INGUINAL HERNIAS Flashcards
Indirect Hernia
protrude LATERAL to the inferior epigastric vessels, through the deep inguinal ring
Direct Hernia
protrude MEDIAL to the inferior epigastric vessels, within Hesselbach’s triangle
Hesselbach’s triangle
BORDERS OF THE TRIANGLE
INFERIOR - inguinal ligament
MEDIAL - lateral edge of rectus sheath
SUPEROLATERALLY - inferior epigastric vessels
Femoral Hernia
protrude through the small and inflexible femoral ring
traverse the empty space between the femoral vein and the lymphatic channels
Femoral Ring
BORDERS OF THE FEMORAL RING • ANTERIOR - iliopubic tract and inguinal ligament • POSTERIOR - Cooper’s ligament • MEDIAL – lacunar ligament • LATERAL – femoral vein
Nerve which runs with the spermatic cord in the
inguinal canal
Ilioinguinal nerve
Risk of strangulation
Higher with INDIRECT than direct inguinal hernia, but highest in FEMORAL hernias
Nyhus Classification System
Type I - Indirect Hernia w/ normal internal abdominal ring
Type II - Indirect Hernia; enlarged internal ring w/o impingement on the floor of inguinal canal; does not extend into scrotum
Type IIIA - direct hernia
Type IIIB - indirect hernia large enough to intrude the posterior inguinal floor
- SLIDING, SCROTAL and PANTALOON hernia
Type IV - recurrent hernia
- A - recurrent direct
- B - recurrent indirect
- C - recurrent femoral
- D - recurrent combination
Triangle of Doom
BORDERS
MEDIAL: ductus deferens
LATERAL: gonadal vessels
POSTERIOR: peritoneal edge
CONTENTS
external iliac artery and vein
deep circumflex iliac vein
femoral nerve
genital branch of the genitofemoral nerve
Triangle of Pain
BORDERS
SUPEROMEDIAL: gonadal vessels
INFEROLATERAL: iliopubic tract
LATERAL: reflected peritoneum
CONTENTS
lateral femoral cutaneous nerve
femoral branch of the genitofemoral nerve
femoral nerve
An abnormal protrusion of an organ or tissue through a defect in its surrounding walls
Hernia
MC symptom of inguinal hernia
groin mass that protrudes while standing, coughing, or straining
3-Finger test or Zieman technique
with patient standing the fingers are positioned as follows:
INDEX finger: placed at the DEEP (internal) inguinal ring
MIDDLE finger: placed at the SUPERFICIAL (external) inguinal ring
RING finger: placed at the SAPHENOUS opening (over femoral canal)
patient is asked to cough or strain:
INDIRECT HERNIA: impulse felt at DEEP (internal) inguinal ring
DIRECT HERNIA: impulse felt at SUPERFICIAL (external) inguinal ring
FEMORAL HERNIA: felt at SAPHENOUS opening
Signs of strangulated hernia
- tenderness
- fever
- leukocytosis
- hemodynamic instability
hernia bulge is usually warm and tender
overlying skin may be erythematous or discolored
Incidence of inguinal hernias in men has a bimodal distribution, which peaks
before 1st year of life and after age 40
2 types of collagen found to exist in a decreased
ratio of the skin of inguinal hernia
types I and III
Should be attempted or incarcerated hernias W/O sequelae of strangulation
Taxis
Emergent herniorrhaphy
Indicated if strangulation is suspected or acute
incarceration is present
Elective herniorrhaphy
Indicated to prevent the chance of incarceration/strangulation
Indications for Tissue Repair
o operative field contamination
o emergency surgery
o when the viability of hernia contents is uncertain
Sutures approximate reflection of inguinal ligament (Poupart’s) to the transversus abdominis aponeurosis/
conjoint tendon
Bassini
Cooper’s ligament sutured to transversus abdominis aponeurosis/conjoint tendon
McVay
Tension-free repair” using mesh
Lichtenstein
Imbrication of the floor of the inguinal
canal (a.k.a. “Canadian repair”)
Shouldice
Placing a plug of mesh in hernia defect
and then overlaying a patch of mesh over
inguinal floor
Plug and Patch
Ligation and transection of indirect
hernia sac without repair of inguinal floor
(used only in children)
High Ligation
Indications for laparoscopic inguinal hernia
repair
Bilateral inguinal hernias
Recurring hernia
Need to resume full activity as soon as possible
Addresses both inguinal and femoral ring defects
Indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated
McVay
Consists of a mesh-free repair utilizing a strip of external oblique aponeurosis
Desarda
MC Complications of Inguinal Hernia Repair
bleeding infection seroma urinary retention ileus injury to adjacent structures
This is considered when pain, bulging, or a mass at the site of an inguinal hernia repair are present as well as clinical entities such as seroma, persistent cord lipoma
Recurrent hernia
Common medical issues associated with recurrence
malnutrition immunosuppression diabetes steroid use smoking
Usually a result of ligamentous or muscular trauma and inflammation – reproduced with abdominal muscle contraction
Nociceptive pain
The MC cause of urinary retention after hernia repair
general anesthesia
Injury to the LATERAL FEMORAL CUTANEOUS nerve
Meralgia paresthetica
Mimic acute neuropathic pain, and they occur with a dermatomal distribution
Local nerve Entrapment
Occurs as a result of direct nerve damage or entrapment
Neuropathic pain
Occurs as a result of direct nerve damage or entrapment
Visceral pain
A debilitating chronic complication of inguinal hernia repair
postherniorrhaphy inguinodynia
hernia repair method associated with the LOWEST RECURRENT RATE
Lichtenstein
Change in bowel habits or urinary symptoms
sliding hernia - w/ intestinal contents or involvement
of the bladder within the hernia sac
Contents of spermatic cord
- Cremasteric muscle fibers
- Vas deferens
- Testicular artery
- Testicular pampiniform venous plexus
- +/- hernia sac
- Genital branch of the genitofemoral
nerve
Attaches the testicle to the scrotum
Gubernaculum
Hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels
Femoral Hernia
Boundaries of the femoral canal
- Cooper’s ligament posteriorly
- Inguinal ligament anteriorly
- Femoral vein laterally
- Lacunar ligament medially
Defect of LINEA ALBA anywhere from xiphoid to umbilicus
Epigastric (Ventral) Hernia
Incomplete closure of early natural umbilical defect
Umbilical Hernia
Herniation of intraperitoneal viscera into open umbilical ring
Omphalocele
Defect of anterior abdominal wall to right or left of the midline
Gastroschisis
Herniation along the the LINEA SEMILUNARIS anywhere above level of umbilicus lateral to the symphysis pubis
Spigelian
Herniation through SUPERIOR LUMBAR triangle
Grynfelt (Superior Lumbar)
Herniation through INFERIOR LUMBAR triangle
Petit (Inferior Lumbar)
Herniation through greater sciatic foramen ABOVE piriformis muscle
Suprapiriformic hernia
Herniation through greater sciatic foramen BELOW piriformis muscle
Infrapiriformic hernia
Herniation through lesser sciatic foramen
Subspinous hernia
Herniation through the LUMBOCOSTAL TRIGONE (above and lateral to left lateral lumbocostal arch)
Congenital Diaphragmatic: Bochdalek hernia (posterolateral)
Herniation through the STERNOCOSTAL TRIANGLE (foramina of Morgagni, space of Larrey)
Congenital Diaphragmatic: Bochdalek hernia (posterolateral)
MCC of URINARY RETENTION after hernia repair
General Anesthesia
