Hernias

Question 1

What is the most common cause of a recurrent hernia?

Answer 1

wound infection

Question 2

What are the most and second most common causes of SBO?

Answer 2

• 1: adhesive disease
• 2: hernia

Question 3

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

Answer 3

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

Question 4

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

Answer 4

• skin
• subcutaneous fat
• scarpa’s
• external oblique
• internal oblique
• transversus abdominis
• transversalis fascia
• pre peritoneal fat
• peritoneum

Question 5

Where is the arcuate line?

Answer 5

a third of the way down between the umbilicus and pubis

Question 6

What are the major arteries that supply the rectus?

Answer 6

the superior and inferior epigastrics

Question 7

What are the boundaries of Hesselbach’s triangle? What is the significance?

Answer 7

• medial: rectus
• lateral: inferior epigastrics
• inferior: inguinal ligament
• direct hernias come through this space

Question 8

The inguinal ligament is an extension of what?

Answer 8

the external oblique fascia

Question 9

What is the vitelline duct?

Answer 9

• aka the omphalomesenteric duct
• comes through the umbilicus
• becomes a Meckel’s

Question 10

What are the median and medial umbilical ligaments?

Answer 10

• median is the obliterated urachus
• medial are the umbilical arteries

Question 11

What is the round ligament of the liver?

Answer 11

Ligamentum teres, also the obliterated umbilical vein

Question 12

What do the umbilical vein and arteries become?

Answer 12

the vein is the round ligament of the liver (ligamentum teres) and the arteries are the medial umbilical ligaments

Question 13

When does the midgut herniate and then return to the abdomen during embryologic development?

Answer 13

• herniates at 6 weeks
• returns at 10 weeks

Question 14

Are umbilical hernias usually congenital or acquired?

Answer 14

congenital

Question 15

What is the usual contents of an umbilical hernia?

Answer 15

pre-peritoneal fat

Question 16

Who is a candidate for primary repair of an umbilical hernia?

Answer 16

those with a defect less than one cm or pediatric patients

Question 17

When should you repair a pediatric umbilical hernia?

Answer 17

wait until 5 years of age to do the repair, many will spontaneously resolve

Question 18

What is the etiology of an indirect umbilical hernia?

Answer 18

it is due to a patent processus vaginalis

Question 19

What forms the cremasteric muscle?

Answer 19

the internal oblique

Question 20

What is the most commonly injured nerve during inguinal hernia repair?

Answer 20

the ilioinguinal when opening the external oblique

Question 21

What are the three nerves to be aware of during an inguinal hernia repair?

Answer 21

• genital branch of the genitofemoral
• ilioinguinal
• iliohypogastric

Question 22

What is the most commonly injured nerve during a laparoscopic inguinal hernia repair? When does it get injured?

Answer 22

the lateral femoral cutaneous nerve when placing tacks too laterally

Question 23

Describe the following repairs:
- Bassini
- Shouldice
- Lichtenstein
- McVay

Answer 23

• Bassini: conjoint tendon to the inguinal ligament
• Shouldice: bassini but in four layers
• Lichtenstein: repair with mesh sewn to the inguinal ligament and conjoint tendon
• McVay: open the floor and suture the conjoint tendon to coopers

Question 24

What is the main structure to which the mesh is fixed during a laparoscopic inguinal hernia repair?

Answer 24

Cooper’s ligament

Question 25

Where is the triangle of doom?

Answer 25

- medial to the triangle of pain - contains the iliacs - apex at the iliopubic tract, vas medially, spermatic vessels laterally

Question 26

Where is the triangle of pain?

Answer 26

- lateral to the triangle of doom - lateral to spermatic vessels and below the iliopubic tract

Question 27

Do we prefer macro or microporous mesh for ventral hernia repair?

Answer 27

macroporous

Question 28

Which layer of mesh repair has the highest recurrence rates?

Answer 28

inlay mesh

Question 29

What is cut during the following component separations: - anterior - posterior - transversus

Answer 29

- anterior: divide the external oblique lateral to the sheath - posterior: divide the posterior rectus sheath - transversus: divide the transverses abdominis

Question 30

What did the stitch trial show?

Answer 30

use small (5mm) bites with a small, absorbable suture

Question 31

What is a spigelian hernia?

Answer 31

an intramuscular hernia found at the arcuate line and semilunaris line

Question 32

What is a Littre's hernia?

Answer 32

one that contains a Meckel's

Question 33

What is a pantaloon hernia?

Answer 33

a direct and indirect inguinal hernia

Question 34

What is a sliding hernia?

Answer 34

one in which a retroperitoneal structure forms part of the wall of a hernia sac

Question 35

What is a richter's hernia?

Answer 35

one in which just the wall, not an entire loop, of bowel is herniated; therefore, producing strangulation without obstruction

Question 36

What's the next step if you're repairing an inguinal hernia and you can't find one?

Answer 36

open the floor and look for a femoral hernia

Question 37

If you're doing a laparoscopic inguinal hernia repair and place tacks to Cooper's and. you get large volume arterial bleeding, what happened?

Answer 37

you hit the corona mortis, a branch between the obturator and external iliac

Question 38

What is obturator sign?

Answer 38

groin or medial thigh pain that occurs with internal rotation of the hip and suggestive of an obturator hernia

Question 39

What should you do with an indirect hernia that you can't fully reduce the sac?

Answer 39

ligate the sac, leaving the distal end open to drain, preventing a hydrocele