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119 Cards in this Set

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What is a hernia?

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

What is the incidence of hernias?

5-10% lifetime


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

What are the precipitating factors to hernias?

- 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)

Why should hernias be repaired?

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

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

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

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

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

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

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

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

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

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

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

Defect present without sac or contents protruding completely through it

What is reducing a hernia "en masse" mean?

Reducing the hernia contents and hernia sac

Reducing the hernia contents and hernia sac

What is a "sliding" hernia?

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

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

What is a "Littre's" hernia?

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

What is a "Spigelian" hernia?

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

What is an "internal" hernia?

Hernia into or involving intra-abdominal structure

What is a "Petersen's" hernia?

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

What is a "Obturator" hernia?

Hernia through obturator canal (females > males)

What is a "Lumbar" hernia?

Petit's hernia or Grynfeltt's hernia

What is a "Petit's" hernia?

(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

What is a "Grynfeltt's" hernia?

Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle)



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

What is a "Pantaloon" hernia?

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 -...

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)

What is an "incisional" hernia?

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

What is a "ventral" hernia?

Incisional hernia in the ventral abdominal wall

What is a "parastomal" hernia?

Hernia adjacent to an ostomy (eg, colostomy)

What is a "sciatic" hernia?

Hernia through the sciatic foramen

What is a "Richter's" hernia?

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

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

What is an "epigastric" hernia?

Hernia through the linea alba above the umbilicus

What is an "umbilical" hernia?

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

What is an "intraparietal" hernia?

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

What is a "femoral" hernia?

Hernia medial to femoral vessels (under inguinal ligament)

What is a "Hesselbach's" hernia?

Hernia under inguinal ligament lateral to femoral vessels

What is a "Bochdalek's" hernia?

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

What is a "Morgagni's" hernia?

Anterior parasternal diaphragmatic hernia

What is a "properitoneal" hernia?

Intraparietal hernia between the peritoneum and transversalis fascia

What is a "Cooper's" hernia?

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

What is an "indirect inguinal" hernia?

Inguinal hernia lateral to Hesselbach's triangle

What is a "direct inguinal" hernia?

Inguinal hernia within Hesselbach's triangle

What is a "hiatal" hernia?

Hernia through esophageal hiatus

What is an "Amyand's" hernia?

Hernia sac containing a ruptured appendix (Amyand's = 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



Floor consists of internal oblique and the transversus abdominis muscle

What are the laters of the abdominal wall?

- 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

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

Hernia, Endometrioma

What is the differential diagnosis of a groin mass?

- Lymphadenopathy


- Hematoma


- Seroma


- Abscess


- Hydrocele


- Femoral artery aneurysm


- EIC (epidermal inclusion cyst)


- Undescended testicle


- Sarcoma


- Hernia


- Testicular torsion

What is a direct inguinal hernia?

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

What is the cause of a direct inguinal hernia?

Acquired defect from mechanical breakdown over the years

What is the incidence of direct inguinal hernias?

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

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

What is the cause of an indirect inguinal hernia?

Patent processus vaginalis (ie, congenital)

What is the incidence of indirect inguinal hernias?

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

How is an inguinal hernia diagnosed?

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

What is the differential diagnosis of an 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 for inguinal hernias?

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

What are the types of procedures for repairing inguinal hernias?

- Bassini


- McVay


- Lichtenstein


- Shouldice


- Plug and patch


- High ligation


- TAPP procedure


- TEPA procedure

What is a Bassini procedure?

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

What is a McVay procedure?

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

What is a Lichtensteinprocedure?

"Tension-free repair" using mesh

What is a Shouldice procedure?

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

What is a Plug and Patch procedure?

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)

What is a High Ligation procedure?

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

What is a TAPP procedure?

TransAbdominal Pre-Peritoneal inguinal hernia repair

What is a TEPA procedure?

Totally ExtraPeritoneal Approach

What are the indications for laparoscopic inguinal hernia repair?

1. Bilateral inguinal hernias


2. Recurring hernias


3. Need to resume full activity as soon as possible

What is the first identifiable subcutaneous named layer?

Scarpa's fascia (thin in adults)

What is the name of the subcutaneous vein that is ligated during an 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 months

From what abdominal muscle layer is the cremaster muscle derived?

Internal Oblique Muscle

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

External oblique muscle aponeurosis

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

Anterior superior iliac spine to the pubic tubercle

Which nerve travels on the spermatic cord?

Ilioinguinal nerve

Why do some surgeons deliberately cut the ilioinguinal nerve?

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

What is in the spermatic cord?

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

What is the hernia sac made of?

- Peritoneum (direct)


- 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 deferens?

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; remove surgically, if feasible

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

Testicular appendage (aka the appendix testes); remove with 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 (ie, do not tie the suture down!)

What nerve is found on top of the spermatic cord?

Ilioinguinal nerve

What nerve travels within 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 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 without 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 (the 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 (think FM radio = Femoral hernia = Medial)

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 associated with femoral hernias?

- Women


- Pregnancy


- Exertion

What percentage of all hernias are femoral?

5%

What percentage of patients with femoral hernias are female?

85%

What are the complications of femoral hernias?

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

What is the most common hernia in women?

Indirect inguinal hernia

What is the repair of a femoral hernia called?

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

Should elective TURP or elective herniorrhaphy be performed first?

TURP

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

Sliding esophageal 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 with steady, gentle compression?

Go 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 with "high ligation" of 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 is an infant/toddler feels like a finger of a silk globe when rolled under the examining finger

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

Pull the testicle back down into the scrotum

What are the types of hiatal hernias?

Type I: sliding


Type II: paraesophageal

What is a sliding esophageal hiatal hernia?

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

What is the incidence of sliding esophageal hiatal hernias?

>90% of all hiatal hernias

What are the symptoms of sliding esophageal hiatal hernias?

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

How is a sliding esophageal hiatal hernia diagnosed?

- UGI series


- Manometry


- Esophagogastroduodenoscopy (EGD) w/ biopsy for esophagitis

What are the complications of a sliding esophageal hiatal hernia?

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


- Aspiration pneumonia


- It can also result in UGI bleeding from esophageal ulceration

What is the treatment of a sliding esophageal hiatal hernia?

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

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

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

What is a paraesophageal hiatal hernia?

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

What is the incidence of paraesophageal hiatal hernias?

<5% of all hiatal hernias (rarE)

What are the symptoms of paraesophageal hiatal hernias?

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

What are the complications of paraesophageal hiatal hernias?

- Hemorrhage


- Incarceration


- Obstruction


- Strangulation

What is the treatment of paraesophageal hiatal hernias?

Surgical, because of frequency and severity of potential complications

What is a type III hiatal hernia?

Combined type I and type II

What is a type IV hiatal hernia?

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