Module 4 Hernias

Polyester fiber mesh

*Least inert of synthetic meshes *Never used in presence of infection *Multifilament fiber construction can harbor bacteria

How are tracers placed for Laparoscopic hernia repair?

-3 Trocars Pneumoperitoneum is established *1st trocar is placed through umbilical port *2nd and 3rd trocars are placed lateral to the rectus sheath at the level of the umbilicus on the side of the defect

What are repairs for a herniorrhaphy?

-Bassni's Repair -Shouldice Repair -Mc Vay -Preperitoneal

What structures make up the spermatic cord?

-Deferent duct -Pampinform plexus -Cremaster muscle

What are different hernia types?

-Groin -Ventral (front) -Incisional -Diaphragmatic (hiatal)

What contents are located in the female inguinal canal?

-Ligament of uterus -Ilioinguinal (Nerve)

What are the names of direct inguinal hernia repairs?

-McVay or Coopers -Lichtenstein -Mesh-plug -Prolene hernia system

What are ways to repair a hiatal hernia?

-Nissen Fundoplication -Tightening the hiatal ring

Stainless steel mesh

-Not used much anymore *rigid *hard to apply *discomfort *inert of mesh material *can be used if presence of infection *used during 2nd intention healing

What are hernia repair complications?

-Perforated bowel -Infection -Break in sterility

What are advantages of synthetic mesh material?

-Pliable (easy to cut, easy to place) -Porous (allow fibrous tissue to grow through mesh-strengthen tissue)

What are examples of synthetic mesh material used?

-Polyprolene (Prolene) *relatively inert *can be used in presence of infection *excellent elasticity *high tensile strength -Polyglaction 910 (vicryl) *provides temporary support while healing -PTFE (Gortex) *soft and flexible *non-absorbable *can not be used in presence of infection

What are common mesh used in hernioplasty?

-Prolene -Dacron -Mersilene

What are common synthetic mesh used?

-Prolene -Dacron -Mersilene

What suture is used to tack down mesh or hernioplasty?

-Prolene -Silk -Polyester

What are the steps for an open incisional hernia repair?

-Re-open the old incision and previous incision edges are trimmed to allow dissection and reduction of the hernia sac. -Old sutures are removed -Push the contents of the hernia back inside the abdominal cavity, closing the hernia with sutures, and placing a synthetic mesh to reinforce the area. -All layers of abdominal wall are closed. -This approach is used in patients with a history of multiple previous hernia repairs, a history of multiple previous abdominal surgeries, and patients with large hernias.

What are different hernias?

-Reducible- Can go back in (when you lay or push against it) -Irreducible/incarcerated- Stuck outside (can loose blood supply) -Strangulated- Blood flow is compromised (emergent) -Richters- Portion of bowel wall is herniated -Direct- Acquired by person (straining) -Indirect- Congenital (born with it) -Pantaloon- both indirect and direct (2 hernias) -Femoral- In femoral cavity -Epigastric- in epigastric cavity (hiatal) -Hypogastric -Umbilical- Belly button -Inguinal- In inguinal cavity/crest (Hesselbach Triangle)

What hernia repairs are open procedure?

-Shouldice -Bassini's

How is a femoral hernia repaired?

-Small incision -Hernia is separated from surrounding -Closed with mesh and sutures

What contents are located in a male inguinal canal?

-Spermatic Cord -Genital branch of femoral nerve -Illioinguinal (Nerve)

What are complications of inguinal hernia repairs?

-Wound seroma/hematome -Urinary retention -Incisional surgery site infection

On what count is the hernia sac closed?

1st Count

What is a hernia?

A protrusion of organs through a defect or weakness in the abdominal wall.

What is a class one clean wound?

An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered.

What is Hesselbach's triangle?

Area between Inferior epigastric artery, lateral border of rectus abdominus, and inguinal ligament

What is Valsalva's Manuver? How is it utilized?

Blowing w/ a closed airway -This helps to promptly expose the hernia

What is a hernia repair classified as?

Class I Clean

What are advantages of tension free hernia repair?

Creates a very tight and strong wall over hernia defect. -Acts as a bridge

What kind of hernias are those in Hesselbachs Triangle?

