Inguinal Hernia Flashcards

Question

**What is the primary danger associated with a sliding hernia?**

Answer 1

Failure to recognize the visceral component of the hernia sac before injury to bowel/ bladder.

Answer 2

**Ovaries/fallopian tubes**

Answer 3

**Cecum/sigmoid colon**

Answer 4

**Divide the inguinal or lacunar ligament**

Answer 5

Explore through **preperitoneal incision** by opening the peritoneum, versus laparoscopy.

Answer 6

**High ligation** of the hernia sac

Answer 7

**Retroperitoneal fat** that has herniated through the deep inguinal ring

Answer 8

**Up to 20 cm of mobilization**

Answer 9

**Vas deferens** medially; **Spermatic vessels** laterally; **External iliac vessels** inferiorly

Answer 10

External iliac vessels Deep circumflex iliac vein Genital branch of genitofemoral nerve Femoral nerve

Answer 11

**Spermatic vessels** medially **Iliopubic tract** superolaterally

Answer 12

**Lateral femoral cutaneous nerve** and **anterior femoral cutaneous nerve of the thigh**

Answer 13

Placing tacks in this area may lead to **chronic pain** from injury to the **lateral femoral cutaneous nerve/anterior femoral cutaneous nerve** of the thigh.

Answer 14

Also known as the **corona mortis**, a vascular ring formed by the joining of an aberrant artery with the normal obturator artery arising from a branch of the internal iliac artery; during a laparoscopic hernia repair, this vessel can be torn from both ends and bleed profusely.

Answer 15

**Pull the testicle back down into the scrotum.**

Answer 16

**Urinary retention**

Answer 17

Estimated to be **1% to 2%**

Answer 18

No; considered a **clean operation**.

Answer 19

Patients with **significant underlying disease (ASA score \>III)**

Answer 20

**Cefazolin, 1 to 2g IV 30 to 60 minutes before incision**; If penicillin allergic, give **Clindamycin 600mg IV** or **Vancomycin 1g IV.**

Answer 21

**Ilioinguinal nerve** **Iliohypogastric nerve** **Genital branch of the genitofemoral nerve**

Answer 22

**Lateral femoral cutaneous** and **genitofemoral nerves**

Answer 23

Initial treatment should include a long trial of **observation**, **NSAIDS**, and possibly **nerve blocks** (exhaust every possible solution before taking the patient back, unless the patient is experiencing nerve entrapment immediately postoperatively in the PACU; in that case, take them back). Repeat exploration with neurectomy and mesh removal as needed.

Answer 24

**Thrombosis of the small veins of the pampiniform plexus** within the spermatic cord resulting in **venous congestion of the testis** with resultant progressive pain and swelling usually resulting in **testicular atrophy** (the most common cause is **extensive dissection of a scrotal hernia sac**).

Answer 25

The floor of the inguinal canal **near the pubic tubercle** where the tension on the suture line is the greatest.

Answer 26

**1% to 3%**

Answer 27

Usually **within the first 2 years** after repair

Answer 28

**Primary repair**

Answer 29

Incisional hernia with a **large defect (\>2-3 cm diameter)**

Answer 30

**Epigastric hernia**

Answer 31

**Spigelian hernia**

Answer 32

The **risk for incarceration** associated with its **relatively narrow neck.**

Answer 33

**Obturator hernia** causing pain along the medial aspect of the proximal thigh from nerve compression.

Answer 34

Medial: **Quadratus lumborum** Lateral: **Internal abdominal oblique** Superior: **12th rib** Floor: **Transversalis fascia** Roof: **External abdominal oblique**

Answer 35

Medial: **Latissimus dorsi** Lateral: **External abdominal oblique** Inferior: **Iliac crest** (Floor: **Internal abdominal oblique**)

Answer 36

**Grynfeltt hernia**

Answer 37

Presence of an **uncomfortable or slowly enlarging mass in the gluteal or intragluteal area**

Answer 38

Abort the hernia repair; Perform a **primary tissue or biologic tissue repair**; Perform a **delayed repair using prosthetic mesh in 3 to 4 days**.

Answer 39

Hernia sac **containing a ruptured appendix.**

Answer 40

A **posterior diaphragmatic hernia** usually occurring on the **left** (Bochdalek = back and to the left)

Answer 41

An anterior parasternal diaphragmatic hernia

Answer 42

A **femoral hernia with 2 sacs** that tracks into the scrotum or labia majorum through the femoral canal

Answer 43

Hernia containing a **Meckel diverticulum**

Answer 44

Hernia **through the linea semilunaris**

Answer 45

A hernia that is **lateral to the femoral vessels and under the inguinal ligament.**

Answer 46

A hernia that **straddles the inferior epigastric vessels** representing both a **direct hernia through the floor of the canal and an indirect hernia** protruding through the internal ring

Answer 47

**Incarcerated/strangulated hernia** involving **only 1 sidewall of the bowel**

Answer 48

Hernia **containing abdominal contents** occurring **between the layers of the abdominal wall**

Answer 49

Characterized by a **dilated superficial ring** of the inguinal canal and **chronic groin pain in athletes (not a true hernia)**

Answer 50

**The iliopubic tract**

Answer 51

**The Bassini repair**

Answer 52

**The Shouldice repair**

Answer 53

**McVay (Cooper ligament) repair**

Answer 54

**Lichtenstein repair**

Answer 55

**Plug and patch repair**

Answer 56

**Prolene hernia system (PHS) repair**

Answer 57

**Totally extraperitoneal (TEP) repair**

Answer 58

**Transabdominal preperitoneal (TAPP) repair**

Answer 59

**Stoppa repair**

Answer 60

**Component separation technique**

Answer 61

**C** The most common location for recurrence following laparoscopic hernia repair is the **medial aspect of the mesh.** This relates to **failure to secure the mesh medially** and using a piece of mesh that is **too small**. With a large direct defect, it is important to have adequate coverage anteriorly or the mesh can prolapse into the hernia defect.

