Hernias

Front 1

What is a hernia?

Back 1

Protrusion of a peritoneal sac through a musculoaponeurotic barrier (e.g., abdominal wall); a fascial defect

Front 2

What is the in incidence of hernias?

Back 2

5%-10% lifetime; 59% are indirect inguinal, 25% are direct inguinal, and 5% are femoral

Front 3

What are the precipitating factors?

Back 3

Increased intra-abdominal pressure: straining at defecate or urination, obesity, pregnancy, as cites, valsavagenic COPD; an abnormal congenital anatomical route (patent processus vaginalis)

Front 4

Why should hernias be repaired?

Back 4

To avoid complications of incarceration/strangulation, bowel necrosis, SBO, pain

Front 5

What is more dangerous: a small or large hernia defect?

Back 5

Small defect bc a tight defect is more likely to strangulate if incarcerated

Front 6

Incarcerated

Back 6

Swollen or fixed w/in the hernia sac; may cause intestinal obstruction

Front 7

Reducible

Back 7

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

Front 8

Strangulated

Back 8

incarcerated hernis w/resulting ischemia; will result in signs and sx of ischemia and intestinal obstruction or bowel necrosis

Front 9

Complete

Back 9

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

Front 10

Incomplete

Back 10

defect present w/o sac or contents protruding completely through it

Front 11

what is a reducing hernia en masse?

Back 11

reducing the hernia contents and hernia sac

Front 12

sliding hernia

Back 12

hernia sac partially formed by the wall of a viscus (i.e., bladder/cecum)

Front 13

littre's hernia

Back 13

hernia involving a meckel's diverticulum

Front 14

spigelian hernia

Back 14

hernia through the linea semilunaris (spigelian fascia); AKA spontaneous lateral ventral hernia

Front 15

internal hernia

Back 15

hernia into or involving intra-abdominal structure

Front 16

petersen's hernia

Back 16

seen after bariatric gastric bypass, internal herniation of small bowel through the mesenteric defect from the Roux limb

Front 17

obturator hernia

Back 17

hernia through obturator canal (females>males)

Front 18

lumbar hernia

Back 18

petit's hernia or grynfeltt's hernia

Front 19

petit's hernia

Back 19

(rare) hernia through petit's triangle (inferior lumbar triangle)

Front 20

grynfeltt's hernia

Back 20

hernia through grynfeltt-lesshaft triangle (superior lumbar triangle)

Front 21

pantaloon hernia

Back 21

hernia sac exists as both a direct and indirect hernia straddling the inferior epigastric vessels and protruding the floor of the canal as well as the internal ring

Front 22

incisional hernia

Back 22

hernia through an incisional site, most common causes is a wound infection

Front 23

ventral hernia

Back 23

incisional hernia in ventral abdominal wall

Front 24

parastomal hernia

Back 24

hernia adjacent to an ostomy (e.g., colostomy)

Front 25

sciatic hernia

Back 25

hernia through the sciatic foramen

Front 26

richter's hernia

Back 26

incarcerated or strangulated hernia involving only 1 sidewall of the bowel, which can spontaneously reduce, resulting in gangrenous bowel and perforation w/in the abdomen w/o signs of obstruction

Front 27

epigastric hernia

Back 27

hernia through the linea alba above the umbilicus

Front 28

umbilical hernia

Back 28

hernia through the umbilical ring (in adults, assoc. w/ ascites, pregnancy, obesity)

Front 29

intraparietal hernia

Back 29

abdominal contents migrate b/w layers of abdominal wall

Front 30

femoral hernia

Back 30

hernia medial to femoral vessels (under inguinal ligament)

Front 31

hesselbach's hernia

Back 31

hernia under inguinal ligament lateral to femoral vessels

Front 32

bochdalek's hernia

Back 32

hernia through the posterior diaphragm, usually on the left

Front 33

morgagni's hernia

Back 33

anterior parasternal diaphragmatic hernia

Front 34

properitoneal hernia

Back 34

intraparietal hernia b/w the peritoneum and transversalis fascia

Front 35

cooper's hernia

Back 35

hernia through the femoral canal and tracking into the scrotum or labia majus

Front 36

indirect inguinal

Back 36

inguinal hernia lateral to hesselbach's triangle

Front 37

direct inguinal

Back 37

inguinal hernia w/in hesselbach's triangle

Front 38

hiatal hernia

Back 38

hernia through esophageal hiatus

Front 39

amyand's hernia

Back 39

hernia sac containing a ruptured appendix

Front 40

what are the boundaries of hesselbach's triangle?

Back 40

1. inferior epigastric vessels 2. inguinal ligament (poupart's) 3. lateral border of the rectus sheath. NOTE: floor consists of internal oblique and transversus abdominis muscle

Front 41

layers of the abdominal wall

Back 41

skin, subq fat, scarpa's fascia, ext oblique, int oblique, transv abdominus, tranv fascia, preperitoneal fat, peritoneum (note: all 3 muscle layer aponeuroses form the ant rectus sheath, w/post rectus sheath being deficient below arcuate line)

Front 42

differential dx for mass in healed c-section incision

Back 42

hernia, ENDOMETRIOMA

Front 43

DDx for groin mass

Back 43

lymphadenopathy, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC, undescended testicle, sarcoma, hernias, testicle torsion

Front 44

what is a direct inguinal hernia?

