Surgical Recall: 36 - Hernias

Front 1

What is a hernia?

Back 1

(L. rupture): Protrusion of a peritoneal sac through a musculoaponeurotic barrier (eg, abdominal wall); a fascial defect

Front 2

What is the incidence of hernias?

Back 2

5-10% lifetime

50% are indirect inguinal, 25% are direct inguinal, and ~5% are femoral

Front 3

What are the precipitating factors to hernias?

Back 3

- Increased intra-abdominal pressure

- Straining at defecation or urination (rectal cancer, colon cancer, prostatic enlargement, constipation)

- Obesity

- Pregnancy

- Ascites

- Valsavagenic (coughing) COPD

An abnormal congenital anatomic route (ie, 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 does "reducible" mean in terms of a hernia?

Back 5

Ability to return the displaced organ or tissue/hernia to its usual anatomic site

Front 6

What does "incarcerated" mean in terms of a hernia?

Back 6

Swollen or fixed within the hernia sac (incarcerated = imprisoned); may cause intestinal obstruction (ie, an irreducible hernia)

Front 7

What does "strangulated" mean in terms of a hernia?

Back 7

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

Front 8

What does "complete" mean in terms of a hernia?

Back 8

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

Front 9

What does "incomplete" mean in terms of a hernia?

Back 9

Defect present without sac or contents protruding completely through it

Front 10

What is reducing a hernia "en masse" mean?

Back 10

Reducing the hernia contents and hernia sac

Front 11

What is a "sliding" hernia?

Back 11

Hernia sac partially formed by the wall of a viscus (ie, bladder, cecum, sigmoid, ovary)

Front 12

What is a "Littre's" hernia?

Back 12

Hernia involving a Meckel's diverticulum (usually strangulates/incarcerates)

Front 13

What is a "Spigelian" hernia?

Back 13

Hernia through the linea semilunaris (or spigelian fascia); also known as spontaneous lateral ventral hernia

Front 14

What is an "internal" hernia?

Back 14

Hernia into or involving intra-abdominal structure

Front 15

What is a "Petersen's" hernia?

Back 15

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

Front 16

What is a "Obturator" hernia?

Back 16

Hernia through obturator canal (females > males)

Front 17

What is a "Lumbar" hernia?

Back 17

Petit's hernia or Grynfeltt's hernia

Front 18

What is a "Petit's" hernia?

Back 18

(Rare) hernia through Petit's triangle (aka inferior lumbar triangle)

Think: petite = small = inferior

Petit's triangle: medial external oblique, lateral latissimus dorsi, and iliac crest

Front 19

What is a "Grynfeltt's" hernia?

Back 19

Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle)

Triangle: sacrospinalis muscle, internal oblique muscle, and 12th rib inferior margin

Front 20

What is a "Pantaloon" hernia?

Back 20

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 (two sacs separated by the inferior epigastric vessels - the pant crotch - like a pair of pantaloon pants)

Front 21

What is an "incisional" hernia?

Back 21

Hernia through an incisional site; most common cause is a wound infection

Front 22

What is a "ventral" hernia?

Back 22

Incisional hernia in the ventral abdominal wall

Front 23

What is a "parastomal" hernia?

Back 23

Hernia adjacent to an ostomy (eg, colostomy)

Front 24

What is a "sciatic" hernia?

Back 24

Hernia through the sciatic foramen

Front 25

What is a "Richter's" hernia?

Back 25

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

Front 26

What is an "epigastric" hernia?

Back 26

Hernia through the linea alba above the umbilicus

Front 27

What is an "umbilical" hernia?

Back 27

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

Front 28

What is an "intraparietal" hernia?

Back 28

Hernia in which abdominal contents migrate between the layers of the abdominal wall

Front 29

What is a "femoral" hernia?

Back 29

Hernia medial to femoral vessels (under inguinal ligament)

Front 30

What is a "Hesselbach's" hernia?

Back 30

Hernia under inguinal ligament lateral to femoral vessels

Front 31

What is a "Bochdalek's" hernia?

