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  1. Inguinal hernias:
    External abdominal oblique:
    Internal abdominal oblique:
    Transversalis muscle:
    Inguinal ligament:
    -Lacunar Ligament:
    Ileopubic tract:
    Cooper's ligament:
    Conjoined tendon:
    Vas Deferens:
    Hesselbach's triangle
    External abdominal oblique- forms external abdominal oblique fascia and shelving edge

    Internal abdominal oblique- forms cremasteric muscles

    Transversalis muscle- forms inguinal canal floor

    • Inguinal ligament (Poupart's ligament)- from external abdominal oblique, runs from anterior superior iliac spine to the pubis
    • - Lacunar ligament- where the inguinal ligament splays out to insert in the pubis

    • Ileopubic tract- from transversalis, runs from anterior, superior, iliac spine to the pubis
    • - is below the inguinal ligament

    Cooper's ligament- pectineal ligament

    Conjoined tendon- composed of the aponeurosis of the internal abdominal oblique and transversus abdominis muscles

    Vas deferens- runs medial to cord structures

    • Hesselbach's triangle- rectus muscle, inferior inguinal ligament, and inferior epigastrics
    • - direct hernias are inferior/medial to the epigastric vessels
    • - indirect hernias are superior/lateral to the epigastric vessels
  2. Risk factors for inguinal hernia in adults:
    • 1) age
    • 2) obesity
    • 3) heavy lifting
    • 4) COPD (coughing)
    • 5) chronic constipation
    • 6) straining (BPH)
    • 7) ascites
    • 8) pregnancy
    • 9) peritoneal dialysis
  3. Indirect hernias:
    • 1) most common
    • 2) from persistently patent processus vaginalis
  4. Direct hernias:
    • 1) lower risk of incarceration
    • 2) rare in females
    • 3) higher recurrence than indirect
  5. Pantaloon hernia:
    direct and indirect components
  6. Incarcerated hernia:
    can lead to bowel strangulation; should be repaired emergently
  7. Sliding hernias
    Females: ovaries or fallopian tubes most common

    Males: cecum or sigmoid most common

    Bladder can also be involved
  8. Females with ovary in canal:
    • 1) ligate the round ligament
    • 2) return ovary to peritoneum
    • 3) perform biopsy if looks abnormal
  9. Hernias in infants and children
    • 1) just perform high ligation (nearly always indirect)
    • 2) open sac prior to ligation
  10. Lichtenstein repair:
    • 1) mesh
    • 2) recurrence decreased with use of mesh (decreased tension)
  11. Bassini repair
    approximation of the conjoined tendon and transversalis fascia (superior) to the free edge of the inginal ligament (inferior)
  12. McVay (Cooper's ligament) repair:
    • approximation of the conjoined tendon and transversalis fascia (superior to cooper's ligament (pectineal ligament, inferior)
    • - needs a relaxing incision in the external abdominal oblique fascia
  13. Laparoscopic hernia repair:
    indicated for bilateral or recurrent inguinal hernia
  14. Urinary retention
    most common early complication following hernia repair
  15. wound infection:
    Recurrence rate:
    • 2%
    • 2%
  16. Testicular atrophy
    • usually secondary to dissection of the distal component of the hernia sac causing vessel disruption
    • - thrombosis of spermatic cord veins
    • - usually occurs with indirect hernias
  17. Pain after hernia:
    usually compression of ilioinguinal nerve

    Treatment- local infiltration can be diagnostic and therapeutic
  18. Ileoinguinal nerve injury:
    loss of creamasteric reflex, numbness on ipsilateral penis, scrotum, and thigh

    - nerve is usually injured at the external ring; nerve runs on top of cord
  19. Genitofemoral nerve injury
    • - usually injured with laparoscopic hernia repair
    • Genital branch- cremaster (motor) and scrotum (sensory)
    • Femoral branch- upper lateral thigh (sensory)
  20. Cord lipomas
    should be removed
  21. Trapezoid of doom
    1- laparoscopic hernia repairs- femoral branch of genitofemoral nerve, lateral cutaneous nerve, and femoral artery

    need to dissect lateral to vessels; stay along inguinal ligament
  22. Femoral Hernia
    1) most common in males

