What is the most common cause of hernia recurrence following repair?
wound infection
Name the layers of the abdominal wall lateral to the rectus.
- skin
- subcutaneous fat
- scarpa’s fascia
- external oblique
- internal oblique
- transversus abdominis
- transversals fascia
- pre peritoneal fat
- peritoneum
Where does the posterior sheath end?
at the arcuate line, one third of the distance below the umbilicus to the pubic symphysis
What is the blood supply to the rectus?
inferior and superior epigastrics
What are the boundaries of Hasselbach’s triangle? What is the significance of this space?
the space of a direct inguinal hernia
- medial: rectus
- lateral: inferior epigastrics
- inferior: inguinal hernia
A meckel’s diverticulum is derived from what embryonic structure?
the omphalomesenteric (or vitelline) duct
The urachus gives rise to what adult structure?
the median umbilical ligament
The obliterated umbilical vein and arteries give rise to what adult structures?
- vein: ligamentum teres, the round ligament of the liver
- artery: the medial umbilical ligaments
When does the midgut herniate from and return to the embryonic abdomen?
- herniates at 6 weeks
- returns at 10 weeks
What is the difference in location of the defect in a gastroschisis versus omphalocele?
- gastroschisis is inferior and right of the umbilicus
- omphalocele is at the umbilicus
What should generally be your go-to mesh for hernia repair?
a light-to-medium weight, microporous, polypropylene or polyester mesh
Which umbilical hernias should be repaired primarily?
those < 1cm and those in the pediatric population
When should you repair a pediatric umbilical hernia?
repair if persistent after 5 years of age, prior to starting school
How should you manage a cirrhotic with an umbilical hernia that has skin breakdown and is leaking fluid?
- resuscitate and start antibiotics
- repair urgently, avoiding mesh
- be aggressive about post-operative control of ascites
What is the anatomic relationship between direct and indirect inguinal hernias?
direct are medial to the epigastrics
What are the contents of the spermatic cord?
- cremasteric muscles
- testicular artery
- pampiniform plexus
- vas deferens
- ilioinguinal nerve
- genital branch of the genitofemoral nerve
What is the most commonly injured nerve during an open inguinal hernia repair?
the ilioinguinal nerve, which usually occurs when opening the external oblique
What are the three key nerves to identify during an open inguinal hernia repair?
- ilioinguinal (MC injured)
- genital branch of the genitofemoral
- iliohypogastric
What nerve is most commonly injured during a MIS approach to inguinal hernia repair?
the cutaneous branch of the lateral femoral, usually due to a misplaced tack, laterally
Describe a Bassini repair for inguinal hernia.
the conjoint tendon (transversalis and internal oblique) to the inguinal ligament
Describe a Shouldice repair for inguinal hernia?
a bassini repair (conjoint tendon to inguinal ligament) but in four layers
What is the main structure of fixation in laparoscopic inguinal hernia repair?
Cooper’s ligament
What is the triangle of doom?
- an area of concern in laparoscopic inguinal hernia repair where bleeding is likely if tacks/suture are placed due to the underlying iliacs
- defined by the vas deferens medially and the spermatic vessels laterally with the apex at the inguinal ligament
What tissue repair is appropriate for a femoral hernia?
McVay repair
