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General Surgery > Inguinal Hernia > Flashcards

Inguinal Hernia Flashcards

1
Q

Littre’s hernia

A

Meckel’s diverticulum in hernia sac

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2
Q

Amyand’s hernia

A
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3
Q

Richter’s hernia

A

Antimesenteric border of intestine protrudes through

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4
Q

Pantoloon Hernia

A

A “saddlebag” hernia is any combination of two hernia sacs of the femoral and inguinal region. Often indirect + direct hernia

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5
Q

Romberg Hernia

A

A Pantoloon hernia that is specifically direct + indirect hernia

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6
Q

Maydl’s hernia

A

two small loops of bowel within single hernia sac in a “W” manner

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7
Q

Boundaries of the Hasselbach Triangle

A

Lateral border of rectus muscle

Inferior epigastric artery

inguinal ligament

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8
Q

Surgical importance of the Hasselbach triangle

A

Potentially weak area due to the fact that the triangle is not reinforced by the conjoint tendon

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9
Q

What is a hernia?

A

A hernia is an abnormal protrusion of a viscus through its normal covering

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10
Q

What are the borders of the inguinal canal?

A

Inferior: inguinal ligament

Anterior: external oblique aponeurosis with lateral third of the internal oblique

Posterior: transversalis fascia and conjoint tendon

Superior: internal oblique and tranversalis abdominis

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11
Q

Risk factors for inguinal hernia

A

Gender

Advancing age

Obesity

COPD

Chronic constipation

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12
Q

Types of inguinal hernia

A

Direct : herniation through the Hasselbach Triangle

Indirect: protrusion of abdominal contents through the deep inguinal ring

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13
Q

Where is the deep inguinal ring

A

2cm above the mid-point of the inguinal ligament

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14
Q

Where is the superficial inguinal ring?

A

Triangular aperture of the EOA 1cm above the pubic tubercle

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15
Q

Where is the superficial inguinal ring?

A

Triangular aperture of the EOA 1cm above the pubic tubercle

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16
Q

Nyphus Type 1

A

Indirect hernia with normal internal ring

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17
Q

Nyphus Type II

A

Indirect hernia with enlarged internal ring

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18
Q

Nyphus Type IIIa

A

Direct hernia with weakened posterior wall

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19
Q

Nyphus Type IIIb

A

Indirect hernia with enlarged ring and weekend posterior wall

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20
Q

Nyhus Type IIIc

A

Femoral hernia

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21
Q

Nyhus Type IV (a,b,c,d)

A

Recurrent hernia

a) Direct
b) Indirect
c) Femoral
d) Combination

22
Q

Evidence in asymptomatic inguinal hernia

A

Two RCTs (Fitzgibbon JAMA 2006, O’Dwyer Ann Surg 2006)

FU study by Fitzgibbon (Ann Surg 2013), men over 65

Conclusions

  • Repair does not affect rate of long term chronic pain but beneficial to improving overall health
  • Watchful waiting is reasonable and safe, but symptoms likely to progress and will eventually need surgery
23
Q

What are the surgical options of inguinal hernia repair?

A
  • OPEN
    • Anterior approach
      • Non-Mesh
        • Bassini
        • Shouldice
        • McVay
      • Mesh
        • Lichenstein
        • Preperitoneal (Rives/Stoppa)
    • Posterior approach
      • Nyhus
  • LAPAROSCOPIC
    • Total ExtraPeritoneal (TEP)
    • TransAbdominal PrePeritoneal (TAPP)
24
Q

Describe an ideal mesh

A

Lightweight <80g/m2

Large pore (> 1mm)

Macroporous

Able to cope with transient increase in pressure (>200mmHg during coughing)

Laparoscopic meshes should not cause abdominal adhesions

25
Q

Causes of inguinodynia

A
  • Neuropathic
    • local nerve injury
  • Non-neuropathic
    • fibrosis of ilioinguinal, iliohypogastric and genital branch of genitofemoral nerve
26
Q

Risk factors for inguinodynia

A

Young age

Preoperative pain

Pain in other sites

27
Q

Evidence for use of mesh for repair

A

Meta-analysis by EU Hernia Trialist Collaboration (Ann Surg 2002)

  • Less recurrence
  • Technically easier and results reproducible
28
Q

Indication for laparoscopic approach

A
29
Q

Describe Shouldice repair

A

Four layered open repair without mesh

  • Transverse fascia incised from internal ring to pubic tubercles creating upper and lower flaps
  • Flaps are overlapped with double breasted approach with two layers of sutures
  • Conjoint tendon sutured to the inguinal ligament in two layers
30
Q

Describe the Bassini Repair

A

Open repair, non-mesh technique

  • Incision of transversals fascia from deep ring to pubic tubercle
  • Three layer reconstruction approach (transversals fascia, transverses abdomens, internal oblique ms)
31
Q

Stoppa repair

A

Open repair of preperitoneal approach with mesh

  • Lower midline or transverse incision
  • Enter preperitoneal space
  • Large mesh placement from one ASIS to the other, below the pubic symphysis and above the umbilicus
32
Q

