Inguinal Hernias, Abdominal Wall, Omentum, Mesentery, & Retroperitoneum

Question 1

What are the important boundaries of the inguinal canal?

Answer 1

Anterior: external oblique aponeourosis
Posterior: transversalis fascia & transcersus abdominis
Lateral: internal oblique muscle
Inferior: inguinal ligament (Poupart’s ligament)
Sperior: internal oblique & transversus abdominis muscle

Question 2

What are the structures in the inguinal canal that should be protected to avoid complications?

Answer 2

Three arteries
Three veins
2 nerves
Pampiniform venou plexus
Vas deferens
Enveloped by 3 layers of spermatic fascia

Question 3

What is the difference betw the indirect and direct hernia

Answer 3

Direct = medial to the inferior epigastric vessels within the HEsselbach’s triangle

Indirect = protrudes lateral to the inferior epigastric vessels through the deep inguinal ring

Question 4

What are the boundaries of the Hesselbach’s triangle?

Answer 4

Inferior: inguinal ligament
Medial: lateral edge of the rectus sheath
Lateral: inferior epigastric vessels

Question 5

What is the location of fermoral henia?

Answer 5

Seen BELOW the inguinal ligament

Question 6

What is the landmark used to differentiate direct from indeirect inguinal hernia?

Answer 6

Inferior epigastric vessels

Direct inguinal hernia = MEDIAL to the inferior epigastric vessels

Indirect inguinal hernia = LATERAL to the inferior epigastric vessels

Question 7

What are the points of reference in inguinal hernia?

Answer 7

5 peritoneal folds
Bladder
Inferior epigastric vessels
Psoas muscle
Space of Bogros (preperitoneal space)

Question 8

What artery supplies the rectus abdominis muscle?

Answer 8

Inferior epigastric artery

Question 9

What are the nerves of interest in the inguinal canal?

Answer 9

Ilioinguinal nerve
Iliohypogastric nerve
Genitofemoral nerve
Lateral femoral cutaneounerve

Question 10

What are the important areas of interest of the Preperitoneal anatomy?

Answer 10

Triangle of Doom
Triangle of pain
Circle of death

Question 11

What are the sides of triangle of doom?

Answer 11

Medial: vas deferens
Lateral: vessels of the spermatic cord
External iliac vessels & deep circumflex iliac vein

Question 12

What are the vessels inside the circle of death?

Answer 12

Common iliac
Internal iliac
Obturator
Inferior epigastric
External iliac vessels

Question 13

What is the cause of inguinal hernia in pediatric px?

Answer 13

Failure of the processus vaginalis to close

Question 14

How do you differentiate through physical exam indirect & direct inguinal hernia?

Answer 14

Indirect = herniating organ is felt pushng on the tip of the finger

Direct = felt at the dorsal aspect

Question 15

What is the definitive treatment of inguinal hernia?

Answer 15

Surgical repair: open approach

Question 16

What are indications for urgent repair of inguinal hernia?

Answer 16

Incarceration
Strangulation

Question 17

What is inarceration in inguinal hernia?

Answer 17

Failure to reduce the herniating organ

Happens in indirect inguinal hernia & femoral hernia

Question 18

What is attempted for incarcerate hernias without sequelae of strangulation?

Answer 18

Taxis

Question 19

What are clinical signs of strangulation?

Answer 19

Tenderness
Fever
Leukocytosis
Hemodynamic instability

Question 20

What is the most comonly performed type of hernia operation and its types?

Answer 20

Open inguinal hernia repair
= mesh repair (more common) & tissue repair (px with infected fields)

Question 21

What are the types of tissure repair used in open approach of ingiunal hernias?

Answer 21

Bassini repair
SHouldice repair
Mcvay cooper’s ligament repair
Desarda repair

Question 22

What is the gold standard of prosthetic repairs in inguinal hernia?

Answer 22

Lichenstein tension-free repair

Question 23

What is the significance of laparascopic approach in inguinal hernia?

Answer 23

Reinforce the abdominal wall ia posterior approach

NOT ADVISED in px who cannot undergo general anesthesia

Question 24

What is the useful prosthetic repair for bilateral hernias, large hernias, or scarring from previous lower abdominal surgery?

Answer 24

Tapp repair

Question 25

What is the advantage of TEP repair?

Answer 25

Access to the preperitoneal space without intraperitoneal infiltration

Question 26

What are the most common complications of inguinal hernia repair?

Answer 26

Bleeding Infeciton Seroma Urinary retention Ileus Injury to adjacent structures

Question 27

What presents as pain, bulging, or a mass at the site of repair?

Answer 27

Hernia recurrence

Question 28

What aer the 3 mechanisms of pain assoc with hernia?

Answer 28

Nociceptive (somatic) pain = most common Neuropathic pain = direct nerve damage or entrapment Visceral pain = poorly localized

Question 29

What nerves are at great risk of entrapment?

Answer 29

Ilioinguinal & iliohypogastric nerves = anterior repairs Genitofemoral and lateral femoral cutaneous nerves = endoscopic repairs

Question 30

What is the most common injury to the paminiform plexus?

Answer 30

Ischemic orchitis

Question 31

What are the commonly injured vessels in hernia?

Answer 31

Inferior epigastrics and external iliac arteries

Question 32

What are the nin elayers of the abdominal wall?

Answer 32

Skin SQ tissue Superficial fascia: campers & scarpas External oblique m Intenral oblieuq m Transversus abdominis Transversalis fascia Preperitoneal adipose tissue Peritoneum

Question 33

What are the congenital abnormalities of the abdominal walls?

Answer 33

Omphalocele Gastroschisis Vitelling duct abnormalities Urachus

Question 34

What are the diff acquired abnormaltiies of the abdominal wall?

Answer 34

Abdominal wall hernias: - non-incisional hernias (umbilical hernias, spigelian hernias, epigastric hernias) - incisional hernias (simple suture repair, open mesh repair) - rectus abdominis diastasis - rectus sheath hematoma

Question 35

What is a Fothergill’s sign?

Answer 35

Palpatioon of a mass that does not change during contrction of the rectus muscle

Question 36

What are the different acquired disorders of the omentum?

Answer 36

Omental infarction Omental cysts

Question 37

What is the type of cancer most comonly seen to have omental involvement?

Answer 37

Ovarian cancer

Question 38

What are the diff conditions in the mesentery?

Answer 38

Sclerosing mesenteritis Mesenteric cyst Mesenteric tumors

Question 39

What are the 2 types of sclerosing mesenteritis?

Answer 39

Localized = Mesenteric lipodystrophy Diffuse = mesenteric panniculitis

Question 40

What are the confirmatory signs of Sclerosing Mesenteritis in abdominal CT with IV contrast?

Answer 40

Tumor pseudocapsule Fat ring sign

Question 41

What is a confirmatory sign of Mesenteric cyst?

Answer 41

Tillaux’s sign = mass that is only mobile laterally

Question 42

What are the boundaries of Retroperitneum?

Answer 42

Anterior: peritoneum Posterior: iliopsoas & lumbar muscles Superior: diaphragm Inferior: levator ani

Question 43

what are the important spaces in retroperitoneum?

Answer 43

Anterior pararenal spacec Perirenal space Posterior pararenal space