Answer 62

**C** If you are unable to reduce the bowel during a femoral hernia repair through an inguinal approach, the n**ext best step is to incise the inguinal ligament**. Make sure to control the neck of the hernia so that you can ensure viability of the bowel and then repair the hernia and inguinal ligament.

Answer 63

**A** **Obturator hernias** are very rare but occur more frequently in **multiparous elderly women**. They can be associated with the **Howship-Romberg sign**, which is **pain on internal rotation of the thigh**. An obturator hernia occurs through a **weakened obturator membrane**. The defect is usually **narrow** in diameter, which predisposes to small-bowel incarceration and strangulation.

Answer 64

**D** Laparoscopic inguinal hernia repair has advantages in the setting of bilateral and/or recurrent hernias. **Contraindications** include patients who have had **prior laparoscopic hernia repair**, **prior preperitoneal pelvic surgery** or **previous lower midline incision**, **prior pelvic radiation**, or **cannot tolerate general anesthesia.**

Answer 65

**B** **Extensive dissection of the spermatic cord** is the most common risk factor in the development of ischemic orchitis following inguinal hernia repair. **Ischemic orchitis** likely results from **testicular venous congestion from thrombosis of the pampiniform venous plexus**. To help prevent this, the spermatic cord **should not be dissected past the pubic tubercle**, and the hernia sac can be ligated and divided, leaving the distal sac in place. Ligation of the testicular artery is usually well tolerated, as evidenced by the 2-stage Fowler-Stevens orchiopexy for high undescended testis, because the testicle has a rich collateral blood supply from the cremasteric artery (branch of inferior epigastric artery) and the artery to the ductus deferens (branch of inferior vesical artery).

Answer 66

**D** Umbilical hernia repair in cirrhotic patients with **uncontrolled ascites** has a high morbidity and mortality rate. Optimal therapy includes **aggressive diuresis and sodium/fluid restriction to control ascites**, **IV antibiotics** to combat possible bacterial peritonitis, and **bed rest** to reduce stress on the hernia and leaking site, followed by **repair of the hernia after the ascites is controlled.**

Answer 67

**A** The pudendal nerve is not at risk of injury during laparoscopic hernia repair. To help reduce the incidence of nerve injury during laparoscopic hernia repair, placing tacks lateral to the epigastric vessels is avoided.

Answer 68

**C** **Umbilical hernias in adults should usually be performed promptly** because of the risk of incarceration. Umbilical hernias are rarely incarcerate, and most surgeons will **defer surgery until about 4 to 5 years of age** because the majority of umbilical hernias in infants will **close spontaneously by 2 years of age.** Umbilical hernias are about 8 times more common in African American children than in white children.

Answer 69

**B** Inguinal hernia in **infants** results from a **patent processus vaginalis** and not from a weakness in the floor of the inguinal canal. **High ligation of the hernia sac** is usually all that is required except in the instance of a large defect, which may require tightening of the internal ring or reconstruction of the inguinal floor.

Answer 70

**C** **Indirect inguinal hernias account for two-thirds of inguinal hernias**. **Femoral hernias** account for approximately 5% of abdominal wall hernias and occur **more frequently in women**. Inguinal hernias are approximately 25 times more common in men than in women. The **most common hernia in both men and women is an indirect inguinal hernia.**

Answer 71

**C** **Richter hernia** occurs in the setting of other hernias and is not an anatomically distinct hernia type like the other listed hernias. **Part of the circumference of bowel is incarcerated** or even strangulated within the fascial defect of any hernia in the viscera area.

Answer 72

**A** All groin hernias protrude through the myopectineal orifice of Fruchaud (MPO), which is a **primary weakness or defect in the transversalis fascia** of the aponeurosis immediately outside the peritoneum.

Answer 73

**B** The findings are suspicious for a **sarcoma**. The first best step is **incisional biopsy**, especially in light of the size of the mass.

Answer 74

**C** The **McVay repair** is effective for **femoral hernia** but always requires a **relaxing incision to relieve tension.** Since it's a nonmesh repair, the recurrence rate can be as high as 30%.

Answer 75

**D** The **space of Retzius (retropubic)** lies **behind the transversalis fascia** and also the symphysis pubis lies anteriorly and pubic rami laterally, with the pubic bone making up the sidewall.

Answer 76

ANSWER: A-II; B-IV; C-V; D-III; E-I COMMENTS: A Richter hernia is an abdominal wall hernia that only contains the antimesenteric border of the small intestine. This type of hernia may be dangerous, because the incarcerated portion can strangulate without showing symptoms. A Littre’s hernia is an abdominal wall hernia containing a Meckel’s diverticulum. A lumbar hernia is a rare back hernia that can form through the superior or inferior lumbar triangles. The superior triangle has boundaries of the 12th rib, internal oblique muscle, and thoracic paraspinal muscle. The inferior triangle has boundaries of the iliac crest, external oblique muscle, and latissimus dorsi muscle. A spigelian hernia is a lateral abdominal wall hernia that forms between the semilunar line and the rectus muscle. These often form no noticeable bulge because the external oblique aponeurosis is intact. An Amyand’s hernia is an abdominal wall hernia that contains the appendix.

