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Surgical Recall > SR 36 - Hernias > Flashcards

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
Q

Umbilical hernia

A

Through the umbilical ring

Associated with ascites, pregnancy, obseity

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26
Q

Intraparietal hernia

A

Abdominal contents migrate bweteen the layers of the abdominal wall

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27
Q

Femoral hernia

A

Hernia medial to femoral vessels (under inguinal ligament)

Travels beneath teh inguinal ligament down teh femoral canal medial to the femoral vessels

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28
Q

Hesselbach’s hernia

A

Hernia under inguinal ligament lateral to femoral vessels

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29
Q

Bochdalek’s hernia

A

through posterior diaphragm, usually on the left

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30
Q

Morgagni’s hernia

A

Anterior parasternal diaphragmatic hernia

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31
Q

Properitoneal hernia

A

Intraparietal hernia between the peritoneum and transversalis fascia

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32
Q

Cooper’s hernia

A

Through the femoral canal and tracking into the scrotum or labia majorus

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33
Q

Indirect inguinal hernia

A

Lateral to Hesselbach’s triangle

Travels through the internal ring of the inguinal canal, travling down toward the external ring

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34
Q

Direct inguinal hernia

A

Within Hesselbach’s triangle

Travels directly though the abdominal wall (not through the internal ring)

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35
Q

Hiatal hernia

A

Through esophageal hiatus

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36
Q

Amyand’s hernia

A

Hernia sac contains a ruptured appendix

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37
Q

What are the boundaris of Hesselbach’s triangle?

A 
Inferior epigastric vessels
Inguinal ligament of Poupart
lateral border of the rectus sheath
Peritoneum
Floor consists of internal oblique and transversus abdominis muscle
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38
Q

What are the layers of the abdominal wall?

A 
Skin
SubQ fat (camper's fascia)
Scarpa's fascia (membrane)
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia
Preperitoneal fat
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39
Q

What is the DDx for a mass in a healed C-section incision?

A

Hernia

Endometrioma

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40
Q

DDx for a groin mass?

A

LAD, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm (pulsating), EIC (epidermal inclusion cyst), undescended testicle, sarcoma, hernias, testicle torsion

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41
Q

What is the cause of a direct inguinal hernia?

A

Acquired defect from mechanical breakdown over the years

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42
Q

What nerve runs with the spermatic cord in the inguinal canal?

A

Ilioinguinal nerve

43
Q

What is the cause of indirect inguinal hernia?

A

Patent processus vaginalis

44
Q

How is an inguinal hernia diagnosed?

A

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
Q

DDx of an inguinal hernia?

A

LAD, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess

46
Q

What is the risk of strangulation with inguinal hernias?

A

Higher with indirect than direct inguinal hernia

But highest in femoral hernias

47
Q

What is the treatment for inguinal hernias?

A

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
Q

Inguinal hernia repair - describe the procedure:

Bassini

A

Sutures approximate relfection of inguinal ligament to the transversus abdominis aponeurosis/conjoint tendon

49
Q

Inguinal hernia repair - describe the procedure:

McVay

A

Cooper’s ligament sutured to transversus abdominis aponeurosis/conjoint tendon

50
Q

Inguinal hernia repair - describe the procedure:

Lichtenstein

A

Tension free repair using mesh

51
Q

Inguinal hernia repair - describe the procedure:

Shouldice

A

AKA Canadian repair

Imbrication of the floor of the inguinal canal

52
Q

Inguinal hernia repair - describe the procedure:

Plug and patch

A

Place a plug of mesh in hernia defect adn then overlay a patch of mess over inginal floor (few if any stitches)

53
Q

Inguinal hernia repair - describe the procedure:

High ligation

A

Used in children only

Ligation and transection of indirect ehrnia sac without repair of inguinal floor

54
Q

Inguinal hernia repair - describe the procedure:

TAPP procedure

A

Transabdominal preperitoneal inguinal hernal repair

55
Q

Inguinal hernia repair - describe the procedure:

TEPA procedure

A

Totally extraperitoneal appraoch

56
Q

What are teh indication for laparoscopic inguinal hernia repair?

A
  • Bilateral inguinal hernias
  • Recurring hernia
  • Need to resume full activity as soon as possible
57
Q

Surgical inguinal hernia repair:

What is the first identifiable subcutaneous named layer?

A

Scarpa’s fascia

58
Q

Surgical inguinal hernia repair:

What is the name of the subcutaneous vein that is ligated?

A

Superficial epigastric vein

59
Q

Surgical inguinal hernia repair:

What happens if you cut the ilioinguinal nerve?

A

Numbness of inner thigh or lateral scrotum

Goes way in 6 months

60
Q

Surgical inguinal hernia repair:

From what abdominal muscle layer if the cremaster muscle derived?

A

Internal oblique muscle

61
Q

Surgical inguinal hernia repair:

From what abdominal muscle layer is the inguinal ligament derived?

A

External oblique msucle aponeurosis

62
Q

Surgical inguinal hernia repair:

To what does the inguinal ligament attach?

