Hernia

Question 1

5 elements to reduce risk of hernia recurrence and chronic pain after surgery

Answer 1

1) Use large sheet of mesh (7x15cm)
2) Extends at least 3-4cm above Hesselbach’s triangle
3) 2cm medial to pubic tubercle
4) 5-6cm lateral to internal ring

Question 2

Howship-Romberg sign

Answer 2

Confirms presence of obturator hernia

Positive when pain extends down medial aspect of thigh w/ abduction, extension, internal rotation of knee

Question 3

Structures most likely injured when securing mesh inferiorly along shelving edge of inguinal ligament during open repair with mesh

Answer 3

external iliac/femoral vessels (especially veins)

Question 4

ilioinguinal nerve function

Answer 4

cutaneous innervation to superior medial thigh

M: skin over anterior 1/3 of scrotum and root of penis

F: skin over anterior 1/3 of labium majus and root of clitorus

Question 5

iliohypogastric nerve function

Answer 5

supplies skin to pubic region

Question 6

Tx of Chronic inguinodynia after hernia repair

Answer 6

cont postop pain for >=3 mo
1st line: med mgmt
2nd line: groin nerve block superomedial to ASIS (local anesthetic injection, corticosteroids, hyaluronic acid)
3rd line: triple neurectomy (for pts who initially respond to nerve block but have recurrent pain)

Question 7

McVay hernia repair

Answer 7

Conjoint (internal oblique and transverses abdomens aponeurosis) to Cooper’s ligament

Used for femoral hernia

Question 8

Spigelian hernia

Answer 8

at or below arcuate line

b/w rectus and semilunar line

Question 9

Bassini repair

Answer 9

Conjoint tendon to inguinal ligament

Closes direct and indirect spaces, not femoral space

Question 10

Shouldice repair

Answer 10

Multi-layer closure

Most durable tissue repair, lowest recurrence rate

Question 11

How does wound infection affect risk of hernia development after surgery

Answer 11

doubles risk of developing hernia

Question 12

When should smoking be stopped prior to elective surgery

Answer 12

4 weeks prior

Question 13

Ideal BMI for hernia repair

Answer 13

<40

Question 14

HgA1c levels for hernia repair

Answer 14

<8.0%, BG <200 postop

Question 15

3 nerves identified during inguinal hernia repair

Answer 15

iliohypogastric: located b/w external and internal oblique muscles
ilioinguinal: lies on top of the cord

genital branch of genitofemoral: inferior to the cord; covered and protected by cremasteric muscles

Question 16

Boundaries of inguinal canal

Answer 16

Ant: external oblique
Posterior: transversalis fascia
Superior: internal oblique & transverse abdominis
inferior: inguinal ligament

Question 17

Boundaries of femoral canal

Answer 17

Ant: inguinal ligament
Post: pectineal (cooper’s ligament)
Med: lacunar ligament
Later: femoral vein

Question 18

Choice for mesh in IPOM hernia repair

Answer 18

Intraperitoneal only mesh (IPOM) means that mesh is placed intraperitoneally on anterior abdominal wall with contact to intra-abdominal orgns

need mesh that has a coating in order to protect the organs from adhering to polypropylene or polyester surface

coating: PTFE, hydrogel, etc.

Question 19

MC injured nerves with open inguinal hernia repair

Answer 19

ilioinguinal, genital branch of genitofemoral, iliohypogastric

Question 20

MC injured nerves with laparoscopic inguinal hernia repair

Answer 20

genitofemoral, and lateral femoral cutaneous nerve