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General Surgery > Inguinal Hernia > Flashcards

Inguinal Hernia Flashcards

1
Q

How long is the inguinal canal?

A

approximately 4- to 6 cm-long .

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2
Q

What are the boundaries of the inguinal canal ?

A
  • Anteriorly: The external oblique aponeurosis.
  • Posteriorly:The transversalis fascia and transversus abdominis muscle.
  • Laterally: The internal oblique muscle.
  • Superiorly: the internal oblique muscle.
  • Inferiorly: The inguinal (Poupart’s) ligament.
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3
Q

What are the contents of the spermatic cord ?

A

3 arteries, 3 nerves, 3 fascias, 3 other things:

  • 3 arteries: Testicular, Deferential (artery of the ductus deferens), Cremasteric.
  • 3 nerves: genital branch of the genitofemoral, sympathetic nerve fibers +/- cremasteric nerve.
  • 3 fascias: external spermatic fascia, cremasteric fascia, internal spermatic fascia.
  • 3 other things: ductus deferens, pampiniform plexus, lymphatic vessels.
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4
Q

What are the ligaments that contribute to the inguinal canal ?

A

1- Inguinal ligament.
2- Cooper’s ligament ((pectineal ligament).
3- The lacunar ligament (ligament of Gimbernat).

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5
Q

What is the iliopubic tract ?

A
  • It is an aponeurotic band that begins at the anterior superior iliac spine and inserts into Cooper’s ligament from above.
  • It forms on the deep inferior margin of the transversus abdominis and transversalis fascia.
  • It helps form the inferior margin of the internal inguinal ring as it courses medially, where it continues as the anteromedial border of the femoral canal.
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6
Q

What is the lacunar ligament, or ligament of Gimbernat ?

A

It is the triangular fanning of the inguinal ligament as it joins the pubic tubercle.

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7
Q

What is Cooper’s (pectineal) ligament ?

A

Cooper’s (pectineal) ligament is the lateral portion
of the lacunar ligament that is fused to the periosteum of the
pubic tubercle.

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8
Q

What is the the conjoined tendon ?

A

The conjoined tendon is commonly described as the fusion of the inferior fibers of the internal oblique and transversus abdominis aponeurosis at the point where they insert on the pubic tubercle.

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9
Q

What is the difference between Indirect hernias direct

hernias ?

A
  • Indirect hernias:
    protrude lateral to the inferior epigastric vessels, through the deep inguinal ring.
  • Direct hernias:
    protrude medial to the inferior epigastric vessels, within
    Hesselbach’s triangle.
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10
Q

What are the borders of Hesselbach’s triangle ?

A
  • Inferiorly: inguinal ligament
  • Medially: lateral edge of rectus sheath
  • Superolaterally: the inferior epigastric vessels.
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11
Q

What are the borders of the femoral ring?

A
  • Anteriorly: the iliopubic tract and inguinal ligament.
  • Posteriorly: Cooper’s ligament.
  • Medially: the lacunar ligament.
  • Laterally: the femoral vein.
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12
Q

What is the the classification that categorizes hernia defects by location, size, and type ?

A

Nyhus classification system.

  • Type I.
  • Type II
  • Type IIIA
  • Type IIIB
  • Type IIIC
  • Type IV
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13
Q

What is Nyhus classification Type I ?

A

Indirect hernia; internal abdominal ring
normal; typically in infants, children,
small adults.

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14
Q

What is Nyhus classification Type IIIB ?

A 
Indirect hernia that has enlarged enough
to encroach upon the posterior inguinal
wall; indirect sliding or scrotal hernias
are usually placed in this category
because they are commonly associated
with extension to the direct space; also
includes pantaloon hernias.
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15
Q

What is the space of Retzius ?

A

It is the most medial aspect of the preperitoneal space, that which lies superior to the bladder.

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16
Q

The rectus abdominis muscle supplied by which artery ?

A

inferior epigastric artery.

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17
Q

The inferior epigastric artery is derived from which artery ?

A

External iliac artery.

18
Q

What are the Nerves of interest in the inguinal region?

A
  1. The ilioinguinal nerve.
  2. The iliohypogastric nerve.
  3. The genitofemoral nerve.
  4. The lateral femoral cutaneous nerves.
19
Q

What does the ilioinguinal nerve supplies?

A

It supplies:
- somatic sensation to the skin of the upper and medial thigh.
- In males: the base of the penis and upper scrotum.
In females: the mons pubis and labium majus.

20
Q

What are the borders and contents of the Triangle of doom in laparoscopic hernia repair?

A
  • Medially: by the vas deferens.
  • Laterally: by the vessels of the spermatic cord.

The contents of the space include:

  • The external iliac vessels.
  • Deep circumflex iliac vein.
  • Femoral nerve.
  • The Genital branch of the genitofemoral nerve.
21
Q

What are the borders and contents of the The triangle of pain in laparoscopic hernia repair ?

