Hernias

Question 1

What is the floor of the inguinal canal that prevents all hernias there?

Answer 1

Transversalis fascia

Question 2

What on bloody hell is the iliopubic tract?

Answer 2

It’s the backside of the inguinal ligament.

Exactly the same. It’s just that they HAD TO name is something freaking different just because you’re looking at it from the inside

Question 3

Borders of the hasselbach triangle?

Answer 3

Medially: rectus muscle
Superiorly: epigastric vessels
Inferiorly: inguinal ligament/iliopubic tract

Question 4

What is conjoined in the conjoined tendon?

Answer 4

Fusion of the transversis abdominis and the internal oblique

Question 5

Inguinal canal as a long box with six sides.

What/where are the internal ring vs external ring?

Superior wall
Inferior wall
Floor (posterior wall)
Roof (anterior wall)

Answer 5

External ring is towards to scrotum. Internal ring is the opening of the processus vaginalis

Superior wall: conjoined tendon
Roof (Anterior wall): external oblique aponeurosis
Floor (posterior wall): transversalis fascia
Inferior wall: inguinal ligament/lacunar ligament (provides the shelving edge)

Question 6

Describe the bassini repair. What are the 3 layes you incorporate into the repair?

Answer 6

You have to incise the transversalis fascia. Then you incorporate:

1) Conjoined tendon superiorly
2) Transversalis fascia and 3) inguinal ligament inferiorly

Question 7

Describe the McVay repair

Answer 7

Make the relaxing incision on top of the rectus medially.

Then suture the conjoined tendon (transversus abdominis aponeurosis) superiorly to the Cooper’s ligament (posterior aspect of the superior ramus of pubic symphysis) medially

Lateral to the femoral canal you suture the conjoined tendon to the inguinal ligament

Question 8

During a laparoscopic inguinal hernia repair, placing tacks in the triangle bordered by bad deferens and spermatic vessels will result in what?

Answer 8

Bleeding. Triangle of doom.

Do not place tacks below the inguinal ligament during lap repair.

Spermatic vessels come from lateral to medial horizontally.
Bad deferens comes from below to up

Femoral vessels lie between these two

Question 9

Where is the triangle of pain?

Answer 9

Below the inguinal ligament, lateral to the spermatic vessels

Question 10

Repair of choice for uncomplicated femoral hernia?

Answer 10

Open preperitoneal mesh repair

Question 11

Hat is the recurrence rate for incisional hernia repair without mesh?

Answer 11

Up to 50%

With mesh: 1-9%

Question 12

Describe the component separation

Answer 12

Divide the external oblique just beyond the semilunar line

Allows for the sliding of the fascia towards the midline

Question 13

3 months after a lap inguinal, pt has persistent groin pain exacerbated by physical activity. what to do next and why?

Answer 13

MRI first to rule out non-neuropathic pain such as hernia recurrence or meshomas.

if (+) neuropathic pain, then rx is percutaneous nerve ablation. inguinal nerve block is diagnostic but also only temporary

Question 14

Inguinal hernia. What are the borders of the mesh placement to minimize recurrence and pain?

Answer 14

Use a large mesh (7x15cm), to extend 3-4cm above hasselbach triangle, 2cm medial to the public tubercle and 5-6cm lateral to the internal ring

Question 15

Which part of component separation is a major source of mortality and morbidity?

Answer 15

Creation of large lipocutaneous flap. Wound issues

Question 16

When you do a McVay, what do you cut for the relaxing incision?

Answer 16

External oblique aponeurosis and the anterior rectus sheath

Question 17

How do you obtain access to the femoral space from the anterior approach?

Answer 17

By opening the posterior inguinal wall

Question 18

Rate of strangulation for asymptomatic reducible femoral hernia?

For emergency surgery, rate of bowel resection and mortality for femoral hernia?

Answer 18

Up to 45%

25% bowel resection
10% mortality

Question 19

What’s in the medial and lateral umbilical folds?

Answer 19

Medial: umbilical artery remnant
Lateral: epigastric vessels

Question 20

In the pediatric population, umbilical hernia over what cm has relatively low chance of closing on its own?

Answer 20

Over 1.5cm

Question 21

For recurrent hernia, between laparoscopic and open:

• recurrence rate
• PT’s return to normal activities
• operative time
• complication rate
• post-op pain

Answer 21

• no difference in recurrence rate
• open has slower return to normal activities
• laparoscopic may take longer
• no difference in complication rate
• open has more pain

Question 22

Where is the spigelian hernia?

Answer 22

Lateral edge of the rectus sheath and the semilunar line at the level of the arcuate line

Question 23

In general who has higher recurrence after ventral hernia repair males or females?

Answer 23

Males

Question 24

Does umbilical hernias have a sex preference?

Answer 24

Females (3) > males (1)

Question 25

Recurrence rate of umbilical hernia suture repair

Answer 25

5-10%

Question 26

What are the two possible sites for lumbar hernias? What are their boundaries?

Which one is more common?

Answer 26

Superior lumbar triangle (Grynfeltt-Lesshaft): lateral edge of quadratus lumborum, costal margin, posterior edge of internal oblique

Inferior lumbar triangle (Petit): lateral edge of lat dorsi, posterior edge of the external oblique, superior to iliac crest

Superior is more common

Question 27

What is a Gilbert repair and how is the recurrence rate compared to Lichtenstein?

Answer 27

It’s a plug and patch repair

Similar outcomes and recurrence rate as Lichtenstein (onlay)

Question 28

What is a stoppa-reves repair?

Answer 28

Involves infraunbilical midline incision to put an inguinal mesh preperitoneally

Question 29

Recommended method of midline closure according STITCH trial

What suture?

How far from the edge?

How far apart?

Answer 29

2-0 PDS 5mm apart, 5mm from edge

Question 30

Most common nerve injured during lap inguinal hernia repair?

They don’t give you lateral femoral cutaneous as an option

Answer 30

Genitofemoral

Question 31

What is a cross-linked mesh? is it better?

Answer 31

attribute used to describe BIOLOGIC meshes. Cross-linking appears to increase durability, tensile strength, and resistance to bacterial contamination. There is no evidence, though, that cross-linking or non–cross-linking is superior to the other.

SESAP

Question 32

60yo BMI40 COPD Diabetic smoker comes to you for a repair of ventral hernia that’s 50 x 25cm. what’s the highest risk factor for recurrence?

Answer 32

2 highest risk factors: hernia width + infection/contamination

COPD, BMI, smoking are all less of risk factors compared to those 2

sesap

Question 33

T/F: asymptomatic type III paraesophageal hernias can be watched

Answer 33

true. mortality from emergency surgery for these is only ~5% and mortality risk for elective surgery ~1.5%. the need for emergency surgery is also only about ~1.5%

SESAP

Question 34

for paraesophageal hernia repair, compare thoracic vs laparoscopic approaches:

• length of stay
• risk of PE
• need for mechanical ventilation

Answer 34

• thoracic had longer length of stay, higher PE, higher need for mech ventilation

SESAP

Question 35

watchful waiting for hernias:

Answer 35

false. repair will be needed in 65-75% of the patients
true. you can’t do watch and wait for females. urgent hernia repair needed in almost 20% of females
false. rate of acute incarceration is actually low. 2%