Surgery Ms Iii

Front 1

What is a hernia

Back 1

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

Front 2

What is the incidence of hernias

Back 2

Between 5% and 10% lifetime; 50% are indirect inguinal, 25% are direct, & aprox 5% are femoral

Front 3

What are the precipitating factors of a hernia

Back 3

Increased intra-abdominal pressure; Straining at defication or urination (rectal cancer, colon cancer, prostatic enlargement, consitipation), obesity, pregnancy, ascites, valsavagenic (coughing), COPD; an abnormal congenital anatomic route (i.e. 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

A small defect because a tight defect is more likely to strangulate if incarcerated

Front 6

Reducible hernia

Back 6

the ability to return the displaced organ or tissue/hernia contents to their usual anatomic site

Front 7

Incarcerated hernia

Back 7

Swollen or fixed w/in the hernia sac (incarcerated = imprisoned); may cause intestinal obstruction (i.e. an irreducible hernia)

Front 8

Strangulated hernia

Back 8

Incarcerated hernia with resulting ischemia; will result in S/Sx of ischemia and intestinal obstruction or bowel necrosis

Front 9

Complete hernia

Back 9

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

Front 10

Incomplete hernia

Back 10

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

Front 11

Sliding hernia

Back 11

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

Front 12

Littre's hernia

Back 12

hernia involving a meckel's diverticulum (think alphabetically: Littre's Meckel's = L.M.)

Front 13

Spigelian hernia

Back 13

hernia through the linea semilumaris (or spigelian fascia); a.k.a. spontaneous lateral ventral hernia (think Spigelian = Semiluminaris)

Front 14

Internal hernia

Back 14

hernia into or involving intra-abdominal structures

Front 15

Obturator hernia

Back 15

hernia through the obturator canal (F > M)

Front 16

Lumbar hernia

Back 16

Petit's hernia or Grynfeltt's hernia

Front 17

Petit's hernia

Back 17

(rare) hernia through Petit's triangle (a.k.a inferior lumbar triangle) (think petit = small = inferior)

Front 18

Grynfeltt's hernia

Back 18

hernia through Grynfelt-Lesshaft triangle (superior lumbar triangle)

Front 19

Pantaloon hernia

Back 19

hernia sac exists as both a direct and indirect hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring (2 sacs separated by the inferior epigastric vessels

Front 20

Incisional hernia

Back 20

hernia through an incisional site; most common cause of wound infection

Front 21

Ventral hernia

Back 21

incisional hernia in the ventral abdominal wall

Front 22

Parastomal hernia

Back 22

hernia adjacent to an ostomy

Front 23

Sciatic hernia

Back 23

hernia through the sciatic foramen

Front 24

Richter's hernia

Back 24

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

Front 25

Epigastric hernia

Back 25

hernia through the linea alba above the umbilicus

Front 26

Umbilical hernia

Back 26

hernia through the umbilical ring, in adults associated with ascites, pregnancy, and obesity

Front 27

Intraparietal hernia

Back 27

hernia on which abdominal contents migrate b/w layers of the abdominal wall

Front 28

Femoral hernia

Back 28

hernia medial to the femoral vessels (under inguinal ligament)

Front 29

Hesselbach's hernia

Back 29

hernia under inguinal ligaments lateral to the femoral vessels

Front 30

Bochdalek's hernia

Back 30

hernia through the posterior diaphragm, usually on the left (think: Boch de lek = "back to the left" on the diaphragm)

Front 31

Morgagni's hernia

Back 31

anterior parasternal diaphragmatic hernia

Front 32

Properitoneal hernia

Back 32

intraparietal hernia b/w the peritoneum and transversalis facia

Front 33

Cooper's hernia

Back 33

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

Front 34

Indirect Inguinal

Back 34

Inguinal hernia lateral to Hesselbach's triangle

Front 35

Direct Inguinal

Back 35

Inguinal hernia within Hesselbach's triagnle

Front 36

Amyand's hernia

Back 36

hernia sac containing a ruptured appendix (think: Amyand's = Appendix)

Front 37

What are the boundaries of Hesselbach's triangle

Back 37

1. Inferior epigastric vessels
2. Inguinal ligament (Poupart's)
3. Lateral border of the rectus sheath
Floor consists of internal oblique and then transversus abdominis muscle

Front 38

What are the layers of the abdominal wall

Back 38

Skin
Subcutaneous fat
Scarpa's fascia
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia
Preperitoneal fat
Peritoneum
-NOTE: all 3 muscle layer aponeuroses form the anterior rectus sheath, with the poster rectus sheath being deficient below the arcuate line

Front 39

DDx of a groin mass

Back 39

Lymphadenopathy, hematoma, seroma, abscess, hydrocelee, femoral artery, aneurysm, EIC, undescended testicle, sarcoma, hernias, testicle torsion

Front 40

Direct Inguinal Hernia: What is it

Back 40

A hernia within the floor of Hesselbach's triange, i.e. the hernia sac does not transverse the internal ring (Think of directly through the abdominal wall)

Front 41

Direct Inguinal Hernia: What is the cause

Back 41

Acquired defect from mechanical breakdown over the years

Front 42

Direct Inguinal Hernia: What is the incidence

Back 42

approx 1% of all men; frequently increases w/ advanced age

Front 43

Direct Inguinal Hernia: What nerve runs with the spermatic cord in the inguinal canal

Back 43

ilioinguinal nerve

Front 44

Indirect Inguinal Hernia: What is it

Back 44

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); think of th hernia sac traveling indirectly through the abdominal wall from the internal ring to the external ring

Front 45

Indirect Inguinal Hernia: What is the cause

Back 45

Patent processus vaginalis (i.e. congenital)

Front 46

Indirect Inguinal Hernia: Incidence

Back 46

Approx 5% of all men, most common hernia in both men and women

Front 47

Indirect Inguinal Hernia: How is it diagnosed

Back 47

Relies mainly of H&P with index finger invaginated into the external ring and palpation of hernia; examine the pt standing up if diagnosis is not obvious
NOTE: if swelling occurs before the inguinal ligament, it is possibly a femoral hernia

Front 48

Indirect Inguinal Hernia: What is the risk of strangulation

Back 48

Higher with indirect than direct inguinal hernia, but highest in femoral hernias

Front 49

Indirect Inguinal Hernia: Treatment

Back 49

Emergent herniorrha[hy is indicated if strangulation is suspected or acute incarceration is present; otherwise, elective herniorrhaphy is indicated to prevent chance of incarceration/strangulation

Front 50

DDx of Inguinal hernia

Back 50

Lymphadenopathy, psoas abscess, ectopic testes, hydrocele of the cord, saphernous varix, lipoma, varicocele, testicular torsion, femoral artery aneurysm, abscess

Front 51

Hernia repair: Bassini

Back 51

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

Front 52

Hernia repair: McVay

Back 52

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

Front 53

Hernia repair: Lichtenstein

Back 53

"Tension-free repair": using mesh

Front 54

Hernia repair: Shouldice

Back 54

Imbrication of the floor of the inguinal canal (a.k.a "Canadian repair")

Front 55

Hernia repair: Plug and patch

Back 55

placing a plug of mesh in hernia defect and then an overlying patch of mesh over the inguinal floor

Front 56

Hernia repair: High ligation

Back 56

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

Front 57

Hernia repair: TAPP procedure

Back 57

TransAbdominal PrePeritoneal inguinal hernia repair

Front 58

Hernia repair: TEPA procedure

Back 58

Totally ExtraPeritoneal Approach