Space of Rietzius

A

Extraperitoneal retropubic space between pubis and bladder

Boundaries:

  • Anterior: Transversalis fascia
  • Posterior: Umbilicovesical fascia
  • Superior: umbilicus
  • Inferior: pubovesical fascia
33
Q

Space of Bogros

A

Lateral extension of space fo Rietzius to the level of ASIS

  • Boundaries
    • Anterior: transversals fascia
    • Medial: Adherent zone of umbilicovesical fascia transversals fascia and peritoneum
    • Lateral: iliacus muscle and pelvic wall
    • Inferior: psoas, external iliac vessel, femoral nerve
34
Q

Iliopubic tract

A

Thickened inferior margin of transversals fascia, runs deep to the inguinal ligament, from pubic symphysis to ASIS

35
Q

Myopectineal orifice

A

Where all groin hernias originate from

  • Boundaries:
    • Superior: arching fibers of transverses abdominis
    • Inferior: ilium covered by pectineal ligament
    • Medial: rectus muscle
    • Lateral: fascia covering iliopsoas muscle
36
Q

Triangle of doom

A

Contains the external iliac vessels

  • Boundaries:
    • Medial: vas deferens
    • Lateral: gonadal vessels
    • Inferior: peritoneal edge
    • Apex: deep ring
37
Q

Triangle of Pain

A
  • Boundaries:
    • Medial: testicular/gonadal vessels
    • Lateral: iliopubic tract
    • Inferior: peritoneal edge
38
Q

Nerves crossing the triangle of pain

A

Femoral nerve

Lateral femoral cutaneous nerve of thigh

Femoral branch of genitofemoral nerve

39
Q

Corona Mortis

A

Arterial ring formed by the anastomosis of an aberrant artery from the epigastric artery with the oburator artery

It passes over the pubic tubercle, infers-medial to deep ring

20-30% of patients

40
Q

Mesh coverage requirements for open repair

A
  • Extending 5-6cm lateral to deep ring
  • 2cm medial to pubic tubercle
  • Superiorly attached high up under the superior leaf of EOA
  • Inferiorly reaching or overlap inguinal ligament
41
Q

Mesh coverage requirements for laparoscopic repair

A
  • Inferiorly below pubis and pectineal ligament
  • Large enough to cover all three potential hernia site, 3cm overlapping
  • Crosses over the midline medially
  • Peritoneum and any lipoma of cord must be well behind the inferior edge
42
Q

Complications of hernia repair

A
  • Early
    • Seroma
    • Hematoma
    • Wound infection
    • AROU
    • Bladder injury
    • Ischemic orchitis, testicular atrophy, damage to vas
    • Damage to intestines
  • Late
    • Chronic pain
    • Recurrence
43
Q

Spermatic cord rule of three

A
  • Contents
    • Vas deferens
    • Lymphatic
    • Obliterated processus vaginalis
  • 3 Nerves:
    • Genital branch of genitofemoral nerve
    • Cremasteric nerve
    • Autonomic/ Sympathetic
  • 3 Arteries
    • Testicular artery
    • Artery to the Vas
    • Cremasteric artery
  • 3 Veins
    • Pampiniform plexus
    • Vein from vas
    • Cremasteric vein
  • 3 Fascial coverings ( external spermatic, cremasteric, internal spermatic)
44
Q

Signs of poor bowel viability

A
  • Gangrenous change
  • Loss of normal sheen
  • Absent of peristalsis
  • Malodorous
  • Bloody fluid in sac
  • Loss of pulsation in mesentery
45
Q

Femoral triangle

A
  • Inguinal hernia
  • Adductor longus
  • Sartorius
46
Q

Contents of the femoral triangle

A
  • N:Femoral nerve outside femoral sheath
  • A: Femoral artery inside femoral sheath
  • V: Femoral vein inside femoral sheath
  • E: empty space
  • L: lymphatics contains deep inguinal node
47
Q

Boundaries of the femoral canal

A
  • Anterior: Inguinal ligament
  • Medial: Lacunar ligament
  • Posterior: Pectineal ligament
  • Lateral: femoral vein
48
Q

Surgical approaches for femoral hernia repair

A
  • Low approach: Lockwood
  • Trans-inguinal: Lothieson
  • High: McEvedy
49
Q

Lockwood repair

A
  • Low repair
  • Incision 1 cm below and parallel to inguinal ligament
  • Suture pectina fascia to inguinal ligament
  • Avoid injury/compression to femoral vein
50
Q

Lothieson approach

A
  • incision similar to inguinal hernia
  • Divide the transversalis fascia to reach pre-peritoneal plane
  • Identify and reduce hernia sac
  • Close the femoral ring by suture or mesh plug
  • Reconstruct inguinal canal
51
Q

Surgical technique to minimise incision hernia

A
  • Slowly absorbable or non absorbable suture
  • Place stitches
    • in aponeurosis only
    • 5-8mm from wound edge
    • 4-5mm apart
  • Suture length to wound length ratio lower than 4

General Surgery (2 decks)

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