    • 2) Femoral canal boundaries:
    • 1- cooper's ligament
    • 2- inguinal ligament
    • 3- femoral vein
    • 4- poupart's ligament is medial

    3) Femoral hernia is medial to the femoral vein and lateral to the lymphatics (in empty space)

    4) high risk of incarceration --> may need to divide the inguinal ligament to reduce the bowel

    5) hernia passes under the inguinal ligament

    6) characteristic bulge on the anterior-medial thigh below the ligament

    7) Hernia is usually repaired through an inguinal approach with McVay or Bassini repair
  23. Umbilical Hernia
    1) increased incidence in African-Americans

    2) delay repair until age 5

    3) risk of incarceration in adults, not children
  24. Spigelian hernia
    1) lateral border of rectus muscle, through linea semilunaris

    2) almost always inferior to the semicircularis (arcuate line)

    3) occurs between the muscle fibers of the internal abdominal oblique muscle and line of insertion of the external abdominal oblique aponeurosis into the rectus sheath
  25. Richter's hernia
    noncircumferential incarceration of the nonmesenteric bowel wall
  26. Littre's hernia
    incarcerated meckel's
  27. Petit's hernia
    • inferior lumbar hernia
    • 1) external abdominal oblique
    • 2) latissmus dorsi (or lumbodorsal aponeurosis)
    • 3) Iliac crest

    • Petit's hernia is a hernia that protrudes through the lumbar triangle. This triangle lies in the posterolateral abdominal wall and is bounded anteriorly by the free margin of external oblique muscle, posteriorly by the latissimus dorsi and inferiorly by the iliac crest. The neck (the spot where the hernia protrudes into the opening) is large, and therefore this hernia has a lower risk of strangulating than some other hernias.
    • Petit's hernia occurs more often in males than in females and more often on the left side than on the right.
  28. Grynfeltt's hernia
    • 1) superior lumbar hernia
    • 2) internal abdominal oblique
    • 3) lumbodorsal aponeurosis
    • 4) 12th rib (or posterior lumbocostal ligament)
  29. Sciatic hernia (posterior pelvis)
    herniation through the greater sciatic foramen; high rate of strangulation
  30. Obturator hernia (anterior pelvis)
    • 1) Howship-Romberg sign- inner thigh pain with internal rotation
    • 2) Elderly women, previous pregnancy, and bowel gas below superior pubic ramus
    • 3) Treatment: operative reduction, may need mesh; check other side for similar defect
    • 4) diagnosis is usually made at time of surgery for small bowel reduction
  31. Incisional hernia
    1) most likely to recur; inadequate closure is the most common cause
  32. Peristomal hernia
    • 1) true hernias- need to remove and place in rectus muscle (missed the rectus)
    • 2) Prolapse- keep stoma at same site, fix mesentary (is in rectus but prolapsing through)
    • 3) Pseudohernia- secondary to being in the oblique muscle; need to move to rectus
  33. Rectus sheath
    • 1) anterior- complete
    • 2) posterior- absent below semicircularis (below umbilicus)
    • 3) The posterior aponeurosis of the internal abdominal oblique and transversalis aponeurosis move anterior
  34. Rectus sheath hematomas:
    • 1) most common after trauma; epigastric vessel injury
    • 2) painful abdominal wall mass
    • 3) Mass more prominent and painful with flexion of the rectus muscle (Fothergill's sign)
    • 4) Treatment: nonoperative usual, surgery if expanding
  35. Desmoid tumors
    1) women, benign but locally invasive, high number of recurrences

    2) Gardner's syndrome

    3) painless mass

    4) Treatment: wide local excision; if involving small bowel, excision may not be indicated --> often not completely resectable and can cause worsening fibrosis

