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Surgery > Medbear Hernia > Flashcards

Medbear Hernia Flashcards

1
Q

Define hernia

A

Abnormal protrusion of viscus through an abnormal opening in the wall of the cavity in which it is normally contained

It can be:
- Reducible
- Incarcerated
- Strangulated

3 parts: Neck, body, sac

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2
Q

List the 6 layers of anterior abdominal wall

A
  1. Skin and subcutaneous tissue
  2. Superficial fascia - composed of 2 distinct layer
    - CAMPER’S FASCIA - superficial fatty layer
    - SCARPA’S FASCIA - deep fibrous layer
  3. Myofascial
    - Abdominal wall muscles
    - Fascial interface
    - Rectus sheath
  4. Transversalis fascia
  5. Extra-peritoneal fat
  6. Parietal peritoneum
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3
Q

State the origin and insertion of rectus abdominis

A

Origin: Pubic line

Insertion: Xiphoid process and 5-7th costal cartilage

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4
Q

What nerves supplies the rectus abdominis?

A

THORACOABDOMINAL NERVES

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5
Q

State the origin and insertion of external oblique.

A

Origin: Lower 8 ribs (5th - 12th rib)

Insertion: Iliac crest, Pubic crest, Linea alba

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6
Q

Which nerves innervate the external oblique?

A

THORACOABDOMINAL NERVES (T7-11) +
SUBCOSTAL NERVES (T12)

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7
Q

State the origin and insertion of internal oblique

A

Origin: Lumbar fascia, iliac crest and inguinal ligament

Insertion: Costal margin, Aponeurosis of rectus tendon to pubic crest and pectineal line

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8
Q

Which nerves innervates the internal oblique?

A

THORACOABDOMINAL (T7-11) +
SUBCOSTAL (T12) +
ILIOINGUINAL NERVE (L1)

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9
Q

State the origin and insertion of transversus abdominis.

A

Origin: Costal margin, lumbar fascia, anterior iliac crest, inguinal ligament

Insertion: Aponeurosis of conjoint tendon to pubic crest and pectineal line

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10
Q

Which nerve supplies the transversus abdominis?

A

THORACOABDOMINAL (T7-11) +
SUBCOSTAL (T12) +
ILIOINGUINAL

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11
Q

List the blood supply of the abdomen based on Zone 1, Zone 2 and Zone 3.

A
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12
Q

State the principle of abdominal hernia surgery.

A
  1. Identification of hernia sac
  2. Reducing the contents of the hernia sac +/- removal of non-viable tissue
  3. Excision and closure of the sac
  4. Repair of the abdominal wall defect
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13
Q

List the different abdominal mesh used for hernia repairs (based on locations in the abdomen)

A
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14
Q

State the boundaries of inguinal canal
Anterior wall:
Posterior wall:
Roof:
Floor:

A

Anterior wall: External Oblique Aponeurosis

Posterior wall: Transversalis fascia

Roof: Arching fibres of the IO and TA before they merge as the conjoint tendon

Floor: Inguinal ligament and lacunar ligament medially

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15
Q

State the boundaries of the Hesselbach’s triangle
Laterally
Medially
Inferiorly
Floor

A

Laterally -> Inferior epigastric artery
Medially -> Lateral border of rectus abdominis
Inferiorly -> Inguinal ligament
Floor -> Transversalis fascia

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16
Q

State the clinical presentation of inguinal hernia

What radiological evaluation can be done to investigate on inguinal hernia?

A
  • Intermittent bulge in the groin
  • Pain in the groin without bulge
  • Purposeful Valsava maneuvre can reproduce the symptoms

Radiological evaluation:
1. Dynamic US (with Valsava -> to accentuate small hernia)
2. AXR (Supine) (if suspect intestinal obstruction secondary to obstructed inguinal hernia)
3. CT AP (if the diagnosis is in doubt)

17
Q

List 5 clinical difference between indirect hernia and direct hernia

A
18
Q

State 3 types of open inguinal hernia repair (with mesh/without mesh).

A
  • Herniotomy (removal of hernia sac only)
  • Herniorrhaphy (herniotomy + repair of posterior wall of inguinal canal)
  • Hernioplasty (reinforcement of posterior inguinal canal wall with a synthetic mesh)
19
Q

What are the advantages of laparoscopic repair vs open repair in a case of hernia?