Answer 77

ANSWER: E COMMENTS: Groin pain following an inguinal hernia repair is much more common than recurrence and has occurred at incidence as high as 29%–76% in several series. Transient pain with mild numbness inferior to the incision is common. Persistent, intense pain and loss of sensation suggest nerve injury or entrapment. In open repairs, the most common nerves involved are the ilioingui- nal, iliohypogastric, or genital branch of the genitofemoral nerve. Injury to the lateral femoral cutaneous and genitofemoral nerves in laparoscopic repairs may occur from tack placement. Mesh inguino- dynia, or post herniorraphy pain syndrome, has been reported to result from an inflammatory response to mesh or resultant scar tissue, or both. Although nerve blocks may be diagnostic or thera- peutic, exploration may be necessary along with neurectomy, surgi- cal removal of all or part of a nerve. To prevent the problem from occurring, the best intervention is to be meticulous with identification and avoid entrapment of the aforementioned nerves in open repairs. In addition, tack placement should be avoided, particularly in the triangle of doom in laparo- scopic procedures.

Answer 78

**C** A **McVay repair** is described in answer E and can be used for **femoral hernias**. A transition stitch and a relaxing incision are needed for a McVay repair—medial to the edge of the femoral canal the transversus abdominis aponeurosis is stitched to Cooper’s ligament, and lateral to the femoral canal the transversus abdominis is attached to the iliopubic tract. A Bassini repair is a tissue repair, and answer D describes a Lichtenstein repair. Since the Bassini repair is completely superior to the inguinal ligament, it cannot be used to repair a femoral hernia.

Answer 79

**B** **Laparoscopic hernia repair** is appropriate for **femoral hernias** and indicated for **bilateral or recurrent inguinal hernias**. There are two techniques to gain exposure to the inguinal region. A **TEP** uses an **infraumbilical port and a balloon dissector in the preperitoneal space** to expose the inguinal canal and hernia. A **TAPP** uses an **infraumbilical port to gain access to the peritoneum**. A peritoneal flap is created to expose the hernia. The **lateral edge of the dissection is the anterior superior iliac spine** in both approaches. The hernia is reduced, and a large mesh is placed over the defect. Important landmarks are the **inferior epigastric vessels** running along the edge of the rectus muscle dividing indirect and direct hernias. **Tacks are placed medial to Cooper’s ligament** to secure the mesh in place. *No tacks should be placed inferior to the iliopubic tract* because the femoral branch of the genitofemoral nerve and the lateral femoral cutaneous nerve are located lateral and inferior. The **triangle of pain** contains the **genitofemoral nerve and lateral cutaneous femoral nerve** and is bound by the iliopubic tract superiorly and genital vessels inferiorly. The **triangle of doom** contains the **external iliac vessels**, and the femoral nerve is bound by the iliopubic tract superiorly, vas deferens medially, and spermatic vessels laterally.

Answer 80

**C** The transversalis fascia is the portion of the endo-abdominal fascia that underlies the transversus abdominis muscle. It has several thickenings, the most important of which is the **iliopubic tract**, which arises from the iliopectineal arch, inserts on the anterior superior iliac spine, and extends over the femoral vessels to the pubis. Proper utilization of the transversalis fascia during the repair of an inguinal hernia is important to the success of operations not using the prosthetic material. The **iliopubic tract** has particular significance because of its importance as a **landmark** to laparoscopic surgeons. Many of the **branches of the lumbar plexus run inferior to the tract**, and damage to these nerves may be the result of aggressive dissection or the placement of tacks or staples to affix a mesh below this structure.

Answer 81

**D** Approximately three-fourths of all abdominal wall hernias occur in the inguinal region, and roughly **two-thirds of them are indirect inguinal hernias**. Groin hernias are considered to be at least **25 times more common in males** than in females. The incidence of inguinal hernias is **increased by prematurity.** The **most common hernia in each gender is an indirect inguinal hernia**. Femoral hernias are rare in men. On the other hand, direct hernias are uncommon in women. It has been estimated that inguinal hernias develop in 25% of males and 2% of females during their lifetime. Therefore hernias constitute a significant economic problem in terms of loss of time from work.

Answer 82

ANSWER: D COMMENTS: Through physical stress, the connective tissue breaks down. As a result, the strength of the transverse aponeurosis and fascia decreases from intraabdominal pressure, smoking, aging, connective tissue disease, and systemic illnesses. Therefore direct inguinal hernias are acquired from the “wear and tear” of daily life, including straining to urinate or defecate, chronic coughing, and heavy lifting. A decrease in the content of hydroxyproline in the aponeurosis of patients with hernias has been demonstrated, along with alterations in the ultrastructure of collagen. Large indirect hernias may weaken the floor of the Hesselbach’s triangle and result in a functional direct component. Because the area of the Hesselbach’s triangle is weaker without a narrow-necked sac, the risk for incarceration is low. Rarely, incarceration results when a direct hernia passes through the external ring posterior to the cord structures. The spermatic cord should be explored to rule out the presence of an indirect sac. A pantaloon hernia is composed of both direct and indirect inguinal hernias.

Answer 83

**E** Inguinal hernias in infants and children are **nearly always indirect** and result from the **failure of obliteration of the processus vaginalis**. Effective treatment **requires only high ligation** and transection of the sac with or without excision of the distal component. Repair **need not be delayed** unless the infant has associated medical problems. In fact, bowel obstruction and gonadal or intestinal infarction as a result of strangulation are most likely to occur during the first 6 months of life. Therefore the **repair should be performed soon after the diagnosis is made.** Exploration of the opposite side in children with a unilateral inguinal hernia is controversial. The **incidence of a contralateral hernia** following unilateral inguinal herniorrhaphy in children has been reported to be **10%–30%**. **Contralateral exploration** should be performed routinely in the subset of patients most likely to have a clinically occult hernia: **children younger than 2 years, girls younger than 3 years (higher bilateral rate), patients with ventriculoperitoneal shunts, and children younger than 2 years with a left-sided hernia**. This last recommendation is based on the fact that most (60%) pediatric hernias are right sided. **Intubation of the clinically apparent hernia sac with a laparoscope is one method of examining the contralateral side**.

