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

56
Q

What is the traditional approach to the ilioinguinal nerve during hernia repair?

A

It is protected; however, neurectomy may avoid chronic groin pain postoperatively.

57
Q

What does the iliohypogastric nerve supply?

A

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

58
Q

Rectus sheath:

A

Ends: arcuate line (third of distance between umbilicus and pubis symphysis)
-Bloody supply to the rectus: inferior and Superior Epigastrics

59
Q

Hesselbach’s Triangle Anatomy

A

-Inferior Border: Inguinal Ligament (extension of the external oblique fascia)
-Medial Border: Rectus
-Lateral Border: Epigastrics
-Hernia in Hesselbach’s triangle = Direct Hernia

60
Q

Abdominal wall defect in Omphalocele? Gastroschisis?

A

-Omphalocele: through the umbilical stalk
-Gastroschisis: Inferior/Right of the umbilicus

61
Q

-When does the midgut herniate? And what does it return?

A

-Herniates at 6 weeks
-Returns at 10 weeks

62
Q

What are the embryological structures that are at or go through umbilicus?

A

-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

63
Q

Watchful waiting in minimally symptomatic hernia

A

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
64
Q

Open vs laparoscopic techniques

A
  • 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

65
Q

Rectus sheath hematoma

A

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

66
Q

Petit Hernia

A

bounded by latissimus dorsi, iliac crest, external oblique muscle (inferior lumbar triangle)

67
Q

Grynfeltt hernia

A

-More common than petit
-bounded by quadratus lumborum, internal oblique and the 12th rib (superior lumbar triangle)

68
Q

Genitofemoral nerve:

A

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

69
Q

Lateral femoral cutaneous

A

MC nerve injured with lap inguinal hernia repairlateral thigh sensory

70
Q

Mesh overlap

A

≥ 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

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