Back 31

Hernia through the posterior diaphragm, usually on the left ("boch-da-lek" = "back-to-the-left" on the diaphragm)

Front 32

What is a "Morgagni's" hernia?

Back 32

Anterior parasternal diaphragmatic hernia

Front 33

What is a "properitoneal" hernia?

Back 33

Intraparietal hernia between the peritoneum and transversalis fascia

Front 34

What is a "Cooper's" hernia?

Back 34

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

Front 35

What is an "indirect inguinal" hernia?

Back 35

Inguinal hernia lateral to Hesselbach's triangle

Front 36

What is a "direct inguinal" hernia?

Back 36

Inguinal hernia within Hesselbach's triangle

Front 37

What is a "hiatal" hernia?

Back 37

Hernia through esophageal hiatus

Front 38

What is an "Amyand's" hernia?

Back 38

Hernia sac containing a ruptured appendix (Amyand's = Appendix)

Front 39

What are the boundaries of Hesselbach's triangle?

Back 39

1. Inferior epigastric vessels

2. Inguinal ligament (Poupart's)

3. Lateral border of the rectus sheath

Floor consists of internal oblique and the transversus abdominis muscle

Front 40

What are the laters of the abdominal wall?

Back 40

- Skin

- SubQ fat

- Scarpa's fascia

- External oblique

- Internal oblique

- Transversus abdominus

- Transversalis fascia

- Pre-peritoneal fat

- Peritoneum

Note: all 3 muscle layers aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line

Front 41

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

Back 41

Hernia, Endometrioma

Front 42

What is the differential diagnosis of a groin mass?

Back 42

- Lymphadenopathy

- Hematoma

- Seroma

- Abscess

- Hydrocele

- Femoral artery aneurysm

- EIC (epidermal inclusion cyst)

- Undescended testicle

- Sarcoma

- Hernia

- Testicular torsion

Front 43

What is a direct inguinal hernia?

Back 43

Hernia within the floor of Hesselbach's triangle, ie, the hernia sac does not traverse the internal ring (think directly through the abdominal wall)

Front 44

What is the cause of a direct inguinal hernia?

Back 44

Acquired defect from mechanical breakdown over the years

Front 45

What is the incidence of direct inguinal hernias?

Back 45

About 1% of all men; frequency increases with advanced age

Front 46

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

Back 46

Ilioinguinal nerve

Front 47

What is an indirect inguinal hernia?

Back 47

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 (ie, if complete); think of the hernia sac traveling indirectly through the abdominal wall from the internal ring to the external ring)

Front 48

What is the cause of an indirect inguinal hernia?

Back 48

Patent processus vaginalis (ie, congenital)

Front 49

What is the incidence of indirect inguinal hernias?

Back 49

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

Front 50

How is an inguinal hernia diagnosed?

Back 50

Relies mainly on history and physical exam 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 below the inguinal ligament, it is possibly a femoral hernia

Front 51

What is the differential diagnosis of an inguinal hernia?

Back 51

- Lymphadenopathy

- Psoas abscess

- Ectopic testis

- Hydrocele of the cord

- Saphenous varix

- Lipoma

- Varicocele

- Testicular torsion

- Femoral artery aneurysm

- Abscess

Front 52

What is the risk of strangulation for inguinal hernias?

Back 52

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

Front 53

What are the types of procedures for repairing inguinal hernias?

Back 53

- Bassini

- McVay

- Lichtenstein

- Shouldice

- Plug and patch

- High ligation

- TAPP procedure

- TEPA procedure

Front 54

What is a Bassini procedure?

Back 54

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

Front 55

What is a McVay procedure?

Back 55

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

Front 56

What is a Lichtensteinprocedure?

Back 56

"Tension-free repair" using mesh

Front 57

What is a Shouldice procedure?

Back 57

Imbrication of the floor of the inguinal canal (aka "Canadian repair")

Front 58

What is a Plug and Patch procedure?

Back 58

Place a plug of mesh in hernia defect and then overlay a patch of mesh over the inguinal floor (requires few if any sutures in mesh)

Front 59

What is a High Ligation procedure?