Answer 84

**E** The primary repair of incisional hernias can be associated with a **30%–50%** or higher recurrence rate, depending on the size of the hernia. Except for small incisional hernias, a prosthetic mesh is necessary to reduce recurrence rates to 10% or possibly less. Patients with incisional hernias usually have predisposing factors, such as **obesity, chronic debilitating illness, diabetes, advanced age, and smoking**. The predisposing factors also play a role in the failure of primary repair. Recurrence rates after the other listed hernia repairs should all be 5% or less.

Answer 85

**C** Umbilical hernias are the result of a **patent umbilical ring**, whereas an omphalocele is the result of the failure of abdominal wall closure in the midline during early intrauterine life. Umbilical hernias are said to be present in **40%–90% of African- American infants**. Incarceration is rare in infants. Unless the defect is large, most surgeons **defer repair until the child is approximately 4 years of age because spontaneous closure does occur**. In **adults, however, repair should be carried out promptly because of the risk for incarceration**. There is no convincing evidence that a “vest- over-pants” type of repair is structurally superior to a simple approximation of the fascial margins. Repair in adults may benefit from the use of prosthetic material, such as polypropylene, if the fascial defect is large or tension is present. There are several variations of mesh repairs with no evidence-based consensus of choice at this time.

Answer 86

ANSWER: C COMMENTS: The risk for strangulation in incarcerated femoral hernias is reported to be as high as 20%–40%. It is believed that the window for successful treatment to avoid bowel resection is 4 to 6 h. This clinical condition is considered a surgical emergency, and fresh-frozen plasma can be administered just before and during surgery. A laparoscopic repair can be challenging with an incarcer- ated hernia, and in addition there is a concern for increased bleeding in the patient. Laparoscopic repair also requires the use of a mesh, which may become infected. Although mesh decreases recurrence in femoral hernias, it is probably not advisable in this setting. An open approach is probably preferred and can be a tissue- to-tissue repair. Any attempt at reduction is probably contraindi- cated because of the high potential for strangulation. If the bowel drops into the abdomen during an open approach, insertion of a scope into the hernia sac may be useful in evaluating the integrity of the affected bowel.

Answer 87

**C** Repair of any hernia in a patient with ascites is a challenging problem. In general, any consideration of an elective repair **should be deferred until the ascites is controlled with maximal medical therapy.** If the ascites can be controlled, umbilical hernias should be repaired in patients with cirrhosis because of the high morbidity and mortality if the hernia ruptures. If there is skin breakdown and leakage of ascites, an urgent repair may be necessary to prevent peritonitis. Frequent paracentesis may be helpful in this difficult scenario with associated high morbidity.

Answer 88

**A-IV; B-II; C-V; D-III; E-I** A **clean wound** is only in contact with the normal skin flora and should have a surgical site infection rate of **\<2%**. An *elective inguinal hernia repair* is a clean wound. A **clean-contaminated wound** enters a viscus in a controlled manner; the hernia has a surgical site infection risk of **2%–10%**. *Gynecologic cases, prepped colon or small bowel procedures, and head and neck cases* are clean-contaminated cases. A **contaminated wound** has intestinal spillage without active signs of infection and has an infection rate of **∼10%** even with antibiotics. Examples of a contaminated wound are *ischemic bowel and an unprepped colon.* **Dirty cases** are surgeries with **active infection** such as an *empyema and perforated appendicitis*. During a hernia repair, the wound class is very important to help guide mesh placement. A synthetic mesh can be used with clean and clean-contaminated wounds. **Biologic meshes are used for contaminated or dirty wounds** if a mesh is needed. “Sterile” is not a part of the Surgical Wound Classification.

Answer 89

**B** Although femoral hernias are found more often in females than in males, inguinal hernias are still more common than femoral hernias. Femoral hernias with small orifices in women are repaired from below the inguinal ligament with a few sutures or plugged with a cone of polypropylene mesh because they are rarely associated with hernias above the inguinal ligament. Large femoral hernias can be repaired with the **McVay Cooper’s ligament procedure** or even better with a **preperitoneal permanent prosthesis** placed either laparoscopically or using an open preperitoneal approach. Femoral hernias **should be repaired promptly because the risk of incarceration is high**. Viability of the intestine must be ensured since incarceration of the antimesenteric border of the intestine (Richter hernia) could result in infarction. The presence of bloody fluid in an otherwise empty sac mandates a careful examination of the intestine to rule out ischemia. The McVay repair may be preferred with incarcerated femoral hernias to avoid infection of the prosthetic mesh. If the hernia sac is too large to reduce through the hernia defect, the **medial insertion of the inguinal ligament can be cut from the pubic tubercle to allow more space**. After reduction, the inguinal ligament is reattached to the pubic tubercle or Cooper’s ligament.

Answer 90

**C** Incarceration with potential resultant strangulation of small bowel is a serious complication of groin hernias. If the patient has an incarcerated inguinal hernia and strangulation is not suspected, an attempt at reduction by using sedation, Trendelenburg positioning, and gentle sustained pressure over the groin mass is appropriate. **Reduction en masse** refers to the persistent nature of incarcerated tissue frequently through the external ring despite an apparently successful reduction. If there is any indication of strangulation, reduction should not be attempted preoperatively. Rather, the sac should first be opened before reduction to inspect the viability of the contents. The presence of bloody fluid in the peritoneal cavity should raise the question of intestinal viability. A delayed repair following a successful reduction may permit resolution of edema. A hydrocele can mimic an incarcerated hernia. Should physical examination fail to establish the diagnosis, a hydrocele will transilluminate clearly but a hernia will not. Ultrasound can confirm the presence of a hydrocele. In patients with a suspected strangulated hernia, spontaneous reduction of the hernia’s contents could occur. However, the surgeon should not assume that the bowel is viable, and examination of the abdominal contents is mandatory. An incarcerated femoral hernia should always be repaired on an urgent basis, as the rate of strangulation is high. Giant inguinal hernias are often chronically incarcerated and can contain the majority of the intraabdominal contents. After reduction, the volume of the abdominal contents is increased enough that the abdominal wall closure can become problematic.

