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120 Cards in this Set

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What is a hernia?
Protrusion of a peritoneal sac through a musculoaponeurotic barrier (e.g., abdominal wall); a fascial defect
What is the in incidence of hernias?
5%-10% lifetime; 59% are indirect inguinal, 25% are direct inguinal, and 5% are femoral
What are the precipitating factors?
Increased intra-abdominal pressure: straining at defecate or urination, obesity, pregnancy, as cites, valsavagenic COPD; an abnormal congenital anatomical route (patent processus vaginalis)
Why should hernias be repaired?
To avoid complications of incarceration/strangulation, bowel necrosis, SBO, pain
What is more dangerous: a small or large hernia defect?
Small defect bc a tight defect is more likely to strangulate if incarcerated
Incarcerated
Swollen or fixed w/in the hernia sac; may cause intestinal obstruction
Reducible
Ability to return the displaced organ or tissue/hernia contents to their usual anatomical site
Strangulated
incarcerated hernis w/resulting ischemia; will result in signs and sx of ischemia and intestinal obstruction or bowel necrosis
Complete
hernia sac and its contents protrude all the way through the defect
Incomplete
defect present w/o sac or contents protruding completely through it
what is a reducing hernia en masse?
reducing the hernia contents and hernia sac
sliding hernia
hernia sac partially formed by the wall of a viscus (i.e., bladder/cecum)
littre's hernia
hernia involving a meckel's diverticulum
spigelian hernia
hernia through the linea semilunaris (spigelian fascia); AKA spontaneous lateral ventral hernia
internal hernia
hernia into or involving intra-abdominal structure
petersen's hernia
seen after bariatric gastric bypass, internal herniation of small bowel through the mesenteric defect from the Roux limb
obturator hernia
hernia through obturator canal (females>males)
lumbar hernia
petit's hernia or grynfeltt's hernia
petit's hernia
(rare) hernia through petit's triangle (inferior lumbar triangle)
grynfeltt's hernia
hernia through grynfeltt-lesshaft triangle (superior lumbar triangle)
pantaloon hernia
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
incisional hernia
hernia through an incisional site, most common causes is a wound infection
ventral hernia
incisional hernia in ventral abdominal wall
parastomal hernia
hernia adjacent to an ostomy (e.g., colostomy)
sciatic hernia
hernia through the sciatic foramen
richter's hernia
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
epigastric hernia
hernia through the linea alba above the umbilicus
umbilical hernia
hernia through the umbilical ring (in adults, assoc. w/ ascites, pregnancy, obesity)
intraparietal hernia
abdominal contents migrate b/w layers of abdominal wall
femoral hernia
hernia medial to femoral vessels (under inguinal ligament)
hesselbach's hernia
hernia under inguinal ligament lateral to femoral vessels
bochdalek's hernia
hernia through the posterior diaphragm, usually on the left
morgagni's hernia
anterior parasternal diaphragmatic hernia
properitoneal hernia
intraparietal hernia b/w the peritoneum and transversalis fascia
cooper's hernia
hernia through the femoral canal and tracking into the scrotum or labia majus
indirect inguinal
inguinal hernia lateral to hesselbach's triangle
direct inguinal
inguinal hernia w/in hesselbach's triangle
hiatal hernia
hernia through esophageal hiatus
amyand's hernia
hernia sac containing a ruptured appendix
what are the boundaries of hesselbach's triangle?
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
layers of the abdominal wall
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)
differential dx for mass in healed c-section incision
hernia, ENDOMETRIOMA
DDx for groin mass
lymphadenopathy, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC, undescended testicle, sarcoma, hernias, testicle torsion
what is a direct inguinal hernia?
hernia w/in floor of hesselbach's triangle (hernia sac does not traverse internal ring --> directly through abdominal wall)
cause of direct inguinal hernia
acquired defect from mechanical breakdown over the years
incidence of direct inguinal hernia
~1% of all men, frequency increases w/advanced age
what nerve runs w/the permatic cord in the inguinal canal?
ilioinguinal nerve
what is an indirect inguinal hernia?
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)
what causes indirect internal inguinal?
patent processus vaginalis (congenital)
what is the incidence of indirect inguinal hernia?
~5% of all men; most common hernia in both men and women
how is an inguinal hernia diagnosed
relies mainly on hx and PE w/index finger invaginated into external ring and palpation
DDx of inguinal hernia
lymphadenopathy, psoas abscess, ectopic testis, hydrocele of the cord, saphenous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess
what is the risk of strangulation?
femoral highest risk > indirect > direct
tx of inguinal hernia
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
bassini procedure
sutures approximate reflection of inguinal ligament (poupart's) to the transversus abdominis aponeurosis/conjoint tendon
mcvay procedure
cooper's ligament sutured to transversus abdominis aponeurosis/conjoint tendon
lichtenstein procedure
tension-free repair using mesh
shouldice procedure
imbrication of the floor of the inguinal canal (canadian repair)
plug and patch procedure
placing a plut of mesh in hernia defect and then overlaying a patch of mesh over inguinal floor
high ligation
ligation and transection of indirect hernia sac w/o repair of inguinal floor (used only in children)
TAPP procedure
transabdominal preperitoneal inguinal hernia repair
TEPA procedure
totally extraperitoneal approach
what are the indications for laparoscopic inguinal hernia repair?