A

Anterior superior iliac spine to the pubic tubercle

63
Q

Surgical inguinal hernia repair:

Which nerve travels on the spermatic cord?

A

Ilioinguinal nerve

64
Q

Surgical inguinal hernia repair:

Why do some surgeons deliberatly cut the ilioinguinal nerve?

A

With preoperative consent, they cut it to remove the risk of entrapment and postoperative pain

65
Q

What is in the spermatic cord?

A 
Cremasteric muscle fibers
Vas deferens
Testicular artery
Testicular pampiniform venous plexus
\+/- Hernia sac
Genital branch of the genitofemoral nerve
66
Q

What is the inguinal hernia sac made of?

A

Peritoneum (direct)

Patent processus vaginalis (indirect)

67
Q

What attaches the testicle to the scrotum?

A

Gubernaculum

68
Q

What is the most common organ in an inguinal hernia sac in men?

A

Small intestine

69
Q

What is the most common organ in an inguinal hernia sac in women?

A

Ovary/fallopian tube

70
Q

What lies in the inguinal canal in the female instead of the VAS?

A

Round ligament

71
Q

Where in the inguinal canal does the hernia sac lie in relation to the other structures?

A

Anteromedially

72
Q

What is a ‘cord lipoma’?

A

Reperitoneal fat on the cord structures (pushed in by the hernia sac)
Not a real lipoma
Remove surigcally

73
Q

What is a small outpouching of testicular tissue off of the testicle?

A

Testicular appendage, AKA appendix testes

Remove with electrocautery

74
Q

What action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?

A

remove teh suture as soon as possible and apply pressure.

Do NOT tie the suture down

75
Q

What nerve travels within the spermatic cord/

A

Genital branch of the genitofemoral nerve

76
Q

Surgical inguinal hernia repair:

What is a ‘relaxing incision’?

A

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
Q

What is the conjoint tendon?

A

Aponeurotic attachments of the ‘conjoining’ of the internal oblique and transversus abdominis to the pubic tubercle

78
Q

Surgical inguinal hernia repair:

How tight should the new internal inguinal ring be

A

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
Q

What percentage of the strenght of an inginal floor repair does the external oblique aponeurosis represent?

A

NONE

80
Q

What are the boundaries of teh femoral canal?

A

Cooper’s ligament posteriorly
Inguinal ligament anteriorly
Femoral vein laterally
Lacunar ligament medially

81
Q

What factors are you associated with femoral hernias?

A

Women, pregnancy, exertion

82
Q

What are the complications of femoral hernias?

A

1/3 incarcerate - due to narrow neck

83
Q

What is the most common hernia in women?

A

Indirect inguinal hernia

84
Q

What is the repair of a femoral hernia?

A

McVay (Cooper’s ligament repair)

Mesh plug repair

85
Q

Should elective TURP or elective herniorrhaphy be performed first?

A

TURP

86
Q

Why type of esophageal hiatal hernia is associated with GE reflux?

A

Sliding esophageal hiatal hernia

87
Q

How can incarcerated hernias be reduced in the ER?

A

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
Q

What do you do if you cannot reuce an incarcerated hernia with steady, gentle compression?

A

Go to OR for repair

89
Q

What is the Howship-Romberg sign?

A

Pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia

90
Q

What is the ‘silk glove’ sign?

A

Inguinal hernia sac in infant feels like a finger of a silk glove when rolled under the examining finger

91
Q

What must yuo do before leaving the OR after an inguinal hernia repair?

A

Pull the testicle back down to the scrotum

92
Q

Define Type I and Type II hiatal hernias

A

Type I - Sliding

Type II - paraesophageal

93
Q

What is a sliding esophageal hiatal hernia?

A

Type I - sliding

Stomach and GE junction herniate into the thorax via the esophageal hiatus

94
Q

Symptoms of a sliding esophageal hiatal hernia?

A

Generally asymptomatic.

But can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems secondary to aspiration

95
Q

How is a sliding esophageal hiatal hernia diagnosed?

A

UGI series
Manometry
Esophagogasroduodenoscopy (EGD) with biopsy for esophagitis

96
Q

What are complications of esophageal hiatal hernias?

A

Reflux –> esophagitis –> barrett’s esophagus –> cancer and stricture formation
Aspiration pneumonia
UGI bleeding from esophageal ulcerations

97
Q

Treatment for esophageal hiatal hernias?

A

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
Q

What is the surgical treatment for esophageal hiatal hernias?

A

Laproscopic Nissen Fundoplication

Wrap the fundus around the LES and suture it in place

99
Q

What is a paraesophageal hiatal hernia?

A

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
Q

Symptoms of a paraesophageal hiatal hernia?

A

Mechanical obstruction - dysphagia, stasis gastric ulcer, strangulation
NOT associated with reflux as the GE junction is normal

101
Q

What are the complications of a paraesophageal hiatal hernia?

A

Surgical, because of frequency and severity of potential consequences

102
Q

What is a type III hiatal hernia?

A

Combination of type I and type II

103
Q

What is a type of IV hiatal hernia?

A

Organ (i.e. colon or spleen) +/- stomach in the chest cavity

Surgical Recall (32 decks)

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