Direct hernia

What is a class two clean contaminated wound?

Enter the respiratory, alimentary, genital, or urinary tracts. These wounds have entered these tracts under controlled conditions

What is a class three contaminated wound?

Fresh open wounds that can result from insult to sterile techniques or leakage from the gastrointestinal tract into the wound. Incisions made that result in acute or lack of purulent inflammation

What is a bilateral inguinal hernia?

Groin (or inguinal) hernias those that occur on both sides of the lower abdomen or groin.

What is a hernioplasty?

Hernia is repaired -Weakened area is reinforced with wire, fascia or mesh

What is a incarcerated hernia?

Hernia is trapped outside peritoneal cavity -Will cause loss of blood supplies eventually

Where are inguinal hernias located?

Hesselbach's Triangle -This space is larger in a male than female

What is the name of the opening for the esophagus into abdomen?

Hiatal ring

Where do hiatal hernias occur?

In the diaphragm. -Between the thoracic and abdominal cavity

What hernia is higher? Inguinal or Femoral

Inguinal

What is the most common hernia?

Inguinal hernia

How to repair a hernia with mesh?

Instruments are inserted through the muscle wall of your abdomen and the lining covering your organs (the peritoneum). A flap of the peritoneum is peeled back over the hernia and a piece of mesh is stapled or glued to the weakened area in your abdomen wall to strengthen it.

What is a epigastric hernia?

Intestines breach a weak point in the linea alba. Located between diploid and umbilicus

What repair is tension free?

Lichtenstein repair

What is the inguinal canal?

Natural passageways through the caudoventral abdominal wall through which the testes pass -Located between the deep and superficial inguinal rings -Potential space between the internal abdominal oblique and the aponeurosis of the external abdominal oblique

If a hernia is indirect where is it located?

Opposite side of epigastric vessels to Hesselbachs Triangle

What is Nissen fundoplication?

Part of the stomach is wrapped and tracked down around the esophagus like a collar to provide a tight space so intestines can not push through opening. -Maloney dilator is used to tell tightness and tension through esophagus through mouth -5 trocars

For inguinal hernia repairs what drain can be used to retract the spermatic cord?

Penrose drain

What nonabsorbable mesh and suture is mostly used in hernia repairs?

Prolene

How do you operate on a strangulated hernia?

Push back in good intestines -Remove any dead tissue/organs

What is the Lichtenstein repair?

Repair of a direct hernia is a tension-free mesh, defect in the wall is then closed by suture, after which the mesh is fixed to bridge the defect.

What are hernia contents?

Small bowel Omentum Fat Organs/intestines

What scissors are used to cut mesh?

Straight Mayo Scissors

What position are patients in for hernia procedure?

Supine

What is a herniotomy?

Surgical removal of the herniated sac (peritoneum) w/o mesh.

What is a herniorrhaphy?

Surgical repair of a hernia -W/O reinforcment

What is Cooper's ligament?

Suspensory ligament running vertically through the breast that are responsible for maintaining the shape and configuration of the breast. They bear a major portion of the task of preventing breast ptosis (sagging)

What mesh is used to replace the fascia for a hernia repair?

Synthetic

What is the McVay repair?

The conjoined (transversus abdominis and internal oblique) tendon is sutured to the Cooper ligament with interrupted nonabsorbable sutures.

Why are incarcerated or reducible hernias repaired when a patient is not in distress?

To prevent them from obstructing or becoming strangulated.

What is the TEP approach?

Total Extraperitoneal -Uses balloon to inflate abdomen -3 trocars -Mesh on outside -Can be open procedure

What is the TAPP approach?

Transabdominal Preperitoneal -Laparoscopic approach -Pneumoperutoneum is established -Mesh on inside

What is a class four dirty wound?

Traumatic wounds Demonstrate devitalized tissue Commonly result from microorganisms present in perforated viscera or the operative field.

What is a strangulated hernia?

When blood supply to the entrapped contents is compromised. -No blood supply

What is a sliding hernia?

portions of the stomach and gastroesophageal junction slide up above the diaphragm