Answer 91

**A** The advantage of **mesh** in a hernia repair is that it decreases hernia recurrence from 8.2% to 2.7%, but has slightly high rates of infection. **Mesh infection rates are 3%–10%** after a hernia repair. Meta-analysis shows that a laparoscopic ventral hernia repair with a mesh has infection rates of 1%–2% compared with ∼10% for an open ventral hernia repair with mesh, with no difference in the recurrence rate. **PTFE** is a **synthetic mesh** that becomes encapsulated with no ingrowth of tissue; if infected, it must be explanted. Macroporous monofilament meshes are more resistant to infection because macrophages can enter the pores and combat infection. Surgical site infection is the most common reason that a mesh is explanted and leads to higher recurrence rates.

Answer 92

ANSWER: A COMMENTS: Recurrence rates for groin hernias vary from less than 1% to 30%. True recurrence rates are difficult to establish because of inadequate patient follow-up. The Bassini repair and its modifications (Shouldice and McVay) all create tension at the suture line and have been found to have recurrence rates between 10% and 30% when performed outside specialized centers. Several developments in the latter half of the 20th century have significantly influenced the currently accepted level of a recurrence rate of less than 5%. The routine uses of prosthetic material to perform a tension-free hernia repair became accepted by surgeons after being popularized by Lichtenstein in the 1980s. Others, such as Rutkow, Robbins, Kugel, Gilbert, Wantz, Stoppa, Millikan, and Nyhus, have used multiple prosthetic materials and approaches to continue to reduce the recurrence rate to below 1%. The most popular prosthetic materials are polypropylene, polyester fiber mesh, and PTFE. Use of the preperitoneal space also helped lower recurrence rates by allowing larger pieces of prosthetic material to be used and incorporating intraabdominal pressure to aid in keeping the mesh in place. Laparoscopy by itself has not helped lower recurrence rates below those achieved with open tension-free mesh repairs, but it has given the surgeon another option for accessing the preperitoneal space.

Answer 93

**C** Synthetic meshes are composed of PTFE, polypropylene, or polyester. **Porosity** is important in determining the flexibility and infection resistance of the mesh. Large pores decrease the inflammatory foreign body reaction and allow improved penetration by immune cells. Lightweight meshes have large pores with thinner filaments, and heavyweight meshes have small pores with thicker filaments leading to a denser material. Heavyweight meshes are less elastic, which can interfere with the abdominal wall compliance, and have more shrinkage than lightweight meshes. Polypropylene meshes have high rates of adhesion and cannot come into contact with bowel, and PTFE has less adhesion risk. Often composite materials are used with a polypropylene side to promote adherence to the abdominal wall and a PTFE side against the viscera. Biologic meshes are composed of acellular collagen matrices that have been derived from either porcine small intestine or human dermis. Using mesh reduces the rate of recurrence but increases the rate of surgical site infections. Traditional teaching was that in a contaminated field (i.e., with a bowel resection or enterotomy), a synthetic mesh could never be used, but newer data show acceptable rates of surgical site infections in select circumstances.

Answer 94

**C** As commonly performed, the open herniorrhaphy technique is a tension-free repair popularized by Irving L. Lichtenstein and colleagues. The **Lichtenstein repair** is routinely performed in an outpatient setting with local anesthesia. A **polypropylene mesh** is most commonly **sutured medially to the transversus abdominis arch, with the internal oblique being overlapped by approximately 2 cm.** The latter edge of the mesh is sutured to the inguinal ligament. To reduce recurrence rates, Parviz Amid has described overlapping the mesh at least 2 cm over the pubic tubercle and 2 to 4 cm lateral to the internal ring. The Lichtenstein repair was one of the first prosthetic repairs to achieve approximately an overall 1% or lower recurrence rate in the United States.

Answer 95

**C** **Abdominal compartment syndrome** is a serious complication that can develop after a separation-of-component hernia repair, especially if there was a large loss of abdominal domain preoperatively. Signs of increasing abdominal hypertension include **elevated peak airway pressures, declining tidal volumes, increasing abdominal distension and firmness, decreasing urine output, and increasing bladder pressures.** **Intraabdominal hypertension** is defined as **sustained pressure \> 12 mmHg,** and **abdominal compartment syndrome is sustained pressures \> 20 mmHg with evidence of end-organ dysfunction**. Since the measurement of intraabdominal pressure can be influenced by many factors, these numbers are taken within a clinical context. The concern is that with increasing abdominal pressure, intraabdominal organs will become ischemic, and it will be difficult to ventilate. The steps to reduce pressure and improve perfusion include **deepening sedation, paralysis, and, as a last resort, reopening the abdomen.**

Answer 96

**A** Laparoscopic techniques for the repair of inguinal hernias were introduced in the 1990s and have gained mild-to- moderate acceptance, with less than 10% of all inguinal hernia repairs being performed via these approaches. The repairs are usually performed with the patient under general anesthesia, and the cost is considerably higher than that of an open approach with local anesthesia and sedation. Although there is controversy regarding its use for unilateral, newly diagnosed hernias, it seems ideally suited for **recurrent and bilateral hernias**, where the disability and technical difficulty associated with open (conventional) repairs cannot be overlooked. Laparoscopy can be performed **totally extraperitoneally by dissecting within the preperitoneal space or transabdominally.** In either case, a **preperitoneal repair** is performed. Mesh fixation devices placed **below the iliopubic tract risk injury to the genitofemoral nerve and the lateral femoral cutaneous nerve**. Placement of fixation devices is also avoided below the internal inguinal ring in an area known as the “triangle of doom.” This triangle is bordered laterally by the spermatic vessels and medially by the vas deferens. Located within this triangle are the external iliac artery and vein and the femoral nerve.

