Lecture 7

Question 1

Acute abdomen:
1) What are the main Sxs?
2) What are some concerns for life-threatening causes of abd pain?

Answer 1

1) Usual sudden onset abdominal pain+ associated nausea, vomiting, ill-appearing patient
-Elderly: may be only hypotension + AMS
2) Unstable vital signs
Signs of peritonitis on exam
Concern that pain is due to life-threatening condition
Concern for infection on initial exam

Question 2

Descr acute abdomen in the elderly

Answer 2

-50% elderly patients with acute abdomen are admitted
-33% undergo surgery
-Obstacles to obtaining history: AMS, multiple family members/caregivers, medications, malnutrition
-AMS & hypotension may be only indicators

Question 3

List common etiologies of acute abdomen

Answer 3

Acute appendicitis
Cholecystitis
Pancreatitis
Diverticulitis
Acute peritonitis
Mesenteric ischemia, ruptured AAA
Ruptured ectopic pregnancy, ovarian torsion
Ureteral colic, pyelonephritis
LBO/SBO, volvulus, intussusception
Perforated peptic ulcer
Incarcerated hernia
Bowel perforation
IBD
Gastroenteritis
Acute gastritis

Question 4

Acute abd: What are some High-risk:
1) Pain features
2) Exam findings
3) Hx

Answer 4

1) Sudden onset, maximal at onset, pain then subsequent vomiting, constant pain <2 days in duration
2) Tense or rigid abdomen, involuntary guarding, signs of shock
3) Age >65, immunocompromised, alcoholism, CVD, major comorbidities, prior surgeries or recent GI instrumentation, early pregnancy

Question 5

Descr the first two steps in diagnosing acute abdomen

Answer 5

1) Determine location of pain.
Visceral pain: slow onset, poorly-localized, dull discomfort
Somatic pain: sudden, sharp, well-localized, lateralizing
2) Determine onset (acute, insidious) and progression of pain

Question 6

Descr the third step of diagnosing acute abdomen

Answer 6

Character of pain (continuous, intermittent, sharp, stabbing, etc):
-Sharp, superficial, constant pain due to peritoneal irritation; often presenting as focal peritonitis (typical of perforated ulcer or a ruptured appendix, ovarian cyst, or ectopic pregnancy)
-Pain out of proportion to clinical picture should raise concern for mesenteric ischemia

Question 7

Descr a Complete abdominal exam (IAPP)

Answer 7

Scars? Distention? Obvious masses?
Guarding?
Murphy sign: acute cholecystitis
Psoas sign: retroperitoneal inflammation
Obturator sign: deep pelvic inflammation
Rovsing’s sign: RLQ inflammation

DRE, pelvic, testicular, & hernia exams as indicated
If required, narcotic pain medication and note response

Question 8

Descr interpretation of labs for acute abd

Answer 8

Careful interpretation (elderly, immunosuppressed, pregnant)
Normal results do not always equal absence of disease
*Always perform pregnancy test in women of childbearing age

Question 9

What should you consider in choosing imaging for acute abd?

Answer 9

Consider likely dx, clinical condition, possibility of pregnancy, cumulative radiation dose
Safe, available, ease of interpretation, therapeutic value

Question 10

Acute abd imaging; describe:
1) Upright CXR
2) US
3) CT
4) MRI

Answer 10

1) Upright CXR: for all; preop assessment, subdiaphragmatic conditions (ex. PNA, ruptured esophagus, free air)
2) Ultrasound: bedside; young, childbearing age, biliary disease, FAST
3) CT: gold standard in non-pregnant patients
PO contrast to dx bowel perforation, anastamotic leaks
4) MRI: value in biliary & pancreatic pathology

Question 11

What are the 4 main muscles of the abd wall?

Answer 11

External oblique
Internal oblique
Transverses abdominis
Rectus abdominis

Question 12

List the layers of the abd wall from external to internal

Answer 12

Skin
Subcutaneous fat
Camper’s layer
Scarpa fascia
External oblique muscle
Internal oblique muscle
Transversus abdominis muscle
Transversalis (endoabdominal) fascia
Preperitoneal fat (adipose tissue)
Peritoneum

Question 13

What are the normal structures of the inguinal canal?

