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SR 36 - Hernias Flashcards

1
Q

What is a hernia?

A

Protrusion of a peritoneal sac through a musculoponeurotic barrier
A fascial defect

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2
Q

What are precipitating factors for hernias?

A

Increased intra-abdominal pressure (straining at defication or urination, obseity, pregnancy, ascities, valsavagenic (coughing), COPD)
Abdomonal congeintal anatomic route (i.e. patent processus vaginalis)

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3
Q

Complications if hernia cannot be repaired?

A 
Incarceration
Strangulation
Bowel necrosis
SBO
Pain
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4
Q

Define reducible (hernia)

A

Ability to return the displaced organ or tissue/hernia contents to their usual antomical site

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5
Q

Define incarcerated (hernia)

A

Swollen or fixed within the hernia sac
An irreducible hernia
May cause intestinal obstruction

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6
Q

Define strangulated (hernia)

A

Incarcerated hernia with resulting ischemia

Symptoms of ischemia and intestinal obstruction or bowel necrosis

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7
Q

Define a complete hernia

A

Hernia sac and its contents protrude all the way through the defect

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8
Q

Define an incomplete hernia

A

Defect present withou sac or contents protruding completely through it

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9
Q

Sliding hernia

A

Hernia sac paritally formed by the wal of a viscus

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10
Q

Littre’s hernia

A

Inovles Meckel’s diverticulum

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11
Q

Spigelian hernia

A

Through linea semilunaris (aka spigelian fascia)

Spontaneous lateral ventral hernia

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12
Q

Internal hernia

A

Hernia into or involving intra-abdominal structures

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13
Q

Petersen’s hernia

A

After bariatric gastric bypass

Internal herniation of small bowel through the mesenteric defect from the Roux limb

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14
Q

Obturator hernia

A

Hernia through the obturator canal

More comon in females

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15
Q

Lumbar hernia

A

Petit’s hernia or Grynfeltt’s hernia

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16
Q

Petit’s hernia

A

Hernia through petit’s triangle - AKA inferior lumbar triangle

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17
Q

Grynfeltt’s hernia

A

Hernia through Grynfeltt-Lasshaft triangle (superior lumbar triangle)

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18
Q

Pantaloon hernia

A

Hernia sac exists as both a driect and indirect hernia straddling the inferior epigastric vessel

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19
Q

Incisional hernia

A

Hernia through an incisional site

Most common cause is a wound infection

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20
Q

Ventral hernia

A

Incisional hernia in the ventral abdominal wall

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21
Q

Parastomal hernia

A

Hernia adjacent to an ostomy

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22
Q

Sciatic hernia

A

Hernia through the sciatic foramen

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23
Q

Richter’s hernia

A

Incarcerated or strangulated hernia involving only one sidewall of the bowel, which can spontaneously reduce, resulting in gangrenous bowel and perforation within the abdomen without signs of obstruction