Answer 97

**B** **Parastomal hernias** are a very common problem after stoma formation, affecting up to **30%** of stomas. **Colostomies are more likely to develop hernias** than ileostomies. Hernias can be asymptomatic, painful, cause skin irritation from poorly fitting appliances, or lead to intestinal strangulation. **Only symptomatic parastomal hernias should be repaired.** Stomas should always be formed **through the rectus sheath** with the smallest defect necessary, and placement of a mesh at initial creation is not routine. There are three main methods to repair a parastomal hernia: **relocation, keyhole mesh (either synthetic or biologic), or Sugarbaker repair**—a single mesh is placed underneath the defect and the intestine is lateralized.

Answer 98

**C** Transection of the vas deferens if identified intra-operatively should be repaired with interrupted fine monofilament suture. A crush injury and stretch can damage the vas as well without complete transection. There appears to be a small association between men who had a hernia repair as a child and adult infertility, but the exact mechanism is not defined. Testicular atrophy develops from ischemia caused by an incarcerated hernia or intraoperative injury. It occurs at a rate of 2.6%–5%, but testicles should only be removed for frank necrosis on intraoperative examination. Ischemic orchitis presents as postoperative testicular pain caused by venous thrombosis from the overaggressive handling of the pampiniform plexus. The occurrence is 1% and is managed conservatively with nonsteroidal antiinflammatory drugs (NSAIDs). Ovarian strangulation can be as high as 30% if found within an incarcerated hernia, primarily from ovarian torsion.

Answer 99

**B** A **TAR** is a **newer modification of the Rives-Stoppa retromuscular hernia repair**. Described by Rosen et al., the repair utilizes the retromuscular space. The posterior rectus sheath is entered and the posterior fascia dissected off the muscle laterally. At 0.5 to 1 cm medial to the linea semilunaris, the posterior rectus sheath is incised and the transversus abdominis muscle attachment is cut. The transversus abdominis is cut cranially to the costal margin and caudally into the space of Retzius. Releasing the transversus abdominis creates laxity of the abdominal wall allowing the posterior rectus fascia to be approximated along the midline. A large sublay mesh is placed into the retrorectus space and tacked in place with a few interrupted sutures. Drains are placed, the anterior rectus sheath is approximated, and the skin closed. In comparison to the traditional separation-of-components technique, additional abdominal wall domain is gained without raising large subcutaneous flaps so the blood supply to the abdominal wall is preserved. This avoids the wound complications usually associated with a separation-of-components repair. In the initial study, the long-term recurrence rate was ∼5%.

Answer 100

**E** In the United States, approximately 2 million laparotomies are performed each year, with a reported incisional ventral hernia rate between 2% and 11%. The population of patients in whom wound dehiscence occurs tends to be obese, and they frequently might have one or more of the following: comorbidities of a smoking history, hypertension, and diabetes. Primary incisional ventral hernia repairs have been associated with recurrence rates of up to 50%. Prosthetic mesh repairs have lowered the recurrence rates to less than 10%. Recently, it has been found that a bilayer prosthesis composed of both polypropylene and PTFE can be placed safely in the abdominal cavity without the development of bowel obstruction or enterocutaneous fistulas. Intraabdominal placement of the mesh allows the greatest underlay of the fascial defect, thereby enabling the greatest amount of tissue ingrowth to occur. When polypropylene alone is placed in the intraabdominal cavity, bowel obstruction, enterocutaneous fistula, and difficult reentry to the abdomen occur with an unacceptable frequency. There is increasing evidence of less recurrence with a laparoscopic incisional hernia repair using a mesh. This is typically an onlay with 3 to 5 cm overlap of the fascial defect. Local wound problems seem to be decreased. Lighter synthetic mesh is gaining in popularity. Again, expertise and experience in this advanced laparoscopic procedure are necessary to achieve low recurrence rates and avoid serious complications. A frequent but easily treated complication of a laparoscopic repair is seroma, which can occur in up to 30%–50% of patients. It is usually self-limited. The use of drains to avoid seroma formation is controversial, and it has not been associated with a decrease in its incidence. Aspiration of seromas is best accomplished under image guidance if they are symptomatic or concern about infection exists.

Answer 101

**E** The repair of a recurrent inguinal hernia can be challenging in terms of preventing recurrence and avoiding morbidity such as chronic pain. Tissue-to-tissue repairs may be repaired with an anterior mesh repair such as the Lichtenstein or plug-and-patch repair. Obtaining a prior operative report is strongly recommended to facilitate selection of the appropriate current repair. A laparoscopic repair for recurrence of a hernia after an open anterior mesh repair is supported by prospective trials. The caveat is that such results require expertise and experience in laparoscopic repair. A **Shouldice repair is not generally recommended for recurrent hernias**. A repair by an expert surgeon should allow resumption of all normal activity and is recommended for active individuals. A repair can be deferred if asymptomatic in selected patients.

Answer 102

**D** The component of groin pain or a sports hernia treated by general surgeons is more precisely referred to as **athletic pubalgia**. This is a **tear of the intersection of the rectus abdominis or adductor longus to the pubis from repetitive stress**. The typical populations with athletic pubalgia are participants in **sports with high-speed changes in direction and twisting such as hockey, soccer, wrestling, and football**. They complain of **pain with motion—especially hip adduction**—but there is **no visible bulge as there is no defect in the abdominal wall**. On examination, there is **point tenderness over the pubic tubercle.** The inflammation and tear at the pubis can be identified on **magnetic resonance imaging (MRI)**. **Dynamic ultrasound shows laxity and bulge of the rectus muscle with no distinct hernia.** Nonoperative management includes **rest, physical therapy, and steroid injections**. If nonoperative management fails, then an inguinal hernia repair (open or laparoscopic) can be used to resolve the pain. A hernia repair is thought to support the laxity of the pelvic floor and cause an inflammatory reaction reattaching the torn aponeurosis to the pubic tubercle. Some surgeons perform a nerve transection of the iliohypogastric and ilio-inguinal nerves.

