Medbear Hernia Flashcards
Define hernia
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
List the 6 layers of anterior abdominal wall
- Skin and subcutaneous tissue
- Superficial fascia - composed of 2 distinct layer
- CAMPER’S FASCIA - superficial fatty layer
- SCARPA’S FASCIA - deep fibrous layer - Myofascial
- Abdominal wall muscles
- Fascial interface
- Rectus sheath - Transversalis fascia
- Extra-peritoneal fat
- Parietal peritoneum
State the origin and insertion of rectus abdominis
Origin: Pubic line
Insertion: Xiphoid process and 5-7th costal cartilage
What nerves supplies the rectus abdominis?
THORACOABDOMINAL NERVES
State the origin and insertion of external oblique.
Origin: Lower 8 ribs (5th - 12th rib)
Insertion: Iliac crest, Pubic crest, Linea alba
Which nerves innervate the external oblique?
THORACOABDOMINAL NERVES (T7-11) +
SUBCOSTAL NERVES (T12)
State the origin and insertion of internal oblique
Origin: Lumbar fascia, iliac crest and inguinal ligament
Insertion: Costal margin, Aponeurosis of rectus tendon to pubic crest and pectineal line
Which nerves innervates the internal oblique?
THORACOABDOMINAL (T7-11) +
SUBCOSTAL (T12) +
ILIOINGUINAL NERVE (L1)
State the origin and insertion of transversus abdominis.
Origin: Costal margin, lumbar fascia, anterior iliac crest, inguinal ligament
Insertion: Aponeurosis of conjoint tendon to pubic crest and pectineal line
Which nerve supplies the transversus abdominis?
THORACOABDOMINAL (T7-11) +
SUBCOSTAL (T12) +
ILIOINGUINAL
List the blood supply of the abdomen based on Zone 1, Zone 2 and Zone 3.
State the principle of abdominal hernia surgery.
- Identification of hernia sac
- Reducing the contents of the hernia sac +/- removal of non-viable tissue
- Excision and closure of the sac
- Repair of the abdominal wall defect
List the different abdominal mesh used for hernia repairs (based on locations in the abdomen)
State the boundaries of inguinal canal
Anterior wall:
Posterior wall:
Roof:
Floor:
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
State the boundaries of the Hesselbach’s triangle
Laterally
Medially
Inferiorly
Floor
Laterally -> Inferior epigastric artery
Medially -> Lateral border of rectus abdominis
Inferiorly -> Inguinal ligament
Floor -> Transversalis fascia
State the clinical presentation of inguinal hernia
What radiological evaluation can be done to investigate on inguinal hernia?
- 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)
List 5 clinical difference between indirect hernia and direct hernia
State 3 types of open inguinal hernia repair (with mesh/without mesh).
- 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)
What are the advantages of laparoscopic repair vs open repair in a case of hernia?
- Shorter length of hospital stay
- Faster return to normal activity
State (5) early complications of a hernia repair surgery.
- Acute retention of urine
- Hematoma
- Seroma
- Nerve injury (e.g ILIOINGUINAL n -> Open surgery, LATERAL FEMORAL CUTANEOUS n -> laparoscopic)
- Wound infection
Name (5) late complication of a hernia repair surgery.
- 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
If you were ask to classify hernia surgery based on wound class, what would hernia surgery classified as?
Clean Operation (Class I)
State the medial, intermediate and lateral compartment of the femoral sheath
Medial = Femoral canal which carries lymphatics, lymph node of Cloquet, and adipose tissue
Intermediate = Femoral vein
Lateral = Femoral artery
State the 2 main function of femoral canal
- Dead space for extension of the distended femoral vein
- Lymphatic pathway from LL to external iliac nodes
Femoral ring = superior opening of the femoral canal
State the boundaries of the femoral ring
Anterior:
Posterior:
Medial:
Lateral:
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
State the boundaries of the femoral triangle
Superior:
Medial:
Lateral:
Floor:
Roof:
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)
What is the difference between inguinal and femoral hernia
For open repair of femoral hernia, there are 3 approaches
List the 3 approaches
- Infrainguinal approach (LOCKWOOD) -> used for elective femoral hernia
- Trans-inguinal approach (LOTHIESSEN) -> can repair both inguinal and femoral hernia
- Supra-inguinal approach (McEvedy) -> used when suspecting strangulating hernia
*Mesh repair is preferred
Classify umbilical hernia based on its size
- Small (0-1cm)
- Medium (1-4cm)
- Large (>4cm)
List 4 differences between true umbilical hernia and paraumbilical hernia
What are the issues of concern for umbilical hernia?
- Narrow neck of hernia sac -> higher risk of strangulation/infarction - should repair
- Fistula formation with discharge of contents may occur
State how would you manage a case of umbilical hernia based on the size defect.
- Defect <1cm - PRIMARY SURGICAL REPAIR
- Defect >1cm & <4cm - OPEN REPAIR WITH MESH
- Defect >4cm - consider laparoscopic repair
State (4) complications of umbilical hernia
- Injury to visceral contents
- Seroma/Hematoma
- Wound infection
- Recurrence - with mesh (1-3%), without mesh (10-30%)
State (5) complications of incisional hernia
- Intestinal obstruction
- Incarceration
- Strangulation
- Skin excoriation
- Persistent pain
Define diastasis recti and its management
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
How would you manage a case of incisional hernia?
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