Back 44

hernia w/in floor of hesselbach's triangle (hernia sac does not traverse internal ring --> directly through abdominal wall)

Front 45

cause of direct inguinal hernia

Back 45

acquired defect from mechanical breakdown over the years

Front 46

incidence of direct inguinal hernia

Back 46

~1% of all men, frequency increases w/advanced age

Front 47

what nerve runs w/the permatic cord in the inguinal canal?

Back 47

ilioinguinal nerve

Front 48

what is an indirect inguinal hernia?

Back 48

hernia through the internal ring of the inguinal canal, traveling down toward the external ring; it may enter the scrotum upon exiting the external ring (i.e., if complete)

Front 49

what causes indirect internal inguinal?

Back 49

patent processus vaginalis (congenital)

Front 50

what is the incidence of indirect inguinal hernia?

Back 50

~5% of all men; most common hernia in both men and women

Front 51

how is an inguinal hernia diagnosed

Back 51

relies mainly on hx and PE w/index finger invaginated into external ring and palpation

Front 52

DDx of inguinal hernia

Back 52

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

Front 53

what is the risk of strangulation?

Back 53

femoral highest risk > indirect > direct

Front 54

tx of inguinal hernia

Back 54

emergent herniorrhaphy is indicated if strangulation is suspected or acute incarceration is present; otherwise elective herniorrhapy is indicated to prevent the chance of incarceration/strangulation

Front 55

bassini procedure

Back 55

sutures approximate reflection of inguinal ligament (poupart's) to the transversus abdominis aponeurosis/conjoint tendon

Front 56

mcvay procedure

Back 56

cooper's ligament sutured to transversus abdominis aponeurosis/conjoint tendon

Front 57

lichtenstein procedure

Back 57

tension-free repair using mesh

Front 58

shouldice procedure

Back 58

imbrication of the floor of the inguinal canal (canadian repair)

Front 59

plug and patch procedure

Back 59

placing a plut of mesh in hernia defect and then overlaying a patch of mesh over inguinal floor

Front 60

high ligation

Back 60

ligation and transection of indirect hernia sac w/o repair of inguinal floor (used only in children)

Front 61

TAPP procedure

Back 61

transabdominal preperitoneal inguinal hernia repair

Front 62

TEPA procedure

Back 62

totally extraperitoneal approach

Front 63

what are the indications for laparoscopic inguinal hernia repair?

Back 63

1. bilateral inguinal hernias, 2. recurring hernia, 3. need to resume full activity ASAP

Front 64

what is the 1st identifiable subQ named layer?

Back 64

scarpa's fascia

Front 65

what is the name of the subQ vein ligated in inguinal hernia repair?

Back 65

superficial epigastric vein

Front 66

what happens if you cut the ilioinguinal nerve?

Back 66

numbness of inner thigh or lateral scrotum; usually goes away in 6 mo.s

Front 67

from what abdominal muscle layer is the cremaster muscle derived?

Back 67

internal oblique

Front 68

from what abdominal muscle layer is the inguinal ligament (poupart's) derived?

Back 68

external oblique muscle aponeurosis

Front 69

to what does the inguinal ligament attach?

Back 69

anterior superior iliac spine to the pubic tubercle

Front 70

which nerve travels on the spermatic cord

Back 70

ilioinguinal nerve

Front 71

why do somce surgeons deliberately cut the ilioinguinal nerve?

Back 71

remove risk of entrapment and postop pain (obtain preop consent 1st)

Front 72

what is in the spermatic cord? (6 things)

Back 72

cremasteric muscle fibers, vas deferens, testicular artery, testicular pampiniform venous plexus, +/- hernia sac, genital branch of genitofemoral nerve

Front 73

what is the hernia sac made of?

Back 73

peritoneum (direct) or patent processus vaginalis (indirect)

Front 74

what attaches the testicle to the scrotum?

Back 74

gubernaculum

Front 75

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

Back 75

small intestine

Front 76

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

Back 76

ovary/fallopian tube

Front 77

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

Back 77

round ligament

Front 78

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

Back 78

anteromedially

Front 79

what is a cord lipoma?

Back 79

preperitoneal fat on the cord structures (pushed in by the hernia sac); not a real lipoma; removed surgically if feasible

Front 80

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

Back 80

testicular appendage (appendix testes); remove w/electrocautery

Front 81

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

Back 81

remove the suture as soon as possible and apply pressure (DO NOT TIE THE SUTURE DOWN)

Front 82

what nerve is found on top of the spermatic cord?

Back 82

ilioinguinal nerve

Front 83

what nerve travels w/in the spermatic cord

Back 83

genital branch of the genitofemoral nerve

Front 84

what are the borders of hesselbach's triangle?