A 
Bordered by:
-The iliopubic tract.
- Gonadal vessels.
Contains: 
- The lateral femoral cutaneous.
- Femoral branch of the genitofemoral.
- Femoral nerves.
22
Q

What is The circle of death in laparoscopic hernia

repair ?

A 
It is a vascular continuation formed by:
- The common iliac.
- Internal iliac.
- Obturator.
- Inferior epigastric.
- External iliac.
 vessels
23
Q

What are the assumed causes of groin herniation ?

A
  1. Weakness in the abdominal wall musculature.
  2. Coughing
  3. Chronic obstructive pulmonary disease
  4. Obesity
  5. Straining: Constipation or Prostatism.
  6. Pregnancy
  7. Birthweight <1500 g
  8. Family history of a hernia
  9. Valsalva’s maneuver
  10. Ascites
  11. Upright position
  12. Congenital connective tissue disorders
  13. Defective collagen synthesis
  14. Previous right lower quadrant incision
  15. Arterial aneurysms
  16. Cigarette smoking
  17. Heavy lifting
  18. Physical exertion
24
Q

In which trimester does the testes descend from the intra-abdominal space into the scrotum?

A

In the third trimester.

25
Q

What is the processus vaginalis (vaginal process) ?

A

It is an embryonic developmental outpouching of the peritoneum. It is present from around the 12th week of gestation, and commences as a peritoneal outpouching.
In males, it precedes the testis in their descent down within the gubernaculum, and closes between 36 and 40 weeks of gestation.

26
Q

Why preterm babies has a high incidence of indirect inguinal hernias ?

A

The processus vaginalis (vaginal process) closes between
36 and 40 weeks of gestation, and failure of the peritoneum to close results in a patent processus
vaginalis (PPV).

27
Q

What is the Differential diagnosis of groin hernia?

A
  1. Malignancy
    • Lymphoma
    • Retroperitoneal sarcoma
    • Metastasis
    • Testicular tumor
  2. Primary testicular
    • Varicocele
    • Epididymitis
    • Testicular torsion
    • Hydrocele
    • Ectopic testicle
    • Undescended testicle
  3. Femoral artery aneurysm or pseudoaneurysm
  4. Lymph node
  5. Sebaceous cyst
  6. Hidradenitis
  7. Cyst of the canal of Nuck (female)
  8. Saphenous varix
  9. Psoas abscess
  10. Hematoma
  11. Ascites
28
Q

Where can femoral hernias be palpated?

A

Femoral hernias should be palpable below the inguinal ligament, lateral to the pubic tubercle.

29
Q

What happens when the genital branch of the genitofemoral nerve is divided in the Shouldice repair ?

A

Ipsilateral loss of sensation to the scrotum in men or the mons pubis and labium majus in females.

30
Q

What are the clinical signs that indicate strangulation ?

A
  • Tenderness
  • Fever
  • Leukocytosis
  • Hemodynamic instability.
  • Hernia bulge is warm, tender and erythematous or discolored.
31
Q

What are the types of tissue- based and prosthetic- based reconstruction in open inguinal hernia repair ?

A

Tissue Repair:

  • Bassini repair.
  • Shouldice repair.
  • McVay repair.
  • Desarda repair.

Prosthetic repair:

  • Lichtenstein tension-free repair
  • Plug and patch repair
32
Q

What are the indications of tissue repair in open inguinal hernia repair

A
  • Operative field contamination.
  • Emergency surgery
  • When the viability of hernia contents is uncertain.
33
Q

What is Amyand’s hernia ?

A

Appendix within inguinal hernia

34
Q

What are the complications of the plug and patch technique of the inguinal hernia repair?

A
  • Bowel obstruction

- Chronic pain.

35
Q

What are the names of the laparoscopic approaches of inguinal hernia repair?

A
  • Transabdominal preperitoneal (TAPP) reapir.
  • Totally extraperitoneal (TEP) repair.
  • Intraperitoneal onlay mesh (IPOM) repair “less commonly performed”.
36
Q

What are the contraindications of laparoscopic and robotic inguinal hernia repair?

A
  • Coagulopathy.
  • Sever cardiopulmonary disease that precluding induction of general anesthesia and pneuomoperitoneum.

Relative contraindications:

  • Previous preperitoneal repair.
  • presence of large incarcerated inguinal hernia.
37
Q

What are the most common options for treatment of postherniorrhaphy inguinodynia ?

A
  • Selective ilioinguinal/iliohypogastric/genitofemoral neurolysis or neurectomy.
  • Removal of mesh and fixation material.
  • Revision of the repair.
38
Q

What is the cause of Ischemic orchitis post inguinal hernia repair?

A

Injury to the pampiniform plexus .

39
Q

What is the cause of testicular atrophy post inguinal hernia repair?

A

Injury to the testicular artery.

40
Q

What is the most common cause of urinary retention after inguinal hernia repair?

A

General anesthesia

41
Q

What are the risk factors of urinary retention after inguinal hernia repair?

A
  • Pain
  • Narcotic analgesia
  • Perioperative bladder distension.

General Surgery (11 decks)

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