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24
Q

Epigastric hernia

A

Through the linea alba above the umbilicus

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25
Umbilical hernia
Through the umbilical ring | Associated with ascites, pregnancy, obseity
26
Intraparietal hernia
Abdominal contents migrate bweteen the layers of the abdominal wall
27
Femoral hernia
Hernia medial to femoral vessels (under inguinal ligament) | Travels beneath teh inguinal ligament down teh femoral canal medial to the femoral vessels
28
Hesselbach's hernia
Hernia under inguinal ligament lateral to femoral vessels
29
Bochdalek's hernia
through posterior diaphragm, usually on the left
30
Morgagni's hernia
Anterior parasternal diaphragmatic hernia
31
Properitoneal hernia
Intraparietal hernia between the peritoneum and transversalis fascia
32
Cooper's hernia
Through the femoral canal and tracking into the scrotum or labia majorus
33
Indirect inguinal hernia
Lateral to Hesselbach's triangle | Travels through the internal ring of the inguinal canal, travling down toward the external ring
34
Direct inguinal hernia
Within Hesselbach's triangle | Travels directly though the abdominal wall (not through the internal ring)
35
Hiatal hernia
Through esophageal hiatus
36
Amyand's hernia
Hernia sac contains a ruptured appendix
37
What are the boundaris of Hesselbach's triangle?
``` Inferior epigastric vessels Inguinal ligament of Poupart lateral border of the rectus sheath Peritoneum Floor consists of internal oblique and transversus abdominis muscle ```
38
What are the layers of the abdominal wall?
``` Skin SubQ fat (camper's fascia) Scarpa's fascia (membrane) External oblique Internal oblique Transversus abdominus Transversalis fascia Preperitoneal fat ```
39
What is the DDx for a mass in a healed C-section incision?
Hernia | Endometrioma
40
DDx for a groin mass?
LAD, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm (pulsating), EIC (epidermal inclusion cyst), undescended testicle, sarcoma, hernias, testicle torsion
41
What is the cause of a direct inguinal hernia?
Acquired defect from mechanical breakdown over the years
42
What nerve runs with the spermatic cord in the inguinal canal?
Ilioinguinal nerve
43
What is the cause of indirect inguinal hernia?
Patent processus vaginalis
44
How is an inguinal hernia diagnosed?
History and physical exam with index finger invaginated into the external ring and palpation of hernia Examine the patient standing up if diagnosis is not obvious
45
DDx of an inguinal hernia?
LAD, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess
46
What is the risk of strangulation with inguinal hernias?
Higher with indirect than direct inguinal hernia | But highest in femoral hernias
47
What is the treatment for inguinal hernias?
Emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present Uncomplicated hernias can have elective herniorrhaphy to prevent the change of incarceration/strangulation
48
Inguinal hernia repair - describe the procedure: | Bassini
Sutures approximate relfection of inguinal ligament to the transversus abdominis aponeurosis/conjoint tendon
49
Inguinal hernia repair - describe the procedure: | McVay
Cooper's ligament sutured to transversus abdominis aponeurosis/conjoint tendon
50
Inguinal hernia repair - describe the procedure: | Lichtenstein
Tension free repair using mesh
51
Inguinal hernia repair - describe the procedure: | Shouldice
AKA Canadian repair | Imbrication of the floor of the inguinal canal
52
Inguinal hernia repair - describe the procedure: | Plug and patch
Place a plug of mesh in hernia defect adn then overlay a patch of mess over inginal floor (few if any stitches)
53
Inguinal hernia repair - describe the procedure: | High ligation
Used in children only | Ligation and transection of indirect ehrnia sac without repair of inguinal floor
54
Inguinal hernia repair - describe the procedure: | TAPP procedure
Transabdominal preperitoneal inguinal hernal repair
55
Inguinal hernia repair - describe the procedure: | TEPA procedure
Totally extraperitoneal appraoch
56
What are teh indication for laparoscopic inguinal hernia repair?
- Bilateral inguinal hernias - Recurring hernia - Need to resume full activity as soon as possible
57
Surgical inguinal hernia repair: | What is the first identifiable subcutaneous named layer?
Scarpa's fascia
58
Surgical inguinal hernia repair: | What is the name of the subcutaneous vein that is ligated?
Superficial epigastric vein
59
Surgical inguinal hernia repair: | What happens if you cut the ilioinguinal nerve?
Numbness of inner thigh or lateral scrotum | Goes way in 6 months
60
Surgical inguinal hernia repair: | From what abdominal muscle layer if the cremaster muscle derived?
Internal oblique muscle
61
Surgical inguinal hernia repair: | From what abdominal muscle layer is the inguinal ligament derived?
External oblique msucle aponeurosis
62
Surgical inguinal hernia repair: | To what does the inguinal ligament attach?
Anterior superior iliac spine to the pubic tubercle
63
Surgical inguinal hernia repair: | Which nerve travels on the spermatic cord?
Ilioinguinal nerve
64
Surgical inguinal hernia repair: | Why do some surgeons deliberatly cut the ilioinguinal nerve?
