HERNIA

Question 1

The majority of Entrapment of the ilioinguinal occurs with what approach

Answer 1

open inguinal hernia repairs.

Entrapment of the nerve by mesh is a very common complication, resulting in postoperative pain, with majority

NOT with laparoscopic repair, because dissection does not violate the inter-muscular plane through which the ilioinguinal nerve travels.

Question 2

Totally Extra-Peritoneal (TEP) and Transabdominal Pre-Peritoneal (TAPP).

Answer 2

Totally Extra-Peritoneal (TEP) and Transabdominal Pre-Peritoneal (TAPP). These methods of utilize the pre-peritoneal fascial plane to access the hernia and avoid dividing the muscles of the anterior abdominal wall.

Question 3

Laparoscopic placement of mesh, however, has the potential to entrap the

Answer 3

lateral femoral cutaneous nerve as it exits the peritoneum.

Question 4

The most common complication of an inguinal hernia repair related to the herniorrhaphy itself is:

Answer 4

postherniorrhaphy pain has emerged as the biggest issue facing hernia surgeons and occurs in as many 53% of patients!!

The pain can be nociceptive, caused by tissue damage, or neuropathic, which is a consequence of nerve damage.

Both are difficult to treat and in extreme cases may require neurectomy and/or neuroma excision.

Question 5

Testicular atrophy following inguinal hernioplasty is usually due to

Answer 5

The primary etiology of testicular atrophy after inguinal hernia repair is damage to the delicate veins of the pampiniform plexus in the spermatic cord resulting in thrombosis and venous insufficiency of the testicle

most often occurs as a result of overly extensive dissection of the cord to isolate an indirect hernia sac.

Question 6

To decrease the risk of testicular atrophy with herniorrhaphy

Answer 6

it is recommended that the surgeon should take care to perform gentle careful dissection of the sac, avoiding trauma to the blood supply of the testicle,

not mobilize the cord beyond the level of the external ring or pubis in order to maintain all scrotal collaterals.

Also, it is not necessary to excise the entire indirect sac; the sac may be transected in the distal inguinal canal, leaving the distal sac with the remainder of the cord structures.

Question 7

Parastomal hernias Indications for repair are and what is managment of choice

Answer 7

prosthetic repair and relocation of the ostomy.

obstruction or difficulty in stoma appliance management.

Prosthetic repair is a good alternative and can be done as an onlay, inlay, sublay, or intraperitoneal.

Question 8

Branches of the lumbar plexus involved in inguinal hernia repair are:

Answer 8

ilioinguinal
iliohypogastric
genitofemoral

Question 9

genitofemoral nerve

Answer 9

is the most anterior and variable, can be single or bifurcated, and innervates the cremasteric muscle and the lateral scrotum.

Question 10

The iliohypogastric nerve

Answer 10

arises from the first lumbar branch

goes between the transversus and the internal oblique muscle.

Question 11

The ilioinguinal nerve

Answer 11

enters the inguinal canal and runs diagonally to pierce the iliopubic tract and is the most vulnerable for iatrogenic injury in open repairs

Question 12

A 58-year-old chronic alcoholic has an umbilical hernia and ascites of recent onset. He has never been treated with diuretics or salt restriction. On examination, he has massive ascites with a large umbilical hernia, with thin skin at the apex. There is a slow ooze of clear, odorless fluid from the hernia.Therapy now should be

Answer 12

Leaking abdominal ascites is an urgent problem that requires aggressive management, and patients should be immediately admitted to the hospital because of the risk of bacterial peritonitis and/or hernia rupture.

Question 13

Umbilical hernia repair in cirrhotics with uncontrolled ascites

Answer 13

mortality (8.3%) and morbidity (16.6%).

Attempting to control the ascites prior to repair with aggressive diuresis and sodium and fluid restriction is prudent.

Bedrest to remove undue strain on the weak and leaking site as well as administration of intravenous antibiotics to help prevent bacterial peritonitis are also indicated. If operation must be undertaken emergently (true rupture), or diuretic therapy fails to control the ascites, combined umbilical herniorrhapy with a peritoneal-venous shunt is effective in achieving a stable repair with a relatively low morbidity.

Question 14

An 82-year-old woman has abdominal pain, nausea, vomiting, and groin pain. What his diagnosis

Answer 14

This patient most likely has a femoral hernia, which is associated with elderly females.

Careful, this is NOT obturator hernia

Question 15

Management of incarcerated femoral hernia

Answer 15

Do not attempt reduction

Urgent repair

Question 16

Femoral hernias occur through

Answer 16

the femoral ring

superiorlu, iliopubic tract,
inferiorly Cooper’s ligament,
laterally by the femoral vein,
medially by the junction of the iliopubic tract and Cooper’s ligament (lacunar ligament).

A femoral hernia produces a mass or bulge below the inguinal ligament.

(bordered by t

he superior pubic ramus inferiorly,

the femoral vein laterally,

the iliopubic tract laterally)

and may continue into the femoral canal, which normally contains only preperitoneal fat and lymph nodes (including Cloquet’s).

Question 17

Operative approach to femoral hernia

Answer 17

either by approximation of the iliopubic tract to Cooper’s ligament or by placement of prosthetic mesh to obliterate the defect.

In patients with a compromised bowel, the Cooper’s ligament approach is the preferred technique because mesh is contraindicated. When the incarcerated contents of a femoral hernia cannot be reduced, dividing the lacunar ligament can be helpful.

An inguinal approach to femoral hernia repair entails first incising the insertion of the iliopubic tract into Cooper’s ligament at the medial margin of the femoral ring,

then opening the hernia sac and examining its contents,

opening the floor of the inguinal canal.

defect is closed by suturing the iliopubic tract and Cooper’s ligament together.

The lacunar ligament is the fan-shaped medial portion of the inguinal ligament.

Question 18

Howship-Romberg sign

Answer 18

pain down the medial aspect of the thigh with abduction, extension, or internal rotation of the knee.

Question 19

Most common clinical presentation of obturator hernia

Answer 19

Intestinal obstruction!

n over 80% of patients.

Howship-Romberg sign less than 50% of patients and can easily be confused with osteoarthritis pain in this population.

Question 20

Repair of obturator hernia surgical approach

Answer 20

attempted through an abdominal approach, a

allows for access to the defect.

Reduction of contents may require incision of the obturator membrane.