Lecture 7 highlights

Question 1

Acute abdomen:
1) What are 4 potential causes?
2) Descr visceral pain
3) Descr somatic pain

Answer 1

1) Infection, inflammation, vascular occlusion, & obstruction
(Cause unclear in up to 30% cases)
2) Slow onset, poorly-localized, dull discomfort
3) Sudden, sharp, well-localized, lateralizing

Question 2

What are the first 4 steps in diagnosing abd pain?

Answer 2

1) Location
2) Onset and progression
3) Character
4) Vomiting? Constipation? Other GI symptoms?

Question 3

Pain out of proportion to clinical picture should raise concern for what?

Answer 3

Mesenteric ischemia

Question 4

Complete abdominal exam (IAPP) includes what categories?

Answer 4

Scars? Distention? Obvious masses?
Guarding?
Murphy sign (acute cholecyst)
Psoas sign (retroperiton infl)
Obturator sign (deep pelvic infl)
Rovsing’s sign (RLQ inflammation)

Question 5

T/F: Normal lab results do not always equal absence of [acute abd] disease

Answer 5

True

Question 6

What is the gold standard imaging in non-pregnant patients w acute abd?

Answer 6

CT

Question 7

What are the 2 main surgeries for acute abdomen?

Answer 7

Laparotomy (ex lap)
Laparoscopy

Question 8

Inguinal hernias:
____________ nerve is more freq injured in open surgeries, _____________ nerve is more freq injured in laparoscopic

Answer 8

Ilioinguinal ; genitofemoral

Question 9

What is the most common type of hernia in males & females (R>L)?

Answer 9

Indirect inguinal hernia

Question 10

1) What type of hernia occurs at Hesselbach’s triangle?
2) Where are femoral hernias found?

Answer 10

1) Direct inguinal
2) Femoral ring

Question 11

Hernias:
1) Who typically has groin hernia surgery?
2) What are the Sxs?

Answer 11

1) Bimodal age distribution for groin hernia surgery: 0-5yo; 75-80yo
2) Asymptomatic or various levels of pain aggravated by coughing or straining

Question 12

1) When may inguinal hernia require urgent or emergent surgery?
2) When will inguinal hernia definitely require emergent repair + abx + etc?

Answer 12

1) Acutely incarcerated
2) Strangulated hernias

Question 13

What should you do for all pts with symptomatic inguinal hernias?

Answer 13

All should be repaired (if pt can tolerate surgery)

Question 14

1) Repair of inguinal floor of ________ inguinal hernias with mesh
2) With ________ hernia, look for indirect and cord lipomas
3) __________ hernias: generally laparoscopic method

Answer 14

1) direct
2) direct
3) Bilateral

Question 15

What are the 4 methods of open inguinal hernia repair? List the key words for each

Answer 15

1) The Bassini repair (traditional)
2) The Shouldice repair (uncommon)
3) The McVay (Cooper’s ligament) repair (TOC for femoral)
4) The Lichtenstein repair (best option; tension free mesh)

Question 16

1) Which type of inguinal hernia is separated from cord by dividing cremaster muscle during open repair?
2) When does inguinal canal floor need to be repaired?

Answer 16

1) Indirect
2) Direct

Question 17

What are the 3 methods of laparoscopic inguinal hernia repair and what do they have in common?

Answer 17

1) Transabdominal Preperitoneal (TAPP) repair
2) Total Extraperitoneal (TEP) repair
3) Intraperitoneal Onlay Mesh (IPOM) repair

All use mesh + general anesthesia
(first two more common)

Question 18

1) What is the open surgery of choice for adults with inguinal hernias, but is uncommon?
2) What is the preferred method of Sx for inguinal hernias overall?

Answer 18

1) Shouldice inguinal hernia repair
2) Laparoscopic repair

Question 19

Laparoscopic repair of inguinal hernias:
1) _________ hernias are mobilized & dissected away from cord structures
2) _________ hernias are isolated from transversalis fascia

Answer 19

1) Indirect
2) Direct

Question 20

1) Where do epigastric hernias protrude through?
2) Where do spigelian hernia protrude through?
3) Do spigelian hernias always need surgery?

Answer 20

1) Linea alba
2) Lateral border of the rectus sheath (linea semilunaris)
3) Yes, bc high rate of incarceration/ strangulation

Question 21

Incisional hernias: What is the most important risk factor?

Answer 21

Obesity

Question 22

List the 4 types of pelvic floor hernias

Answer 22

1) Obturator
2) Sciatic
3) Perineal
4) Lumbar

Question 23

Obturator hernia:
1) What is a main Sx?
2) How is it treated?

Answer 23

1) Howship-Romberg sign: pain down medial thigh with internal rotation of knee
2) Surgically

Question 24

How are Sciatic hernias diagnosed?

Answer 24

CT or MRI

Question 25

Perineal hernia: 1) Main cause? 2) Main Sx? 3) How do you Dx?

Answer 25

1) Acquired following pelvic procedures 2) Frequently asymptomatic & reducible 3) CT or US

Question 26

Lumbar hernias: 1) Usual causes? 2) Where are superior (more common) located? 3) Where are inferior located? 4) Do they req surgery?

Answer 26

1) Previous surgical incisions, trauma 2) Grynfeltt triangle 3) Petit triangle 4) Require surgical repair (open or minimally invasive) with mesh

Question 27

1) Is diastasis recti a hernia? 2) First line Tx? 3) Second line Tx?

Answer 27

1) No 2) Weight loss + core strengthening exercises 3) Abdominoplasty

Question 28

Hiatal hernias: 1) How are they diagnosed? 2) When is operative repair indicated?

Answer 28

1) Barium swallow most sensitive test but EGD often diagnoses 2) Symptomatic patients beyond GERD sxs

Question 29

List and describe the 4 types of hiatal hernias

Answer 29

-Type I Sliding: displaced GE junction above diaphragm (most common) -Type II: gastric fundus herniates ant to the esophagus, GEJ remains in abd -Type III: combo of I and II (GEJ and gastic fundus herniate into the chest) -Type IV: stomach and other abd organs (ie colon) herniates into the chest