Hernias

Question 1

What is the most common cause of recurrent hernia?

Answer 1

wound infection

Question 2

What are the two most common causes of SBO?

Answer 2

adhesive disease followed by hernias

Question 3

Why is the arcuate line anatomically important?

Answer 3

because it is the line below which the posterior rectus sheath disappears

Question 4

What are the layers of the abdominal wall just off midline?

Answer 4

• skin
• subcutaneous fat
• Scarpa’s fascia
• anterior rectus sheath
• rectus muscle
• posterior rectus sheath
• preperitoneal fat
• peritoneum

Question 5

What are the layers of the abdominal wall lateral to the rectus?

Answer 5

• skin
• subcutaneous fat
• Scarpa’s fascia
• external oblique
• internal oblique
• transversus abdominis
• transversals fascia
• preperitoneal fat
• peritoneum

Question 6

Where is the arcuate line?

Answer 6

a third of the distance down from the umbilicus to the pubis symphysis

Question 7

What is the blood supply to the rectus?

Answer 7

inferior and superior epigastrics

Question 8

What is hesselbach’s triangle?

Answer 8

• it is the pace through which a direct hernia protrudes

- medial border is the rectus, inferior border is the inguinal ligament, and lateral border is the epigastrics

Question 9

What is the inguinal ligament composed of?

Answer 9

it is an extension of the external oblique fascia

Question 10

The median and medial umbilical ligaments are remnants of what embryonic structures?

Answer 10

• median: urachus

- medial: umbilical arteries

Question 11

What embryonic structure gives rise to a Meckel’s diverticulum?

Answer 11

the vitelline duct

Question 12

What embryonic structure gives rise to the round ligament of the liver?

Answer 12

the obliterated umbilical vein

Question 13

What structures do the umbilical vein and umbilical arteries give rise to?

Answer 13

• the vein becomes the round ligament of the liver

- the arteries become the medial umbilical ligaments

Question 14

When does the midgut herniate during embryonic development? When does it return to the abdominal cavity?

Answer 14

• herniates around week 6

- returns around week 10

Question 15

Where does an omphalocele herniate through? What about a gastroschisis?

Answer 15

• omphaloceles come through the umbilical stalk

- gastroschisis comes inferior and to the right of the umbilicus

Question 16

What is the most common contents of an umbilical hernia?

Answer 16

preperitoneal fat

Question 17

Which umbilical hernias can be primarily repaired?

Answer 17

those that are less than 1 cm or that are in pediatric patients

Question 18

At what age are pediatric umbilical hernias repaired?

Answer 18

at age five because they are likely to close spontaneously before that

Question 19

What differentiates an indirect from direct hernia anatomically?

Answer 19

indirect arise lateral to the inferior epigastrics while direct are medial to these

Question 20

What is the etiology of an indirect inguinal hernia?

Answer 20

a patent processus vaginalis

Question 21

What are risk factors for a direct inguinal hernia?

Answer 21

• obesity
• smoking
• poor nutrition
• ascites
• anything that increases intra-abdominal pressure

Question 22

What are the contents of the spermatic cord?

Answer 22

• cremasteric muscles
• testicular artery and pampiniform plexus
• vas deferens
• ilioinguinal nerve
• genital branch of the genitofemoral nerve

Question 23

What forms the cremaster muscles?

Answer 23

an extension of the internal oblique muscle fibers

Question 24

What is the most common nerve injured during open inguinal hernia repair?

Answer 24

the ilioinguinal which usually occurs when opening the external oblique

Question 25

What are the three key nerves to identify during an inguinal hernia repair?

Answer 25

- ilioinguinal - iliohypogastric - genital branch of the genitofemoral

Question 26

What is the most common nerve injured during laparoscopic inguinal hernia repair?

Answer 26

the lateral femoral cutaneous due to improperly placed lateral tacks

Question 27

What is a Bassini repair?

Answer 27

- the floor of the canal is opened by cutting the transversalis fascia from the internal ring to the pubic tubercle, exposing preperitoneal fat - then the conjoint tendon (composed of transversus and internal oblique fascia) is sutured to the inguinal ligament

Question 28

What is a Shouldice hernia repair?

Answer 28

the same as a bassini, except that the layers are closed in two separate layers

Question 29

What is a Lichtenstein hernia repair?

Answer 29

a repair with mesh in which the inguinal ligament is sewn to the conjoined tendon

Question 30

How is a pediatric inguinal hernia repaired?

Answer 30

with high ligation of the sac

Question 31

What is the main structure for fixation of the mesh in a laparoscopic inguinal hernia repair?

Answer 31

Cooper's ligament

Question 32

What is the triangle of doom?

Answer 32

- it is the medial triangle with an apex at the iliopubic tract and bounded by the vas medially and the spermatic vessels laterally - it contains the iliac vessels and is a potential area for vascular injury

Question 33

What and where is the triangle of pain?

Answer 33

- it is the more lateral triangle with an inferior apex - contains the nerve structures - bounded medially by the spermatic vessels and superiorly by the iliopubic tract

Question 34

Where is a femoral hernia found?

Answer 34

below the inguinal ligament and medial to the femoral vein

Question 35

How is a femoral hernia repaired?

Answer 35

a McVay repair whereby the inguinal floor is opened and the femoral space is closed by suturing the conjoint tendon to cooper's ligament

Question 36

What are your options for repairing a strangulated hernia?

Answer 36

biologic mesh or primary repair

Question 37

Does onlay, inlay, or underlay ventral hernia repair have the highest recurrence rate?

Answer 37

inlay

Question 38

What layer of the abdominal wall is incised for each of the following: - anterior component separation - transversus abdominis repair - posterior component separation

Answer 38

- anterior: incise the external oblique lateral to the rectus sheath - transversus abdominis repair: incise the transversus abdominis fascia lateral to the rectus sheath - posterior: incise the posterior rectus sheath

Question 39

What is the optimal method for closing fascia?

Answer 39

use of a smaller, absorbable suture while taking 5-7 mm bites

Question 40

What is a spigelian hernia?

Answer 40

an intramuscular hernia at the junction of the semilunaris and arcuate line

Question 41

What is an amyand hernia?

Answer 41

one in which the appendix is found in the inguinal hernia sac

Question 42

What is a Littre's hernia?

Answer 42

one in which a meckel's diverticulum is found in the inguinal hernia sac

Question 43

What is a pantaloon hernia?

Answer 43

an inguinal hernia with an indirect and direct component

Question 44

What is a sliding hernia?

Answer 44

one in which a retroperitoneal structure makes up a portion of the hernia sac

Question 45

What is a Richter's hernia?

Answer 45

one in which a part of the wall of the bowel is present in the hernia sac; therefore, giving strangulation without obstruction

Question 46

What is the next step if you're doing an inguinal hernia repair and skeletonize the cord but still can't find the hernia?

Answer 46

must open the floor and look for a femoral hernia

Question 47

What is the next step for a cirrhotic with massive ascites and an umbilical hernia with intermittent obstructive symptoms?

Answer 47

TIPS to first control the ascites

Question 48

What should you do if you damage the femoral vein during an inguinal hernia repair?

Answer 48

pull out the suture and hold pressure

Question 49

What should you do if you are doing an inguinal hernia repair and can't reduce the sac?

Answer 49

- ligate the proximal portion that will reduce into the abdominal cavity - keep the distal portion open to reduce the chances of a hydrocele