Back 59

Ligation and transection of indirect hernia sac without repair of inguinal floor (used only in children)

Front 60

What is a TAPP procedure?

Back 60

TransAbdominal Pre-Peritoneal inguinal hernia repair

Front 61

What is a TEPA procedure?

Back 61

Totally ExtraPeritoneal Approach

Front 62

What are the indications for laparoscopic inguinal hernia repair?

Back 62

1. Bilateral inguinal hernias

2. Recurring hernias

3. Need to resume full activity as soon as possible

Front 63

What is the first identifiable subcutaneous named layer?

Back 63

Scarpa's fascia (thin in adults)

Front 64

What is the name of the subcutaneous vein that is ligated during an inguinal hernia repair?

Back 64

Superficial epigastric vein

Front 65

What happens if you cut the ilioinguinal nerve?

Back 65

Numbness of inner thigh or lateral scrotum; usually goes away in 6 months

Front 66

From what abdominal muscle layer is the cremaster muscle derived?

Back 66

Internal Oblique Muscle

Front 67

From what abdominal muscle layer is the inguinal ligament (aka Poupart's ligament) derived?

Back 67

External oblique muscle aponeurosis

Front 68

To what does the inguinal (Poupart's) ligament attach?

Back 68

Anterior superior iliac spine to the pubic tubercle

Front 69

Which nerve travels on the spermatic cord?

Back 69

Ilioinguinal nerve

Front 70

Why do some surgeons deliberately cut the ilioinguinal nerve?

Back 70

First they obtain pre-op consent and cut so as to remove the risk of entrapment and post-op pain

Front 71

What is in the spermatic cord?

Back 71

1. Cremasteric muscle fibers

2. Vas deferens

3. Testicular artery

4. Testicular pampiniform venous plexus

5. +/- Hernia sac

6. Genital branch of the genitofemoral nerve

Front 72

What is the hernia sac made of?

Back 72

- Peritoneum (direct)

- Patent processus vaginalis (indirect)

Front 73

What attaches the testicle to the scrotum?

Back 73

Gubernaculum

Front 74

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

Back 74

Small intestine

Front 75

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

Back 75

Ovary / fallopian tube

Front 76

What lies in the inguinal canal in the female instead of the vas deferens?

Back 76

Round ligament

Front 77

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

Back 77

Anteromedially

Front 78

What is a "cord lipoma"?

Back 78

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

Front 79

What is a small out-pouching of testicular tissue off of the testicle?

Back 79

Testicular appendage (aka the appendix testes); remove with electrocautery

Front 80

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

Back 80

Remove the suture as soon as possible and apply pressure (ie, do not tie the suture down!)

Front 81

What nerve is found on top of the spermatic cord?

Back 81

Ilioinguinal nerve

Front 82

What nerve travels within the spermatic cord?

Back 82

Genital branch of the genitofemoral nerve

Front 83

What are the borders of Hesselbach's triangle?

Back 83

1. Epigastric vessels

2. Inguinal ligament

3. Lateral border of rectus

Front 84

What type of hernia goes through Hesselbach's triangle?

Back 84

Direct hernia due to a weak abdominal floor

Front 85

What is a "relaxing incision"?

Back 85

Incision(s) in the rectus sheath to relax the conjoint tendon so that it can be approximated to the reflection of the inguinal ligament without tension

Front 86

What is the conjoint tendon?

Back 86

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

Front 87

How tight should the new internal inguinal ring be?

Back 87

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

Front 88

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

Back 88

Zero!

Front 89

What is a femoral hernia?

Back 89

Hernia traveling beneath the inguinal ligament down the femoral canal medial to the femoral vessels (think FM radio = Femoral hernia = Medial)

Front 90

What are the boundaries of the femoral canal?

Back 90

1. Cooper's ligament posteriorly

2. Inguinal ligament anteriorly

3. Femoral vein laterally

4. Lacunar ligament medially

Front 91

What factors are associated with femoral hernias?