Answer 13

Spermatic cord (male)
Round ligament (female)
Ilioinguinal nerve
Genitofemoral nerve

Question 14

What are some abnormal structures of the inguinal canal?

Answer 14

Abdominal contents:
Bowel, omentum
Hernia sac

Question 15

What are the 3 nerves encountered in inguinal hernia repair?

Answer 15

1) Ilioinguinal (most frequently injured in open inguinal hernia repairs)
2) Iliohypogastric
3) Genitofemoral (genital branch)

Question 16

Define:
1) Reducible
2) Irreducible

Answer 16

1) Contents can return to original anatomic position either spontaneously or via manual manipulation
2) Contents cannot be returned to original anatomic position in nonsurgical manner
-Acute or chronic
-Can cause bowel obstruction

Question 17

Define/ describe strangulated hernia and what you shouldn’t do

Answer 17

Incarcerated hernia with vascular compromise
-Fever, sharp groin main, difficulty passing urine, signs of bowel obstruction
Do NOT attempt to reduce back to abd cavity

Question 18

Define:
1) Complete hernia
2) Incomplete hernia
3) Richter hernia (uncommon type of incomplete)

Answer 18

1) Entire portion of organ herniates
2) Only a portion of organ herniates
3) Part of circumference of bowel incarcerated or strangulated

Question 19

Give an example of congenital vs acquired hernias

Answer 19

Processus vaginalis fails to close during gestation vs patent processes vaginalis with weakness in abd wall

Question 20

Indirect inguinal hernia:
1) What is it?
2) What causes most cases?

Answer 20

1) Intra-abdominal contents protrude at internal inguinal ring
Lateral to inferior epigastric vessels
2) Congenital

Question 21

Direct inguinal hernia:
1) What/ where is it?
2) What is at the inferior border?
3) What abt lateral?
4) Medial?
5) What causes it?

Answer 21

1) Intra-abdominal contents protrude from Hesselbach’s triangle
2) Inferior: inguinal ligament
3) Lateral: inferior epigastric vessels
4) Medial: rectus abdominis
5) Weakness/defect in the transversalis fascia (floor of the triangle)

Question 22

Femoral hernia:
1) Who is it more common in?
2) Where is it?

Answer 22

1) F>M
2) Acquired protrusion of intra-abdominal contents through femoral ring
-small empty space between the lacunar ligament medially and the femoral vein laterally.

Question 23

Hernia Clinical presentation:
1) What should you examine? What should you attempt to do?
2) How do you Dx?
3) What makes adult cases different?

Answer 23

1) Examine standing & supine; Attempt to reduce hernia contents (defect may reduce when supine)
2) H&P usually enough for diagnosis; if not, Ultrasound
-MRI or CT for uncertain diagnosis
3) Hernias do not regress in adults & usually eventually require surgical

Question 24

Inguinal hernia; what Tx for:
1) Symptomatic pts
2) Acutely incarcerated cases
3) Chronically incarcerated cases

Answer 24

1) Requires elective surgical repair.
2) May require urgent or emergent surgery (usually laparoscopic)
3) May first attempt nonoperative reduction of incarceration
-Repair may be deferred/delayed if mass reduces & no strangulation

Question 25

1) How do you Tx strangulated inguinal hernias? 2) What may be indicated to eval for intestinal viability during surgery?

Answer 25

1) IVF, broad-spectrum IV abx, +/- NGT, consult surgery for emergent repair 2) Abdominal exploration (laparoscopy)

Question 26

Inguinal hernia surgery: 1) Outpatient or inpatient? 2) What should you do preop on everyone? 3) What type of anesthesia? Explain

Answer 26

1) Usually outpatient procedure 2) Thorough preoperative eval 3) General, spinal, or local anesthesia -Local adequate for most patients (open) -General or spinal for recurrent hernias b/c local does not readily diffuse scar tissue

Question 27

Inguinal hernia: 1) What type of repair is typically used to reduce recurrence? 2) When can pts return to work?

