HERNIA/ABDOM WALL

Question 1

Describe transversus abdominus release

Answer 1

Transversus abdominis release involves incision of the posterior rectus sheath, development of the retrorectus space between the rectus muscle and posterior rectus sheath, division of the posterior rectus sheath just medial to the laterally perforating neurovascular bundles, and then division of the transversus abdominis with lateral dissection mobilizing the transversalis fascia and peritoneum off of the overlying muscle

Question 2

Anterior release

Answer 2

The anterior release involves creation of subcutaneous flaps, division of the external oblique aponeurosis lateral to the semilunar line, and development of plane between the external oblique aponeurosis and the internal oblique muscle laterally.

Question 3

What nerve is injured - prox thigh numbness, burning

Answer 3

ilioinguinal

Question 4

what is the only open non mesh repair that can be used to repair femoral or inguinal hernia

Answer 4

McVay

Question 5

Where are femoral hernias located

Answer 5

Inferior to inguinal ligament and protrude through femoral ring, which is MEDIAL to femoral vein and LATERAL to the lacunar ligament

Question 6

etiology of direct inguinal hernia

Answer 6

weakness in transversalis fascia medial to the inferior epigastric

Question 7

inguinal canal borders

Answer 7

inguinal ligament inferior
conjoint tendon posterior
external oblique aponeurosis anteriorly

external oblique aponeurosis + musculoaponeurotic internal oblique and transversalis muscle aponeuroses superiorly

Question 8

Lichtenstein repair

Answer 8

Mesh is sewn to the shelving edge of the inguinal ligament
Medial edge is sewn to the aponeurosis tissue overlying pubic tubercle
Superiorly the mesh is secured to the conjoint tendon

Question 9

Inferior to the shelving edge approaches what vessels?

Answer 9

external iliac

Question 10

umbilical hernias in children occur due to

Answer 10

congenital weakness in umbilical ring

Question 11

how should mesh be placed in order to reduce risk of hernia recurrence

Answer 11

large sheet of mesh (7 x 15 cm) with standard shape of tracing of a footprint that edternds to at least 3-4 cm above Hesselbachs triangle, 2 cm medial to the pubic tubercle, and 5-6 cm lateral to the internal ring has been shown to reduce the risk of recurrence and chronic pain after Lcihtenstein tension-free hernioplasty

Question 12

which hernia will be palpated within the inguinal canal and felt against the tip of the finger as the hernia approaches the internal ring

Answer 12

indirect hernia

Question 13

what hernia is felt on the side of the finger within the inguinal canal

Answer 13

direct hernia

Question 14

where does obturator hernia occur in relation to inguinal ligament

Answer 14

inferior

Question 15

best initial step in fetus with CDH at delivery

Answer 15

NG tube and intubation

Question 16

helpful therapy adjuncts in CDH

Answer 16

surfactant (only in preterm), inhaled NO

Question 17

Maintain MAP of ___ to avoid shunting and hypoxia in CDH

Answer 17

50 mm Hg

Question 18

major hindrance to acceptance of component separation

Answer 18

large lipocutaneous flaps created to acccess lateral abdominal wall associated with major wound morbidity

Question 19

hernia backtracks superolaterally from internal inguinal ring between oblique muscles

Answer 19

indirect inguinal hernia

Question 20

collagen link to inguinal hernias

Answer 20

increased type III, decreased type I

Question 21

interstitial hernias are a type of what hernia

Answer 21

indirect inguinal

Question 22

where to make relaxing incision for mcvay repair

Answer 22

external oblique aponeurosis and anterior rectus sheath

Question 23

how long PPI therapy is considered maximal medical mgmt prior to repairing type I hiatal hernia

Answer 23

PPI BID for 8-12 weeks

Question 24

defects greater than what size require mesh in a child (umbilical)

Answer 24

3 cm

Question 25

In a lichtenstein repair the mesh is considered

Answer 25

onlay

Question 26

most common nerve injury in lap inguinal

Answer 26

genitofemoral (genital branch)

also lateral femoral cutaneous

Question 27

tenderness to palpation lateral and inferior to the pubic tubercle

Answer 27

femoral hernia

Question 28

describe a McVay repair

Answer 28

non mesh tissue based repair where conjoined (transversus abdominis and internal oblique) tendon is sutured to cooper’s ligament in a simple interrupted fashion with non absorbable suture

Question 29

describe anterior component separaion

Answer 29

skin and SQ fat dissected free from anterior rectus sheath and aponeurosis of external oblique muscle
aponeurosis of external oblique muscle transectedl ongitudinally about 2 cm lateral from rectus sheath including muscular part on thoracic wall (extending at least 5-7 cm cranially of costal margin). The external oblique muscle is separated from internal oblique muscle as far lateraly as possible. Additional 2-4 cm gained by separating posterior rectus sheath from the rectus muscle.

Question 30

How much unilateral advancement of the abdominal wall can be achieved with the release of the external oblique aponeurosis

Answer 30

up to 10 cm

Question 31

risk of strangulation in a femoral hernia

Answer 31

45%