Surg Med - Hernia Repair

hernia

- a protrusion of an organ or tissue through an ABN opening in the muscle or tissue that normally contains it

- usually occur @ natural weakness or congenital areas where this is a natural opening

inguinal hernia

What is the most common type of hernia?

obesity, heavy lifting, chronic cough/constipation, prior surgery, males, age

RFs for a hernia?

- indirect (lateral) inguinal hernias

- umbilical hernia

- Morgagni/Bochdalek hernias

What types of hernias are congenital?

- traumatic

- iatrogenic/incisional

- pt-related factors

What types of hernias are acquired?

reducible hernia

hernia contents are able to be returned to their appropriate position

incarcerated hernia

hernia contents are unable to be moved from their herniated position → pts may develop obstructive type sxs

strangulated hernia

blood supply to trapped tissue is cut off, leading to tissue death and potential infxn (pt may develop signs of sepsis)

complete hernia

entire organ protrudes

incomplete hernia

only part of organ protrudes

sliding hernia

What type of hernia?:

- part of wall of hernia sac is visceral organ (part of hernia sac is formed from viscus and overlying peritoneum (colon, bladder))

littre's hernia

What type of hernia?:

- incarceration of a Meckel diverticulum inside a femoral hernia

spigelian hernia

What type of hernia?:

- protrusion of abdominal contents and/or peritoneum through a defect in the lower anterior abdomen adjacent to the semilunar line; d/t a defect in the linear semilunaris; usually in region of arcuate line

internal hernia

What type of hernia?:

- protrudes within abdominal/peritoneal cavity (arising from mesenteric defect) - may cause twisting of an area of small bowel that is causing an obstruction

obturator hernia

What type of hernia?:

- pelvic hernia through obturator foramen

petit's hernia

What type of hernia?:

- lumbar hernia through inferior lumbar triangle

grynfeltt's hernia

What type of hernia?:

- lumbar hernia through superior lumbar triangle (bordered by internal oblique mm, erector spinae mm, and 12th rib)

pantaloon hernia

What type of hernia?:

- both direct and indirect inguinal hernia (two adjacent hernias sacs in inguinal or femoral region)

incisional hernia

What type of hernia?:

- at site of previous surgery (example of properitoneal – hernia projects above peritoneum)

ventral hernia

What type of hernia?:

- general term for anterior abdominal wall hernias

richter's hernia

What type of hernia?:

- only part of bowel wall trapped → antimesenteric portion of intestine herniated

- a subset of strangulated hernias in which only the antimesenteric portion of the intestinal wall is trapped by the abdominal wall defect, causing ischemia without obstruction

epigastric hernia

What type of hernia?:

- through linea alba above umbilicus

umbilical hernia

What type of hernia?:

- through umbilical ring

intraparietal hernia

What type of hernia?:

- between layers of abdominal wall

femoral hernia

What type of hernia?:

- through femoral canal

hesselbach's hernia

What type of hernia?:

- lateral to femoral vessels (through lacunar musculorum)

cooper's hernia

What type of hernia?:

- hernia with two hernia sacs, one through femoral canal and other through superficial fascia

Bochdalek's hernia

What type of hernia?:

- posterolateral diaphragmatic hernia - congenital

- Failure of fusion of the septum transversum postero-laterally with the pleuroperitoneal membranes

Morgagni's hernia

What type of hernia?:

- congenital anteromedial/retrosternal diaphragmatic hernia

- Failure of fusion of the septum transversum anteriorly w/ the sternum&ribs

properitoneal hernia

What type of hernia?:

- between peritoneum and transversalis fascia

indirect hernia

What type of hernia?:

- through internal inguinal ring, lateral to inferior epigastric vessels

direct hernia

What type of hernia?:

- through Hesselbach’s triangle, medial to inferior epigastric vessels

hiatal hernia

What type of hernia?:

- through diaphragm at esophageal hiatus

- skin & SQ tissue

- Camper's fascia (superficial fatty layer)

- Scarpa's fascia (deep membranous layer)

- external oblique m

- internal oblique m

- transversus abdominis

- deep fascia (transversalis fascia)

- preperitoneal adipose tissue (extraperitoneal fat)

- parietal peritoneum

Name the layers of the abdominal wall from external/superficial to internal/deep.

medial - lateral margin of rectus sheath

lateral - inferior epigastric vessels

inferior - inguinal ligament

What are the anatomical boundaries of Hesselbach's triangle?

medial - latissimus dorsi m

lateral - external oblique m

inferior - iliac crest

What are the anatomical boundaries of Petit's triangle (aka inferior lumbar triangle)?

superior - 12th rib

medial - erector spinae m

lateral - internal oblique m

What are the anatomical boundaries of Grynfeltt's-Lesshaft's triangle (aka superior lumbar triangle)?

- ductus/vas deferens

- deferential a & v

- testicular a

- pampiniform plexus of vv (formed by up to 12 vv)

- lymphatics

- autonomic nerves

*sympathetics on arteries

*SNS and PSNS on ductus deferens

What structures lie within the spermatic cord?

medial to the inferior epigastric vessels (in hesselbach's triangle) and lateral to rectus abdominis

Where would you find a direct inguinal hernia?

direct inguinal hernia

This type of hernia has a bulge in the groin that is LESS likely to enter the scrotum

ultrasound

What type of imaging should you do for a direct inguinal, indirect inguinal, or femoral hernia?

mesh repair (hernioplasty)

What is the gold standard repair for a direct/indirect inguinal hernia?

lateral to inferior epigastric vessels

Where is an indirect inguinal hernia located?

below the inguinal ligament through the femoral canal

Where is a femoral hernia located?

femoral hernia

The following are s/sx of...?:

- globular swelling inferior to the inguinal ligament and medial to the femoral vein that worsens w/ coughing or straining

no

Should you use mesh to repair a complicated femoral hernia?

Paraesophageal hiatal hernia

- part of the gastric fundus herniates into the thorax

- the GEJ remains in its anatomical position below the diaphragm

Sliding esophageal hernia

- the GEJ and the gastric cardia slide up into the posterior mediastinum

- the gastric fundus remains below the diaphragm (hourglass stomach)

paraesophageal hiatal hernia

With what type of hernia does the GEJ remain below the diaphragm?

sliding esophageal hernia

What type of hernia most commonly presents with reflux (paraesophageal hiatal OR sliding esophageal)?

paraesophageal hiatal hernia

Of paraesophageal hiatal and sliding esophageal hernias, which is more likely to have an increased risk of strangulation?