Answer 27

1) Mesh repair 2) Sedentary: few days Heavy laborer: up to 4-6weeks

Question 28

Which pts require safe observation for asymptomatic or minimally symptomatic patients post-inguinal hernia surgery?

Answer 28

Elderly, sedentary patients Patients with high morbidity for operation Prenant females

Question 29

Inguinal hernia: 1) Goal of surgical repair? 2) What are the 2 different methods?

Answer 29

1) Goal is to restore structures to previous anatomic position & minimize recurrence 2) Open vs. laparoscopic

Question 30

What are the Principles of operative treatment of inguinal hernias?

Answer 30

1) ID & treat correctable aggravating factors and defect repaired without tension 2) Hernia sac isolated, dissected to origin from peritoneum, & ligated 3) Repair of inguinal floor of direct inguinal hernias now with mesh 4) With direct hernia, look for indirect and cord lipomas 5) Bilateral hernias: generally laparoscopic method 6) Multiple causes for recurrence (ie, tension)

Question 31

Open inguinal hernia repair; descr: 1) The Bassini repair 2) The Shouldice repair

Answer 31

1) 5-20% recurrence; traditional autologous tissue repair method 2) 0.6% recurrence; not widely used outside of specialty surgery centers (more extensive dissection required)

Question 32

Open inguinal hernia repair; descr: 1) The McVay (Cooper’s ligament) repair 2) The Lichtenstein repair

Answer 32

1) Procedure of choice for femoral hernias 2) Tension-free mesh repair allowing for early return to activities -Low complication and recurrence rates -Best and most common open repair

Question 33

List the basic steps of open surgical inguinal hernia repair

Answer 33

1) Skin incision, then dissection through skin, subcutaneous fat, Camper’s & Scarpa’s fascia to external oblique aponeurosis 2) Below inguinal ligament medially, the deep fascia of thigh opened to expose femoral canal and check made for concomitant femoral hernia 3) Safeguard ilioinguinal nerve (lying under the aponeurosis) and other nerves such as the genitofemoral nerve and vessels 4) Indirect hernia exposed, separated from cord by dividing cremaster muscle; Mesh to floor of inguinal canal 5) Contents replaced into peritoneal cavity 6) Inguinal canal floor repaired (direct hernia)

Question 34

Descr the preferred method of laparoscopic inguinal hernia repair

Answer 34

1) For Bilateral & recurrent hernias 2) Less postoperative pain, fewer postoperative activity restrictions, earlier return to work 3) Require general anesthesia

Question 35

What are the basic steps of laparoscopic repair of inguinal hernias?

Answer 35

1) Entry into peritoneal cavity or preperitoneal space: camera & instruments ports 2) Access to hernia location 3) Indirect hernias mobilized & dissected away from cord structures 4) Direct hernias isolated from transversalis fascia 5) Mesh placement to reinforce pelvic floor 6) Re-secure peritoneal flap (TAPP)

Question 36

What are some complications of groin hernia repair (both laparoscopic and open)

Answer 36

1) Recurrence varies based on technique and surgeon experience -Mesh < tissue 2) Seromas and hematomas common 3) Testicular atrophy 4) Neuralgia

Question 37

What are 4 laparoscopic specific complications of groin hernia repair?

Answer 37

1) Injury to surrounding structures during port placement 2) Port site hernia 3) Gas embolism 4) Bowel obstruction secondary to adhesions

Question 38

Umbilical hernia: 1) Where does it occur? 2) How does it present? 3) What structure(s) is/are herniating?

Answer 38

1) Protrusion of intra-abdominal contents through umbilical ring 2) Steadily increases in size over time 3) Mostly omentum or peritoneal fat but possibly bowel

Question 39

Umbilical hernias: 1) Is surgery needed? 2) What is the goal of surgery? What type of surgery? 3) Who needs to wait for surgery?

