HERNIAS

Question 1

Femoral Nerve

Answer 1

Motor and sensory to thigh (quads)

Question 2

Genitofemoral nerve

Answer 2

Motor–cremasteric muscle Sensory–genital region

Question 3

Lateral femoral cutaneous nerves

Answer 3

Skin to lateral portion of thigh (often sacrificed)

Question 4

Hesselbach’s Triangle

Answer 4

Medial: rectus sheath Inferior: inguinal ligament Superolateral: inferior epigastric vessels

Question 5

Hernia Dx

Answer 5

Bulge in inguinal region Minor pain or vague discomfort or extreme pain (incarceration) Paresthesias if inguinal nerves are compressed

Question 6

Reducing a hernia

Answer 6

Gentle continuous pressure on the hernial mass toward the inguinal ring in the Trendelenburg position

Question 7

Radiology

Answer 7

Only used in ambiguous diagnosis NOT FIRST LINE US (pretty good)

Question 8

Hernia Severity

Answer 8

Reducible –> Incarcerated –> Strangulated

Question 9

Indirect inguinal hernia

Answer 9

Congenital lesion Bowel, omentum, other abdominal organs protrude through abdominal ring with patent processus vaginalis Indirect hernia cannot develop if processus vaginalis does not remain patent Most common type of hernia

Question 10

Direct inguinal hernia

Answer 10

Proceeds directly through posterior inguinal wall Acquired lesions Older males Pressure and tension on muscles and fascia

Question 11

Femoral Hernias

Answer 11

Mass below the inguinal ligament More common in females than males

Question 12

RFs for inguinal hernias

Answer 12

Family history (8x more likely) Connective tissue disorders Smoking Coughing COPD Obesity Straining Pregnancy Ascites Prematurity, low birth weight Heavy listing

Question 13

Does wearing a truss cure a hernia?

Answer 13

No

Question 14

When to surgically repair a hernia

Answer 14

If they are symptomatic

Question 15

When to repair emergently

Answer 15

Strangulation of hernia -Fever, leukocytosis, hemodynamic instability -Hernia bulge is warm and tender -Overlying skin may be erythematous or discolored -Sx of bowel obstruction

Question 16

Bassini Repair

Answer 16

Original procedure Used for indirect and small direct hernias Closing the area with the patient’s own tissue Higher rates of recurrence

Question 17

McVay (Cooper’s ligament) Repair

Answer 17

Inguinal and femoral hernia repairs

Question 18

Shouldice (Canadian) Repair

Answer 18

Most commonly used Reduced recurrence rate Using patient’s own tissue to close defect Genitoformoral nerve is divided; loss of sensation on scrotum/mons pubis and labia majora

Question 19

The Operation

Answer 19

Incision: 2 finger breadths above inguinal ligament Dissect through subcutaneous and external oblique fascia Mobilize spermatic cord Divide/separate cremasteric muscle fibers from underlying cord structures Dissect hernia sac from cord structures; open Suture ligate neck of sac at level of internal ring

Question 20

Which procedures use the patient’s own tissue?

Answer 20

Bassini McVay Shouldice

Question 21

Lichtenstein (tension-free) Repair

Answer 21

Very common Mesh patch is sutured over defect with a slit to allow passage of the spermatic cord Laparoscopic > Open Recurrence rate is even lower Preferred method

Question 22

Which procedure cannot be used if suspected/known strangulated or incarcerated hernia?

Answer 22

TEPA –Opt for TAPP instead

Question 23

What are the three issues with laparoscopic hernia repair?

Answer 23

Triangle of doom Triangle of pain Circle of death

Question 24

Triangle of doom

Answer 24

Medial border: vas deferens Lateral border: vessels of spermatic cord Posterior border: peritoneal edge Contents: external iliac vessels, deep circumflex iliac vein, femoral nerve, genital branch of genitofemoral nerve

Question 25

Triangle of pain

Answer 25

Iliopubic tract and gonadal vessels Contents: lateral femoral cutaneous, femoral branch of genitofemoral, and femoral nerves

Question 26

Circle of death

Answer 26

Vascular continuation formed by the common iliac, internal iliac, obturator, inferior epigastric, and external iliac vessels

Question 27

IHR Complications

Answer 27

Recurrence Chronic groin pain Cord and testicular (hematoma, ischemic orchitis, division of vas deferens, hydrocele) Bladder injury Wound infection Hematoma Prosthetic complications

Question 28

Abdominal wall hernias

Answer 28

Ventral hernias Congenital: defective midline fusion Acquired: slow architectural deterioration or from failed healing of abdominal wall incision

Question 29

Umbilical hernias

Answer 29

Mostly congenital in origin African descent Usually close by age 5 After 5, surgically repair If presenting in adulthood, considered acquired

Question 30

Umbilical hernia repair

Answer 30

After age 5 Primary sutured repair or placement of prosthetic mesh for larger defects (> 2 cm) using open or laparoscopic methods

Question 31

Spigelain Hernia

Answer 31

“S belt” (6 cm horizontal region below navel, lateral to abdominal muscles) Men around age 50, right side STILL FIX IF ASYMPTOMATIC Simple closure of fascia

Question 32

Incisional Hernias

Answer 32

Development of hernia following surgery (up to 20%) Paramedian incisions help reduce the risk Inadequate healing– not following instructions, post-op strain, infection Obesity is a leading cause (must lose weight before repair) Other RFs: advanced age, malnutrition, ascites, post op hematoma, pregnancy

Question 33

Incisional hernia repair: mesh locations

Answer 33

Underlay: deep to defect (done laparoscopically) Interlay: bridging the gap or within the abdominal wall Onlay: superficial to fascial defect -Laparoscopic preferred