    5) NSAIDs and antiestrogens may help
  36. Retroperitoneal fibrosis
    • 1) can occur with hypersensitivity to methysergide
    • 2) IVP (Intravenous pyelography) most sensitive test
    • 3) symptoms usually related to trapped ureters and lymphatic obstruction
    • 4) Treatment:
    • 1- steroids
    • 2- nephrostomy if infection is present, and surgery if renal function becomes compromised (free up ureters and wrap in omentum)
  37. Mesenteric Tumors
    • 1) Of the primary tumors, most are cystic
    • 1- malignant tumors- closer to the root of the mesentary
    • 2- benign tumors- more peripheral

    2) Malignant- liposarcoma, leiomyosarcoma

    3) most solid tumors of the mesentary are benign

    4) Diagnosis: abdominal CT

    5) Treatment: resection
  38. Retroperitoneal tumors
    • 1) 15% in children, others in 5th-6th decade
    • 2) malignant > benign
    • 3) most common retroperitoneal tumor: #1 lymphoma, #2 liposarcoma
    • 4) Symptoms: vague abdominal and back pain
    • 5) Retroperitoneal sarcomas
    • 1- <25% resectable; local recurrence in 40%; 10% 5yr survival rate
    • 2- have pseudocapsule but cannot shell out --> leave residual tumor
    • 3- metastases go to lung
  39. Omental Tumors
    • 1) most common omental solid tumor is metastatic disease
    • 2) omentectomy for metastatic cancer has a role for some cancers (e.g. ovarian Ca)
    • 3) Omental cysts are usually asymptomatic, can undergo torsion
    • 4) primary solid omental tumors are rare; 1/3 malignant
    • 5) No biopsy--> can bleed
    • 6) Treatment: resection
  40. Peritoneal membrane
    • 1) saline absorbed at 35cc/hr
    • 2) blood absorbed through fenestrated lymphatic channels
    • 3) most drugs are not removed with peritoneal dialysis; NH3, Ca, Fe, and lead are removed
    • 4) movement into the peritoneal cavity with hypertonic intraperitoneal saline load --> 300-500cc/hr, can cause hypotension
  41. CO2 pneumoperitoneum
    • 1) cardiopulmonary dysfunction can occur with intra-abdominal pressure >20
    • 2) Increased:
    • 1- pulmonary artery pressure
    • 2- HR
    • 3- systemic vascular resistance
    • 4- central venous pressure
    • 5- mean airway pressure
    • 6- peak inspiratory pressure
    • 7- CO2

    • 3) Decreased:
    • 1- pH
    • 2- venous return (IVC compression)
    • 3- renal flow secondary to renal vein compression
    • 4- cardiac output

    • 4) hypovolemia lowers pressure necessary to cause compromise
    • 5) PEEP has additive effect:
    • Pressure causes decreased renal blood flow and can increase renin production
    • 6) CO2 can cause some decrease in myocardial contractility
    • 7) CO2 embolus- head down, turn patient to the left (sudden rise in ETCO2 hypotension)
  42. Harmonic Scalpel
    • 1) cost effective for medium vessels (short gastrics)
    • 2) disrupts protein H-bonds, causes coagulation
  43. Ultrasound
    • 1) B-mode used most commonly (B= brightness; assesses relative density of structures)
    • 2) Shadowing- dark area posterior to object indicates mass
    • 3) Enhancement- brighter area posterior to object indicates fluid filled cyst
    • 4) Duplex:
    • Lower frequencies- deep structures
    • Higher frequencies- superfical structures
  44. Argon Beam
    • 1) energy transferred across argon gas
    • 2) depth of necrosis related to power setting (2mm); pretty superficial coagulation
    • 3) Noncontact- good for hemostasis of the liver and spleen, smokeless
  45. Laser
    • - return of electrons to ground state releases energy as heat --> coagulates and vaporizes
    • - used for condyloma accuminata (wear mask)
  46. Nd:YAG laser
    • good for deep tissue penetration; used for bronchial lesions
    • 1-2mm cuts
    • 3-10 mm vaporizes
    • 1-2cm coagulates
  47. Gore-tex (PTFE)
    cannot get fibroblast ingrowth
  48. Dacron (polypropylene)
    allows fibroblast ingrowth
  49. incidence of vascular or bowel injury with Veress needle or trocar
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