A
  • Shorter length of hospital stay
  • Faster return to normal activity
20
Q

State (5) early complications of a hernia repair surgery.

A
  • Acute retention of urine
  • Hematoma
  • Seroma
  • Nerve injury (e.g ILIOINGUINAL n -> Open surgery, LATERAL FEMORAL CUTANEOUS n -> laparoscopic)
  • Wound infection
21
Q

Name (5) late complication of a hernia repair surgery.

A
  • Chronic (>3 months) post-operative groin pain
  • Injury to vas deferens -> Infertility
  • Recurrence (5%) - due to inadequate ring and posterior wall closure
  • Ischaemic orchitis - from thrombosis of pampiniform plexus which drains from the testis
  • Testicular atrophy - due to testicular artery damage
  • Meshoma
22
Q

If you were ask to classify hernia surgery based on wound class, what would hernia surgery classified as?

A

Clean Operation (Class I)

23
Q

State the medial, intermediate and lateral compartment of the femoral sheath

A

Medial = Femoral canal which carries lymphatics, lymph node of Cloquet, and adipose tissue

Intermediate = Femoral vein

Lateral = Femoral artery

24
Q

State the 2 main function of femoral canal

A
  • Dead space for extension of the distended femoral vein
  • Lymphatic pathway from LL to external iliac nodes
25
Q

Femoral ring = superior opening of the femoral canal

State the boundaries of the femoral ring
Anterior:
Posterior:
Medial:
Lateral:

A

Anterior = Inguinal ligament

Posterior = Pectineal ligament (of Astley Cooper) which runs along the pectineal line of superior pubic ramus

Medial = Lacunar ligament

Lateral = Femoral vein

26
Q

State the boundaries of the femoral triangle
Superior:
Medial:
Lateral:
Floor:
Roof:

A

Superior = Inguinal ligament

Medial = Medial border of adductor longus

Lateral = Medial border of Sartorius

Floor = Iliacus, Psoas tendon, Pectineus, Adductor longus

Roof = Superficial fascia (LN & great saphenous vein)

27
Q

What is the difference between inguinal and femoral hernia

A
28
Q

For open repair of femoral hernia, there are 3 approaches

List the 3 approaches

A
  1. Infrainguinal approach (LOCKWOOD) -> used for elective femoral hernia
  2. Trans-inguinal approach (LOTHIESSEN) -> can repair both inguinal and femoral hernia
  3. Supra-inguinal approach (McEvedy) -> used when suspecting strangulating hernia

*Mesh repair is preferred

29
Q

Classify umbilical hernia based on its size

A
  • Small (0-1cm)
  • Medium (1-4cm)
  • Large (>4cm)
30
Q

List 4 differences between true umbilical hernia and paraumbilical hernia

A
31
Q

What are the issues of concern for umbilical hernia?

A
  • Narrow neck of hernia sac -> higher risk of strangulation/infarction - should repair
  • Fistula formation with discharge of contents may occur
32
Q

State how would you manage a case of umbilical hernia based on the size defect.

A
  • Defect <1cm - PRIMARY SURGICAL REPAIR
  • Defect >1cm & <4cm - OPEN REPAIR WITH MESH
  • Defect >4cm - consider laparoscopic repair
33
Q

State (4) complications of umbilical hernia

A
  1. Injury to visceral contents
  2. Seroma/Hematoma
  3. Wound infection
  4. Recurrence - with mesh (1-3%), without mesh (10-30%)
34
Q

State (5) complications of incisional hernia

A
  • Intestinal obstruction
  • Incarceration
  • Strangulation
  • Skin excoriation
  • Persistent pain
35
Q

Define diastasis recti and its management

A

Diastasis recti is the separation of the 2 rectus abdominis muscles by an abnormal distance

Management:
- No treatment needed
- Not a true hernia
- Hence, no risk of incarceration or strangulation

36
Q

How would you manage a case of incisional hernia?

A

Pre-operative management
- Weight loss
- Nutrition optimization
- Treatment of chronic conditions

Surgical repair:
- Primary repair with mesh repair (GOLD STANDARD)
- Location of mesh -> SUBLAY (Retrorectus) recommended
- 2 approach -> Open vs Laparoscopic repair

Surgery (13 decks)

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