Back 84

1. epigastric vessels, 2. inguinal ligament, 3. lateral border of the rectus

Front 85

what type of hernia goes through hesselbach's triangle?

Back 85

direct hernia, due to a weak abdominal floor

Front 86

what is a relaxing incision?

Back 86

incision(s) in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal ligament w/o tension

Front 87

what is the conjoint tendon?

Back 87

aponeurotic attachments of the conjoining of the internal oblique and transversus abdominis to the pubic tubercle

Front 88

how tight should the new internal inguinal ring be?

Back 88

should allow entrance of the tip of a kelly clamp but not a finger (new external inguinal ring should not be tight and should allow entrance of a finger)

Front 89

what percentage of the strength of an inguinal floor repair does the external oblique aponeurosis represent

Back 89

ZERO

Front 90

what is a femoral hernia

Back 90

hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels

Front 91

what are the boundaries of the femoral canal?

Back 91

1. cooper's ligament posteriorly, 2. inguinal ligament anteriorly, 3. femoral vein laterally, 4. lacunar ligament medially

Front 92

what factors are assoc w/ femoral hernias?

Back 92

women, pregnancy, exertion

Front 93

what percentage of all hernias are femoral?

Back 93

5%

Front 94

what percentage of patients w/a femoral hernia are women?

Back 94

85%

Front 95

what are the complications of a femoral hernia?

Back 95

approximately 1/3 incarcerate (narrow, unforgiving neck)

Front 96

what is the most common hernia in women?

Back 96

indirect inguinal hernia

Front 97

what is the repair of a femoral hernia?

Back 97

mcvay (cooper's ligament repair), mesh plug repair

Front 98

should elective TURP or elective herniorrhaphy be performed 1st?

Back 98

TURP

Front 99

which type of esophageal hiatal hernia is a/w GE reflux?

Back 99

sliding esopheageal hiatal hernia

Front 100

classically, how can an incarcerated hernia be reduced in the ER?

Back 100

1. apply ice to incarcerated hernia, 2. sedate, 3. use trendelenburg position for inguinal hernias, 4. apply steady gentle manual pressure, 5. admit and observe for signs of necrotic bowel after reduction, 6. perform surgical herniorrhaphy ASAP

Front 101

what is appropriate if you cannot reduce an incarcerated hernia w/steady, gentle compression?

Back 101

directly to OR for repair

Front 102

what is the major difference in repairing a pediatric indirect inguinal hernia and an adult inguinal hernia

Back 102

in babies and children it is rarely necessary to repair the inguinal floor; repair w/high ligation of the hernia sac

Front 103

what is the howship-romberg sign

Back 103

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

Front 104

what is the silk glove sign?

Back 104

inguinal hernia sac in an infant/toddler feels like a finger of a silk glove when rolled under the examining finger

Front 105

what must you do before leaving the OR after an inguinal hernia repair

Back 105

pull the testicle back down to the scrotum

Front 106

type I v type II hiatal hernias

Back 106

type I = sliding, type II = paraesophageal

Front 107

what is a sliding esophageal hiatal hernia?

Back 107

stomach and GE jcn herniate into the thorax via the esophageal hiatus

Front 108

incidence of sliding esophageal hernia

Back 108

>90% of all hiatal hernias

Front 109

sx of sliding esophageal hernia

Back 109

most patients are asymptomatic, but condition can cause reflux, dysphagia (inflammatory edema), esophagitis, pulm problems 2ary to aspiration

Front 110

dx of sliding esophageal hernia

Back 110

UGI series, manometry, EGD w/bx for esophagitis

Front 111

complications of sliding esophageal hernia

Back 111

reflux --> esophagitis --> barrett's esophagus --> cancer and stricture formation; aspiration pneumonia; UGI bleeding from esophageal ulcerations

Front 112

tx of sliding esophageal hernia

Back 112

85% of cases treated medically w/antacids/H2 blockers/PPIs, head elevation after meals, small meals, no food prior to sleeping; 15% require surgery for persistent sx despite medical tx

Front 113

surgical tx of sliding esophageal hernia

Back 113

laparoscopic nissen fundoplication involves wrapping the fundus around the LES and suturing in place

Front 114

what is a paraesophageal hiatal hernia?

Back 114

herniation of all or part of the stomach through the esophageal hiatus into the thorax w/o displacement of the GE jcn

Front 115

incidence of paraesophageal hiatal hernias

Back 115

<5% of all hiatal hernias (rare)

Front 116

sx of paraesophageal hiatal hernia

Back 116

derived from mechanical obstruction --> dysphagia, stasis gastric ulcer, strangulation; many cases are asymptomatic and not assoc w/reflux b/c of relatively normal position of GE jcn

Front 117

complications of paraesophageal hiatal hernia

Back 117

hemorrhage, incarceration, obstruction, strangulation

Front 118

tx of type II hiatal hernia

Back 118

surgical (b/c of frequency and severity of potential complications)

Front 119

type III hiatal hernia

Back 119

combined type I and II

Front 120

type IV hiatal hernia

Back 120

organ (e.g., colon or spleen) +/- stomach in chest cavity