Hernias (270-280)

Question 1

What types of hernias can be found in the anterior abdominal wall?;

Answer 1

Incisional hernia, umbilical and para-umbilical, epigastric hernia, spegialian hernia (at level of arcuate line at the semilunaris), obturator hernia, richter’s hernia (is a partial herniation of bowel, only the ante-mesenteric border becomes involved [high risk of ischaemia], lumbar hernia, littre hernia (any abdo hernia that contains meckels diverticulum), amyand hernia (inguinal hernia that contains the vermiform appendix), De Garengeot hernia (femoral hernia that contains the vermiform appendix)

Question 2

Name some risk factors for incisional hernia;

Answer 2

Pre-operative- smoking, diabetes, obesity, connective tissue disorders, renal failure.

Intra-operative- poor surgical/suturing technique, wound closed under excessive tension, prolonged operation time, bleeding.

Post-operative- wound infection, same as pre-operative factors, other infection e.g. urine or chest.

Question 3

Name two salient differences between gastroschisis and exomphalos/omphalocele?;

Answer 3

Gastroschisis- no membrane covering = bowel exposed. Exomphalos- membrane covering/present (bowel not exposured)

Question 4

What are the boundaries of the inguinal canal?;

Answer 4

Anterior wall- external oblique aponeurosis (reinforced by internal oblique muscle laterally). Superior wall- internal oblique muscle and transversis abdominis muscle . Posterior wall- Transversalis fascia. Inferior wall- inguinal ligament (reinforced by lacunar ligament medially).

Question 5

Where is the superficial ring located?;

Answer 5

Superior (& slightly medial) to pubic tubercle. Marks end of inguinal canal.

Question 6

Where is the deep ring located?;

Answer 6

Midpoint of inguinal ligamant (1cm above). Lateral to epigastric vessels. [note inguinal ligament is from ASIS to pubic tubercle]

Question 7

What structures pass through the inguinal canal in a male and female?;

Answer 7

Spermatic cord (males only), round ligament (females only), ilioinguinal nerve, genital branch of gentiofemoral nerve.

Question 8

What are the main treatment options for a direct and indirect inguinal hernia?;

Answer 8

Conservative if minimal risk and asymptomatic.
Surgery- open surgery for first time inguinal hernias - the inguinal canal is opened, the hernia reduced and the defect repaired. A prosthetic mesh placed posterior to the cord structures to re-enforce the repair and reduce the risk of recurrence.
Laparoscopic surgery (TEP or TAP) for recurrent or bilateral or contralateral injury to vas deferens or obesity.

Question 9

Where is the mid-inguinal point and what is its clinical significance?;

Answer 9

The mid point between ASIS and pubic symphsis. The femoral pulse can be palpated here.

Question 10

What are the contents of the spermatic cord?;

Answer 10

3 fascia- external spermatic fascia (derived from external oblique aponeurosis), cremaster fascia (derived from internal oblique aponeurosis), internal spermatic fascia (derived from transveraslis fascia). 3 arteries- cremesteric artery, artery to vas deferens, testicular artery. 3 nerve- gential branch of gentiofemoral nerve, ilioinguinal nerve (actually outside), sympathetic nerves. 3 other- vas deferens, pampiform plexus, lymphatics.

Question 11

What is the origin of the following vessels?
(A) Testicular artery
(B) Artery to the vas deferens
(C) Cremasteric artery;

Answer 11

(A) Abdominal aorta at level of L2.
(B) Internal iliac -> superior vescular artery (occasionaly inferior in some population).
(C) External iliac -> Inferior epigastric.