With preoperative consent, they cut it to remove the risk of entrapment and postoperative pain
65
What is in the spermatic cord?
``` Cremasteric muscle fibers Vas deferens Testicular artery Testicular pampiniform venous plexus +/- Hernia sac Genital branch of the genitofemoral nerve ```
66
What is the inguinal hernia sac made of?
Peritoneum (direct) | Patent processus vaginalis (indirect)
67
What attaches the testicle to the scrotum?
Gubernaculum
68
What is the most common organ in an inguinal hernia sac in men?
Small intestine
69
What is the most common organ in an inguinal hernia sac in women?
Ovary/fallopian tube
70
What lies in the inguinal canal in the female instead of the VAS?
Round ligament
71
Where in the inguinal canal does the hernia sac lie in relation to the other structures?
Anteromedially
72
What is a 'cord lipoma'?
Reperitoneal fat on the cord structures (pushed in by the hernia sac) Not a real lipoma Remove surigcally
73
What is a small outpouching of testicular tissue off of the testicle?
Testicular appendage, AKA appendix testes | Remove with electrocautery
74
What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?
remove teh suture as soon as possible and apply pressure. | Do NOT tie the suture down
75
What nerve travels within the spermatic cord/
Genital branch of the genitofemoral nerve
76
Surgical inguinal hernia repair: | What is a 'relaxing incision'?
Incision in the rectus sheath to relax the conjoint tendon so that it can be approximated ot the reflection of the inguinal ligament without tension
77
What is the conjoint tendon?
Aponeurotic attachments of the 'conjoining' of the internal oblique and transversus abdominis to the pubic tubercle
78
Surgical inguinal hernia repair: | How tight should the new internal inguinal ring be
Should allow entrance of the tip of a Kelly clamp but not a finger (The new external ring shoudl allow entrance of a finger)
79
What percentage of the strenght of an inginal floor repair does the external oblique aponeurosis represent?
NONE
80
What are the boundaries of teh femoral canal?
Cooper's ligament posteriorly Inguinal ligament anteriorly Femoral vein laterally Lacunar ligament medially
81
What factors are you associated with femoral hernias?
Women, pregnancy, exertion
82
What are the complications of femoral hernias?
1/3 incarcerate - due to narrow neck
83
What is the most common hernia in women?
Indirect inguinal hernia
84
What is the repair of a femoral hernia?
McVay (Cooper's ligament repair) | Mesh plug repair
85
Should elective TURP or elective herniorrhaphy be performed first?
TURP
86
Why type of esophageal hiatal hernia is associated with GE reflux?
Sliding esophageal hiatal hernia
87
How can incarcerated hernias be reduced in the ER?
Apply ice to area Sedate Use trendelenburg position for inguinal hernias Apply steady gental manual pressure Admit and observe for signs of necrotic bowel after reduction Perform surgical herniorrhaphy ASAP
88
What do you do if you cannot reuce an incarcerated hernia with steady, gentle compression?
Go to OR for repair
89
What is the Howship-Romberg sign?
Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia
90
What is the 'silk glove' sign?
Inguinal hernia sac in infant feels like a finger of a silk glove when rolled under the examining finger
91
What must yuo do before leaving the OR after an inguinal hernia repair?
Pull the testicle back down to the scrotum
92
Define Type I and Type II hiatal hernias
Type I - Sliding | Type II - paraesophageal
93
What is a sliding esophageal hiatal hernia?
Type I - sliding | Stomach and GE junction herniate into the thorax via the esophageal hiatus
94
Symptoms of a sliding esophageal hiatal hernia?
Generally asymptomatic. | But can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration
95
How is a sliding esophageal hiatal hernia diagnosed?
UGI series Manometry Esophagogasroduodenoscopy (EGD) with biopsy for esophagitis
96
What are complications of esophageal hiatal hernias?
Reflux --> esophagitis --> barrett's esophagus --> cancer and stricture formation Aspiration pneumonia UGI bleeding from esophageal ulcerations
97
Treatment for esophageal hiatal hernias?
85% treated medically - H2 blockers, PPIs, head elevation after meals, small meals, no food prior to sleeping 15% - surgery for persistent symptoms despite medical treatment
98
What is the surgical treatment for esophageal hiatal hernias?
Laproscopic Nissen Fundoplication | Wrap the fundus around the LES and suture it in place
99
What is a paraesophageal hiatal hernia?
Type II hiatal hernia Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the GE junction
100
Symptoms of a paraesophageal hiatal hernia?
Mechanical obstruction - dysphagia, stasis gastric ulcer, strangulation NOT associated with reflux as the GE junction is normal
101
What are the complications of a paraesophageal hiatal hernia?
Surgical, because of frequency and severity of potential consequences
102
What is a type III hiatal hernia?
Combination of type I and type II
103
What is a type of IV hiatal hernia?
Organ (i.e. colon or spleen) +/- stomach in the chest cavity

Surgical Recall (32 decks)

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