ICL 3.2: Hernias Flashcards
what is a hernia?
abnormal protrusion of a peritoneal lined sac through the musculoskeletal-aponeutoric covering of the abdomen
what are the most common types of hernias?
- groin hernias (70%)
- umbilical hernias (15%)
- epigastric hernia (7%)
- incisional hernia (8%)
how does nature prevent hernia formation?
- oblique (slanted) inguinal canal
- plugging action of the spermatic cord due to contraction of cremasteric muscle
- shutter action of the arched fibers of the internal oblique and transverse abdomens during contractions
- sliding valve action of the U-shaped internal ring
why are inguinal hernias the most common?
it’s the transition zone between the abdomen and thigh! so it’s a weak area
96% are inguinal and 4% are femoral
what is primary hernia repair?
when you don’t use a mesh to close up/reinforce the hernia, you just suture one layer of fascia to another layer of fascia
recurrence rate of hernias varies with primary hernia repairs; if you have weak tissue like with collagen problems the sutures probably won’t hold
mesh is way better and that’s the standard of care
what is the estimated number of groin hernia repairs performed annually in the USA?
750,000-1 million
what are the layers of the abdominal wall?
- skin
- hypodermis = Camper’s fascia + Scarpa’s fascia
- external oblique muscle
- internal oblique muscle
- transversus abdominis muscle
- transversalis fascia
- preperitoneal fascia
- parietal peritoneum
what are the layers of the spermatic cord?
these are the layers of the tissue surrounding the testicles
- internal spermatic fascia which comes from the transversalis fascia
- cremaster muscle from the internal oblique and transverses abdomens muscled
- external spermatic fascia from the external oblique muscle
how does the peritoneum develop?
it’s initially a patent peritoneum but then it closes up to create the processes vaginalis around the testicles
if the peritoneum remains open you get communication between the peritoneum and scrotum
what are the walls of the inguinal canal?
anterior = aponeurosis of external oblique
posterior = fascia trasversalis
floor = inguinal ligament
roof = arching fibers from the very beginning of the origins of the internal oblique and traversus abdominis to the very end of the their insertions
M = muscles A = aponeurosis L = ligament T = transversalis fascia
what are the contents of the inguinal canal?
3 arteries, 3 tubes, 3 nerves, 3 coverings
arteries = testicular, art to vas, cremasteric
tubes = lymphatics, pampiniform plexus, spermatic cord
nerves = autonomic nerves, genital branch of genitofemoral nerve, olio-inguinal nerve
coverings = external spermatic fascia, cremasteric muscle, internal spermatic fascia
what anatomical landmarks are used to find the inguinal ligament?
ASIS to the pubic tubercle is where the inguinal ligament runs!
what are the boundaries of Hesselbach’s triangle?
laterally = inferior epigastric artery
medially = lateral border of rectus abdomens
inferiorly = inguinal ligament
why is Hasselbach’s triangle an important landmark?
the deep inguinal ring is lateral to the triangle which the superficial inguinal ring is within the triangle
so an indirect hernia is from the deep ring and will be lateral to Hasselbach’s triangle while a direct hernia will be from the superficial ring and be in Hesselbach’s triangle!
what are the risk factors for a hernia?
- congenital (collagen problems)
- chronic cough (asthma, COPD)
- constipation
- prostate issues
- strenuous activities
all of these risk factors cause a build up of intra-abdominal pressure so there’s a lot of strain on the tissues!
risk factors are important so that in the future you can eliminate them so that hernias don’t reoccur
what are the symptoms of a hernia?
- pain
- nausea/vomiting
- reducible or irreducible (can you push it back in?)
- inability to pass gas due to obstruction
which of the following is associated with an increased risk of developing a groin hernia?
A. trauma to the abdominal wall
B. weight lifting
C. family history of groin hernias
D. long-haul truck driving
E. cigarette smoking
all of them!
when there’s a mass in the groin, what conditions are in the differential?
- inguinal hernia
- femoral hernia
- skin lesions
- femoral artery aneurysm
- lymphadenopathy
- undescended testis
- sarcoma
- ilio-psoas abscess
- hydrocele
what are the tools available for fixing a hernia?
- primary tissue repair –> do this only if you can’t place a mesh like if there’s an infection
- tension free repair with mesh
open repair vs. laparoscopic (TAPP and TEP)
- robotic (TAPP and TEP)
hernia that contains mocker’s diverticulum?
littre’s hernia
appendix in the hernia
Amyand hernia
part of the bowel wall protruding out
richter hernia
this patient can present without a bowel obstruction because only part of the bowel is protruding out but it’s still a really serious condition so don’t be fooled!!
what is the femoral canal?
a fascial compartment made of the fascia of the femoral sheath
it is most medial compartment of the femoral sheath.
it is an empty space, containing only lymphatic vessel and one lymph node
the upper opening of the canal is the femoral ring
it opens inferiorly into the saphenous opening in the upper part of the medial surface of the thigh.
what are the boundaries of the femoral ring?
anterior = inguinal ligament
posterior = pectineal ligament
medial = lacunar ligament
laterally = femoral vein