Back 91

- Women

- Pregnancy

- Exertion

Front 92

What percentage of all hernias are femoral?

Back 92

5%

Front 93

What percentage of patients with femoral hernias are female?

Back 93

85%

Front 94

What are the complications of femoral hernias?

Back 94

Approx. 1/3 incarcerate (d/t narrow, unforgiving neck)

Front 95

What is the most common hernia in women?

Back 95

Indirect inguinal hernia

Front 96

What is the repair of a femoral hernia called?

Back 96

McVay (Cooper's ligament repair), mesh plug repair

Front 97

Should elective TURP or elective herniorrhaphy be performed first?

Back 97

TURP

Front 98

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

Back 98

Sliding esophageal hiatal hernia

Front 99

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

Back 99

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 100

What is appropriate if you cannot reduce an incarcerated hernia with steady, gentle compression?

Back 100

Go directly to OR for repair

Front 101

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

Back 101

In babies and children it is rarely necessary to repair the inguinal floor; repair with "high ligation" of hernia sac

Front 102

What is the Howship-Romberg sign?

Back 102

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

Front 103

What is the "silk glove" sign?

Back 103

Inguinal hernia sac is an infant/toddler feels like a finger of a silk globe when rolled under the examining finger

Front 104

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

Back 104

Pull the testicle back down into the scrotum

Front 105

What are the types of hiatal hernias?

Back 105

Type I: sliding

Type II: paraesophageal

Front 106

What is a sliding esophageal hiatal hernia?

Back 106

Both the stomach and GE junction herniate into the thorax via the esophageal hiatus; also known as Type I hiatal hernia

Front 107

What is the incidence of sliding esophageal hiatal hernias?

Back 107

>90% of all hiatal hernias

Front 108

What are the symptoms of sliding esophageal hiatal hernias?

Back 108

Most pts are asymptomatic, but the condition can cause reflux, dysphagia (from inflammatory edema), esophagitis, and pulmonary problems 2/2 to aspiration

Front 109

How is a sliding esophageal hiatal hernia diagnosed?

Back 109

- UGI series

- Manometry

- Esophagogastroduodenoscopy (EGD) w/ biopsy for esophagitis

Front 110

What are the complications of a sliding esophageal hiatal hernia?

Back 110

- Reflux --> esophagitis --> Barrett's esophagus --> cancer or stricture formation

- Aspiration pneumonia

- It can also result in UGI bleeding from esophageal ulceration

Front 111

What is the treatment of a sliding esophageal hiatal hernia?

Back 111

85% of cases are treated medically with antacids, H2 blockres, PPIs, head elevation after meals, small meals, and no food prior to sleeping

15% of cases require surgery for persistent symptoms despite adequate medical treatment

Front 112

What is the surgical treatment for a sliding esophageal hiatal hernia?

Back 112

Laparoscopic Nissen fundoplication (LAP Nissen) involves wrapping the fundus around the LES and suturing it in place

Front 113

What is a paraesophageal hiatal hernia?

Back 113

Herniation of all or part of stomach through esophageal hiatus into the thorax without displacement of the GE junction; also known as type II hiatal hernia

Front 114

What is the incidence of paraesophageal hiatal hernias?

Back 114

<5% of all hiatal hernias (rarE)

Front 115

What are the symptoms of paraesophageal hiatal hernias?

Back 115

Derived from mechanical obstruction:

- Dysphagia

- Stasis gastric ulcer

- Strangulation

Many cases are asymptomatic and not associated with reflux because of a relatively normal position of the GE junction

Front 116

What are the complications of paraesophageal hiatal hernias?

Back 116

- Hemorrhage

- Incarceration

- Obstruction

- Strangulation

Front 117

What is the treatment of paraesophageal hiatal hernias?

Back 117

Surgical, because of frequency and severity of potential complications

Front 118

What is a type III hiatal hernia?

Back 118

Combined type I and type II

Front 119

What is a type IV hiatal hernia?

Back 119

Organ (eg, colon or spleen) +/- stomach in chest cavity