Answer 103

ANSWER: C COMMENTS: Although a primary suture repair with mesh has acceptable recurrence rates for small incisional hernias, recurrence rates are disappointing when these techniques are used for very large hernias. In addition, more complications are associated with a mesh repair of very large hernias either by open or by laparoscopic technique. The separation-of-components technique has demonstrated improved results in the repair of massive incisional hernias, with recurrence rates of approximately 20%. This technique can be used when there is contamination or bowel surgery is required, thereby avoiding the dreaded complication of mesh infection. The separation-of-components technique can be used for failed mesh repairs. In selected cases, the addition of soft synthetic mesh has improved success with the technique.

Answer 104

Answer: B Approximately 75% of abdominal wall hernias occur in the groin. The lifetime risk of inguinal hernia is 27% in men and 3% in women. Of inguinal hernia repairs, 90% are performed in men and 10% in women. The incidence of inguinal hernias in men has a bimodal distribution, with peaks before the first year of life and after age 40. Abramson demonstrated the age dependence of inguinal hernias in 1978. Those between ages 25 and 34 years had a lifetime prevalence rate of 15%, whereas those aged 75 years and over had a rate of 47% (Table 37-1). Approximately 70% of femoral hernia repairs are performed in women; however, inguinal hernias are five times more common than femoral hernias. The most common subtype of groin hernia in men and women is the indirect inguinal hernia. (See Schwartz 10th ed., p. 1495.)

Answer 105

Answer: C Epidemiologic studies have identified risk factors that may predispose to a hernia. Microscopic examination of skin of inguinal hernia patients demonstrated significantly decreased ratios of type I to type III collagen. Type III collagen does not contribute to wound tensile strength as significantly as type I collagen. Additional analyses revealed disaggregated collagen tracts with decreased collagen fiber density in hernia patients’ skin. Collagen disorders, such as Ehlers-Danlos syndrome, are also associated with an increased incidence of hernia formation ( able 37-2). Recent studies have found an association between concentrations of extracellular matrix elements and hernia formation. Although a significant amount of work remains to elucidate the biologic nature of hernias, current evidence suggests they have a multifactorial etiology with both environmental and hereditary influences. (See Schwartz 10th ed., able 37-4, p. 1502.)

Answer 106

Type I Indirect hernia; internal abdominal ring normal; typically in infants, children, small adults Type II Indirect hernia; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotum Type IIIA Direct hernia; size is not taken into account Type IIIB Indirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are usually placed in this category because they are commonly associated with extension to the direct space; also includes pantaloon hernias Type IIIC Femoral hernia Type IV Recurrent hernia; modifiers A–D are sometimes added, which correspond to indirect, direct, femoral, and mixed, respectively

Answer 107

Answer: D Incarceration occurs when hernia contents ail to reduce; however, a minimally symptomatic, chronically incarcerated hernia may also be treated nonoperatively. Taxis should be attempted for incarcerated hernias without sequelae of strangulation, and the option of surgical repair should be discussed prior to the maneuver. To perform taxis, analgesics and light sedatives are administered, and the patient is placed in the Trendelenburg position. The hernia sac is elongated with both hands, and the contents are compressed in a milking fashion to ease their reduction into the abdomen. The indication or emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangulation of hernia contents is a surgical emergency. Clinical signs that indicate strangulation include fever, leukocytosis, and hemodynamic instability. The hernia bulge is usually warm and tender, and the overlying skin may be erythematous or discolored. Symptoms of bowel obstruction in patients with sliding or incarcerated inguinal hernias may also indicate strangulation. Taxis should not be performed when strangulation is suspected, as reduction of potentially gangrenous tissue into the abdomen may result in an intra-abdominal catastrophe. Preoperatively, the patient should receive fluid resuscitation, nasogastric decompression, and prophylactic intravenous antibiotics. (See Schwartz 10th ed., p. 1505.)

Answer 108

Answer: B In cases where the viability of sac contents is in question, the sac should be incised, and hernia contents should be evaluated for signs of ischemia. The defect should be enlarged to augment blood low to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents should be resected, and synthetic prostheses should be avoided in the repair. In elective cases, the sac may be amputated at the internal inguinal ring or inverted into the pre-peritoneum. Both methods are effective; however, patients undergoing sac excision had significantly increased postoperative pain in a prospective trial. Dissection of a densely adherent sac may result in injury to cord structures and should be avoided; however, sac ligation at the internal inguinal ring is necessary in these cases. A hernia sac that extends into the scrotum may require division within the inguinal canal, as extensive dissection and reduction risks injury to the pampiniform plexus, resulting in testicular atrophy and orchitis. At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of tissue-based and prosthetic-based reconstructions. (See Schwartz 10th ed., p. 1505.)

Answer 109

Answer: C The McVay repair addresses both inguinal and femoral ring defects. This technique is indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated (Fig. 37-1). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the pre- peritoneal space. The upper lap is mobilized by gentle blunt dissection of underlying tissue. Cooper ligament is bluntly dissected to expose its surface. A 2- to 4-cm relaxing incision is made in the anterior rectus sheath vertically from the pubic tubercle. This incision is essential to reduce tension on the repair; however, it may result in increased postoperative pain and higher risk of ventral abdominal herniation. Using either interrupted or continuous suture, the superior transversalis flap is then fastened to Cooper ligament, and the repair is continued laterally along Cooper ligament to occlude the femoral ring. Lateral to the femoral ring, a transition stitch is placed, affixing the transversalis fascia to the inguinal ligament. The transversalis is then sutured to the inguinal ligament laterally to the internal ring. (See Schwartz 10th ed., Figure 37-17, pp. 1507–1508.)

