Arcuate line:

-A crescentic line that is situated between upper 2/4 &lower 1/2 of posterior wall of rectus sheath.

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Can Appendicitis Present with No Abdominal Pain?

-Yes. In some cases, a retrocecal appendicitis may not cause any abdominal pain. If the appendix is completely separated from the anterior abdominal peritoneum, then the patient will not develop any localizing symptoms.

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Remember:

Epigastric hernia is more common in men.
Para-umbilical hernia is more common in women.

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Nice summary for Management of urinary tract stones.


Conservative treatment:
-High fluid intake with or without diuretics.
-Analgesics.
-Antispasmodic agents.
-Urinary antiseptics, regular follow-up to monitor stone descent.

#Surgery

-Para umbilical hernia is any hernia within 3cm around umbilicus so any hernia beyond 3cm away from umbilicus is not termed para umbilical hernia.


-Epigastric hernia is misdiagnosed as heartburn because in early cases of epigastric hernia, the main complaint is epigastric pain and not mass.


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-Portal vein consists of SMV and splenic vein.

-It begins behind the head of pancreas and in front of IVC, ends at porta
-hepatis.
-About 3inch length.
-About 0.8-1.2 cm diameter.


Direct tributaries:
Portal vein drains the whole. intra-abdominal alimentary tract and anterior abdominal wall:

- Left and right gastric veins.
-Small pancreatic & duodenal veins.
-Para-umbilical veins into left branch of portal vein.
- Splenic vein.
-SMV.
-Cystic vein.

Pressure: 10 - 20 cmH2O (7 - 11 mmHg).

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Umbilical hernia

◼️It is mostly symptomless.
◼️Strangulation under 3 years of age is rare.
◼️There is no sex predilection, but there is major racial difference because this hernia is 8 times more common in black children than white children.
◼️In 95% of cases in those under 2 years of age, the hernia will spontaneously resolve, because the vast majority of cases resolve on its own, Do nothing but reassurance of the parents.
◼️If it persist at 2 years or more (only in 5%) it will likely not resolve and this herniorrhaphy is indicated.
◼️The operation entails a curved skin incision under the umbilicus with isolated of the sac which is either reduced or transfixed with sutures, the defect in the linea alba is closed.

#Hernia
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VENTRAL HERNIA:

-Any protrusion through abdominal wall with the exception of hernia through the inguinofemoral region is defined as ventral hernia.
-Incisional hernia (80%) and primary defects in abdominal fascia which can cause umbilical hernia, epigastric hernia, paraumbilical hernia or Spigelian hernia are grouped under ventral hernia.

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RECURRENT HERNIA (Inguinal)

-Incidence is 10%.
-If recurrence is within 3 years it is called as early.
-If it is after 3 years it is late.

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What is the conjoint tendon?

-Aponeurotic attachments of the “conjoining” of the internal oblique and transversus abdominis to the pubic tubercle.

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•What are the layers of the abdominal wall?

Skin
Subcutaneous fat
Scarpa’s fascia
External oblique Internal oblique Transversus abdominus
Transversalis fascia
Preperitoneal fat
Peritoneum

•Note:
-All three muscle layer aponeuroses form the anterior rectus sheath, with the posterior rectus sheath being deficient below the arcuate line.

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•What is more dangerous: a small or large hernia defect?

-Small defect is more dangerous because a tight defect is more likely to strangulate if incarcerated.

•Incarcerated means:
Swollen or fixed within the hernia sac (incarcerated imprisoned); may cause intestinal obstruction (i.e., an irreducible hernia).

•Incisional hernia:
-Hernia through an incisional site; most common cause is a wound infection.

•Epigastric hernia:
-Hernia through the linea alba above the umbilicus.

•Cooper’s hernia:
-Hernia through the femoral canal and tracking into the scrotum or labia majus.

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Cloquet's hernia is a hernial sac protruding underneath the fascia of the pectineus muscle, it is also highly liable to strangulate.

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Femoral Vs inguinal hernia

◼️The NECK of an inguinal hernia always emerge from the external inguinal ring whether it is direct or indirect, therefore the neck will be above and medial to the most medial end of the inguinal ligament at its attachment to the pubic tubercle.

◼️The neck of a femoral hernia always pass through the femoral canal, which will be below and slightly lateral to the pubic tubercle.

◼️Applying pressure on the external inguinal ring and asking the patient to cough is another way to differentiate, in femoral hernia a cough impulse is exerted when the pressure is applied and vice versa.

◼️The fundus of a femoral hernia may pass in the path of least resistance and may overlie the inguinal ligament.

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Femoral hernia and the gender

The female to male ratio is 2:1, it is interesting that female patients are usually elderly, whereas male patients are usually between 35-40 years, so it useful to remember the quote (your grandmother and your father have femoral hernia)

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Surgical anatomy of the femoral ring

◼️Anteriorly it is bound by the inguinal ligament.

◼️Medially it is bound by the Lacunar ligament (Gimbernant's ligament).

◼️Posteriorly it is bound by the ileopectineal ligament (Astley cooper's ligament) and the pubic bone and fascia over the pectineus muscle.

◼️Laterally it is bound by a thin membrane seperating it from the femoral vein.

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Reduction en masse


Reduction-en-masse means reduction all together, it refer to a complication of manual reduction of a hernia in which the entire hernial mass including the contents and the sac and the neck are reduced back to the abdomen, so practically the strangulation is not relieved.

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Femoral sheath and femoral canal

◼️The femoral sheath lies in the femoral triangle and it is a sleeve of fascia that is continuous superiorly with the transversalis fascia.

◼️It is divided by septa into compartments.

◼️The most medial compartment is called the femoral canal.

◼️The femoral canal is 1.25cm long and 1.25 cm width at its base which is directed upwards.

◼️The femoral canal contains lymphatic vessels and lymph nodes of Cloquet.

◼️It starts from the femoral ring and ends at the saphenous openings.

◼️From above it is closed by a septum called septum crurale and from below it is closed by the cribriform fascia.

◼️The septum crurale is pierced by lymphatics and is a potential point of weakness making the femoral canal the site of femoral hernias

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The word VAN helps to remind you the order of structures within femoral triangle from medial to lateral they are

V= femoral Vein
A= femoral Artery
N= femoral Nerve

Dont forget the the most medial one is the femoral canal containing lymphatics and lymph nodes of Cloquet

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#Femoral_Triangle

◼️It is a wedge shaped depression formed by the muscles of the upper thigh at the junction between the anterior abdominal wall and lower limb.
◼️The base of the triangle is the inguinal ligament.
◼️Medial border is the medial margin of adductor longus.
◼️Lateral border is the medial margin of sartorius muscle.
◼️Floor of the triangle is formed medially by the pectineus muscle and adductor longus,, laterally it is formed by the iliopsoas muscle descending from the abdomen.
◼️The apex is continuous with a fascial canal called Adductor canal which pass posteromedially down the thigh and ends in a hole in adductor magnus muscle to open on the popliteal fossa.

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