Answer 39

1) Elective if no bowel involvement 2) Contents reduced or excised; open recommended >Mesh to reinforce repair 3) Deferred until >4yo in kids

Question 40

Epigastric hernia: 1) What/ where is it? 2) When does it need to be repaired? 3) What type of surgery?

Answer 40

1) Protrusion of intra-abdominal contents through linea alba above the umbilicus 2) If symptomatic, repair. 3) Small: primary repair (sutures) Larger: mesh (if defect >1cm)

Question 41

Spigelian hernia: 1) What is it? 2) Do they always need surgery? 3) What type of surgery is used?

Answer 41

1) Protrusion of intra-abdominal contents through weakness in lateral border of the rectus sheath (linea semilunaris) 2) Surgical repair recommended due to high likelihood of incarceration or strangulation 3) Recommend laparoscope/robotic repair >Repair with mesh

Question 42

Incisional hernias: 1) Where do they occur? 2) What are some risk factors?

Answer 42

1) Site of previous incision 2) Obesity (most important risk factor) -Poor surgical technique, postop wound infection, age, general debility, DM, smoking, post op pump complications (vigorous coughing), blood loss >1000mL

Question 43

Incisional hernias: 1) How are they repaired? 2) Do they recur?

Answer 43

1) Smaller hernias closed primarily (suture) -Larger hernias closed with relaxing incisions or mesh 2) 30-50% recurrence; 10% recurrence with mesh repair

Question 44

Obturator pelvic floor hernia: 1) What is it? Who is it MC in? 2) What are the Sxs? 3) Tx?

Answer 44

1) Defects through obturator canal; most common in elderly females 2) Howship-Romberg sign: pain down medial thigh with internal rotation of knee -Also crampy abdominal pain, symptoms of SBO -Mass may be palpated on vaginal and/or rectal exam 3) Repaired surgically via transabdominal approach

Question 45

Sciatic hernia: 1) What is it? 2) How does it present? 3) How is it treated?

Answer 45

1) RARE defect of intra-abdominal contents through greater sciatic foramina 2) Gradually enlarging mass in infragluteal region -Possible sciatic nerve compression, bowel obstruction & ischemia 3) Surgically repaired and reinforced with mesh: Transabdominal approach (most common) Transgluteal approach (avoids adhesions)

Question 46

Perineal hernia: 1) What is it? 2) S/Sxs? 3) Tx?

Answer 46

1) Abdominal contents protrude through the perineal floor 2) Frequently asymptomatic & reducible; possible pain with sitting and/or dysuria -Palpable on bimanual rectal-vaginal exam 3) Surgical repair w Transabdominal approach (usual) >Fascial and muscular perineal repair, generally with mesh

Question 47

Lumbar hernias: 1) What are they? 2) Causes? 3) S/Sx? 4) Locations/ types?

Answer 47

1) Fascial defects in the posterior-lateral abdominal wall 2) Occur spontaneously or usually from previous surgical incisions, trauma 3) Flank mass (most common), may be asymptomatic or associated with a dull, heavy, pulling feeling 4) Superior most common through Grynfeltt triangle Inferior less common, through Petit triangle

Question 48

Diastasis recti (aka Rectus Abdominis Diastasis (RAD)): 1) What is it? 2) When does it occur? 3) Is it a hernia?

Answer 48

1) Condition in which the two rectus muscles are separated by an abnormal distance (>2 cm) 2) Common in pregnancy 3) Does not represent abdominal wall hernia (no fascial defect)

Question 49

Diastasis recti: 1) Main S/Sx? 2) Txs?

Answer 49

1) Obvious midline bulge on exam 2) -1st line treatment: weight loss, core-strengthening exercises -If 1st line fails, abdominoplasty with rectus abdominis plication with or without mesh (rare

Question 50

1) What are hiatal hernias? 2) Descr the Tx

Answer 50

1) Herniation of elements of abdominal cavity through esophageal hiatus of diaphragm 2) Laparoscopic usually; return stomach below diaphragm; repair enlarged hiatus; add fundoplication