1. bilateral inguinal hernias, 2. recurring hernia, 3. need to resume full activity ASAP
what is the 1st identifiable subQ named layer?
scarpa's fascia
what is the name of the subQ vein ligated in inguinal hernia repair?
superficial epigastric vein
what happens if you cut the ilioinguinal nerve?
numbness of inner thigh or lateral scrotum; usually goes away in 6 mo.s
from what abdominal muscle layer is the cremaster muscle derived?
internal oblique
from what abdominal muscle layer is the inguinal ligament (poupart's) derived?
external oblique muscle aponeurosis
to what does the inguinal ligament attach?
anterior superior iliac spine to the pubic tubercle
which nerve travels on the spermatic cord
ilioinguinal nerve
why do somce surgeons deliberately cut the ilioinguinal nerve?
remove risk of entrapment and postop pain (obtain preop consent 1st)
what is in the spermatic cord? (6 things)
cremasteric muscle fibers, vas deferens, testicular artery, testicular pampiniform venous plexus, +/- hernia sac, genital branch of genitofemoral nerve
what is the hernia sac made of?
peritoneum (direct) or patent processus vaginalis (indirect)
what attaches the testicle to the scrotum?
gubernaculum
what is the most common organ in an inguinal hernia sac in men?
small intestine
what is the most common organ in an inguinal hernia sac in women?
ovary/fallopian tube
what lies in the inguinal canal in the female instead of the VAS?
round ligament
where in the inguinal canal does the hernia sac lie in relation to the other structures?
anteromedially
what is a cord lipoma?
preperitoneal fat on the cord structures (pushed in by the hernia sac); not a real lipoma; removed surgically if feasible
what is a small outpouching of testicular tissue off of the testicle?
testicular appendage (appendix testes); remove w/electrocautery
what action should be taken if a suture is placed through the femoral artery or vein during an inguinal herniorrhaphy?
remove the suture as soon as possible and apply pressure (DO NOT TIE THE SUTURE DOWN)
what nerve is found on top of the spermatic cord?
ilioinguinal nerve
what nerve travels w/in the spermatic cord
genital branch of the genitofemoral nerve
what are the borders of hesselbach's triangle?
1. epigastric vessels, 2. inguinal ligament, 3. lateral border of the rectus
what type of hernia goes through hesselbach's triangle?
direct hernia, due to a weak abdominal floor
what is a relaxing incision?
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
what is the conjoint tendon?
aponeurotic attachments of the conjoining of the internal oblique and transversus abdominis to the pubic tubercle
how tight should the new internal inguinal ring be?
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)
what percentage of the strength of an inguinal floor repair does the external oblique aponeurosis represent
ZERO
what is a femoral hernia
hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels
what are the boundaries of the femoral canal?
1. cooper's ligament posteriorly, 2. inguinal ligament anteriorly, 3. femoral vein laterally, 4. lacunar ligament medially
what factors are assoc w/ femoral hernias?
women, pregnancy, exertion
what percentage of all hernias are femoral?
5%
what percentage of patients w/a femoral hernia are women?
85%
what are the complications of a femoral hernia?
approximately 1/3 incarcerate (narrow, unforgiving neck)
what is the most common hernia in women?
indirect inguinal hernia
what is the repair of a femoral hernia?
mcvay (cooper's ligament repair), mesh plug repair
should elective TURP or elective herniorrhaphy be performed 1st?
TURP
which type of esophageal hiatal hernia is a/w GE reflux?
sliding esopheageal hiatal hernia
classically, how can an incarcerated hernia be reduced in the ER?
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
what is appropriate if you cannot reduce an incarcerated hernia w/steady, gentle compression?
directly to OR for repair
what is the major difference in repairing a pediatric indirect inguinal hernia and an adult inguinal hernia
in babies and children it is rarely necessary to repair the inguinal floor; repair w/high ligation of the hernia sac
what is the howship-romberg sign
pain along the medial aspect of the proximal thigh from nerve compression caused by an obturator hernia
what is the silk glove sign?
inguinal hernia sac in an infant/toddler feels like a finger of a silk glove when rolled under the examining finger
what must you do before leaving the OR after an inguinal hernia repair
pull the testicle back down to the scrotum
type I v type II hiatal hernias
type I = sliding, type II = paraesophageal
what is a sliding esophageal hiatal hernia?
stomach and GE jcn herniate into the thorax via the esophageal hiatus
incidence of sliding esophageal hernia
>90% of all hiatal hernias
sx of sliding esophageal hernia
most patients are asymptomatic, but condition can cause reflux, dysphagia (inflammatory edema), esophagitis, pulm problems 2ary to aspiration
dx of sliding esophageal hernia
UGI series, manometry, EGD w/bx for esophagitis
complications of sliding esophageal hernia
reflux --> esophagitis --> barrett's esophagus --> cancer and stricture formation; aspiration pneumonia; UGI bleeding from esophageal ulcerations
tx of sliding esophageal hernia
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
surgical tx of sliding esophageal hernia
laparoscopic nissen fundoplication involves wrapping the fundus around the LES and suturing in place
what is a paraesophageal hiatal hernia?
herniation of all or part of the stomach through the esophageal hiatus into the thorax w/o displacement of the GE jcn
incidence of paraesophageal hiatal hernias
<5% of all hiatal hernias (rare)
sx of paraesophageal hiatal hernia
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
complications of paraesophageal hiatal hernia
hemorrhage, incarceration, obstruction, strangulation
tx of type II hiatal hernia
surgical (b/c of frequency and severity of potential complications)
type III hiatal hernia
combined type I and II
type IV hiatal hernia
organ (e.g., colon or spleen) +/- stomach in chest cavity