Hernia Surgery

Question 1

What is a hernia

Answer 1

Protrusion of peritoneal sac through musculo/aponeurotic wall; a facial defect

Question 2

Incidence?

Answer 2

All Lifetime: 5-10%
50% = indirect
25% = direct
5% = femoral

Question 3

Predisposing factors:

Answer 3

Increased intrabdominal pressure (valsalva, obesity, pregnancy, cough/COPD
Indirect = patent processus vaginalis

Question 4

Why repair hernias?

Answer 4

Avoid incarceration, strangulation, necrosis, SBO, pain

Question 5

Pantaloon hernia

Answer 5

Both direct and indirect

Question 6

Watchful waiting for asx inguinal hernia?

Answer 6

68% crossover at 7 years d/t sx

Incarceration 1.8/1000 patient years (~.2%)

Question 7

What’s worse large or small hernias?

Answer 7

Small -> higher rate of incarceration/strangulation

Question 8

Spigelian hernia

Answer 8

Intramuscular (no bulge) between rectus muscle and semilunar line
(also known: spontaneous lateral, ventral hernia)

Question 9

Littre’s hernia

Answer 9

Hernia involving a Meckel’s diverticulum

Question 10

Petersen’s hernia

Answer 10

After gastric bypass

Small bowel through mesenteric defect

Question 11

Petit’s hernia

Answer 11

Through inferior lumbar triangle

Question 12

Grynfeltt’s hernia

Answer 12

Through superior lumbar triangle

Question 13

Parastomal hernia

Answer 13

Herniation next to ostomy

Question 14

Amyand’s hernia

Answer 14

Hernia containing ruptured appendix

Question 15

Hesselbach’s triangle

Answer 15

Inferior epigastric vessels
Inguinal canal
Lateral rectus sheath
Floor = internal oblique and transversus abdominis

Question 16

Direct inguinal hernia

Answer 16

Within hesselbeck’s triangle
Through the abdominal wall floor
Medial to inferior epigastric vessels

Question 17

Incidence of direct inguinal hernia

Answer 17

1% of all men

Increased risk with increased age

Question 18

Nerve that runs with/on top of spermatic cord

Function?

Answer 18

Ilioinguinal nerve

Sensation of lateral scrotum/labia majora and anterio/medial proximal thigh

Question 19

Indirect inguinal hernia

Answer 19

Through deep and superficial ring

Patent processus vaginalis

Question 20

Risk of strangulation b/t direct, indirect, femoral

Answer 20

Femoral > indirect > direct

Question 21

First identifiable subq layer?

Answer 21

Scarpa’s fascia

Question 22

Subq vein that is ligated?

Answer 22

Superficial epigastric vein

Question 23

From what layer is the cremaster muscle derived?

Answer 23

External oblique muscle aponeurosis

Question 24

Where does the inguinal ligament attach?

Answer 24

ASIS to pubic tubercle

Question 25

Nerve that travels on the SC? | Nerve that travels in the SC?

Answer 25

On: Ilioinguinal (lateral scrotum, medial thigh) In: Genital branch of the genitofemoral (anterior scrotum)

Question 26

What is in SC?

Answer 26

``` Cremasteric muscle fibers Vas deferens Testicular artery Pampiniform plexus Nerves (ilioinguinal, genital branch of genitofemoral) +/- Hernia sac ```

Question 27

What is a hernia sac made of?

Answer 27

Indirect: patient processus vaginalis Direct: peritoneum

Question 28

What attaches testicle to scrotum?

Answer 28

Gubernaculum

Question 29

Most common organ in indirect sac in men?

Answer 29

Small bowel

Question 30

Most common organ in indirect sac in women?

Answer 30

Ovary/fallopian tube

Question 31

Where in the inguinal canal does hernia sac locate

Answer 31

Anteriomedially (think embryology: Mesonephros is posterior/lateral to peritoneum therefore sac is anterior medial)

Question 32

What lies in inguinal canal in females instead of the vas?

Answer 32

Round ligament

Question 33

Conjoint tendon

Answer 33

Conjoining of internal oblique and transversus abdominis

Question 34

Femoral hernia

Answer 34

Traveling beneath inguinal ligament in femoral canal but medial to femoral vessels

Question 35

Boundaries of femoral canal

Answer 35

``` Cooper's ligament (post) Inguinal ligament (ant) Femoral vein (lat) Lacunar ligament (med) ```

Question 36

Percentage of femoral hernia that are female?

Answer 36

85%

Question 37

Percent of femoral hernia that incarcerate?

Answer 37

33%