Answer 110

Answer: B Laparoscopic inguinal hernia repairs reinforce the abdominal wall via a posterior approach. Principal laparoscopic methods include the transabdominal preperitoneal (TAPP) repair, the totally extraperitoneal (TEP) repair, and the less commonly performed intraperitoneal onlay mesh (IPOM) repair. Although laparoscopic repairs in experienced hands are relatively expedient, they necessitate the administration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair. Occasionally, general anesthesia induction may result in reduction of an incarcerated or strangulated inguinal hernia. If the surgeon suspects this might have occurred, the abdomen should be explored or nonviable tissue either via laparoscopy or upon conversion to an open laparotomy. (See Schwartz 10th ed., p. 1509.)

Answer 111

Answer: D When a patient develops pain, bulging, or a mass at the site of an inguinal hernia repair, clinical entities such as seroma, persistent cord lipoma, and hernia recurrence should be considered. Common medical issues associated with recurrence include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical causes of recurrence include improper mesh size, tissue ischemia, infection, and tension in the reconstruction. A focused physical examination should be performed. As with primary hernias, ultrasound, (CT), or magnetic resonance imaging (MRI) can elucidate ambiguous physical findings. When a recurrent hernia is discovered and warrants reoperation, an approach through a virgin plane facilitates its dissection and exposure. Extensive dissection of the scarred field and mesh may result in injury to cord structures, viscera, large blood vessels, and nerves. After an initial anterior approach, the posterior laparoscopic approach will usually be easier and more effective than another anterior dissection. Conversely, failed preperitoneal repairs should be approached using an open anterior repair. (See Schwartz 10th ed., p. 1514.)

Answer 112

Answer: A Pain after inguinal hernia repair is classified into acute or chronic manifestations of three mechanisms: nociceptive (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain is reproduced with abdominal muscle contraction Treatment consists of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and reassurance, as it resolves spontaneously in most cases. Neuropathic pain occurs as a result of direct nerve damage or entrapment. It may present early or late, and it manifests as a localized, sharp, burning, or tearing sensation. It may respond to pharmacologic therapy and to local steroid or anesthetic injections when indicated. Visceral pain refers to pain conveyed through afferent autonomic pain fibers. It is usually poorly localized and may occur during ejacula- tion as a result of sympathetic plexus injury. (See Schwartz 10th ed., p. 1514.)

Answer 113

Answer: B The preperitoneal anatomy seen in laparoscopic hernia repair led to characterization of important anatomic areas of interest, known as the triangle of doom, the triangle of pain, and the circle of death (Fig. 37-2). The triangle of doom is bordered medially by the vas deferens and laterally by the vessels of the spermatic cord. The contents of the space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital branch of the genitofemoral nerve. The triangle of pain is a region bordered by the iliopubic tract and gonadal vessels, and it encompasses the lateral femoral cutaneous, femoral branch of the genitofemoral, and femoral nerves. The circle of death is a vascular continuation formed by the common iliac, internal iliac, obturator, inferior epigastric, and external iliac vessels. (See Schwartz 10th ed., able 37-9, pp. 1499 and 1501.)

Answer 114

Answer: A The most common cause of urinary retention after hernia repair is general anesthesia, which is routine in laparoscopic hernia repairs. Among 880 patients undergoing inguinal hernia repair with local anesthesia only 0.2% developed urinary retention, whereas the rate of urinary retention was 13% among 200 patients undergoing repair with general or spinal anesthesia. Other risk factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative bladder distention. Initial treatment of urinary retention requires decompression of the bladder with short-term catheteriza- tion. Patients will generally require an overnight admission and trial of normal voiding before discharge. Failure to void normally requires reinsertion of the catheter for up to a week. Chronic requirement of a urinary catheter is rare, although older patients may require prolonged catheterization. (See Schwartz 10th ed., p. 1515.)

Answer 115

Answer: C Although controversy persists regarding the utility of TEP versus TAPP, reviews to date find no significant differences in operative duration, length of stay, time to recovery, or short-term recurrence rate between the two approaches. In TAPP repair, the risk of intra-abdominal injury is higher than in TEP repair. This finding prompted the International Endohernia Society (IEHS) to recommend that TAPP should only be attempted by surgeons with sufficient experience. A Cochrane systematic review found that rates of port-site hernias and visceral injuries were higher for the TAPP technique, whereas TEP may be associated with a higher rate of conversion to an alternative approach; however, neither finding was sufficiently compelling to recommend one technique over the other. (See Schwartz 10th ed., p. 1517.)

Answer 116

Answer: B Approximately 75% of abdominal wall hernias occur in the groin. The lifetime risk of inguinal hernia is 27% in men and 3% in women. Of inguinal hernia repairs, 90% are performed in men and 10% in women. The incidence of inguinal hernias in men has a bimodal distribution, with peaks before the first year of age and after age 40. Abramson demonstrated the age dependence of inguinal hernias in 1978. Those between 25 and 34 years had a lifetime prevalence rate of 15%, whereas those aged 75 years and over had a rate of 47% ( able 37-1). Approximately 70% of femoral hernia repairs are performed in women; however, inguinal hernias are five times more common than femoral hernias. The most common subtype of groin hernia in men and women is the indirect inguinal hernia. (See Schwartz 10th ed., p. 1495.)

Answer 117

Answer: A Inguinal hernias may be congenital or acquired. Most adult inguinal hernias are considered acquired defects in the abdominal wall although collagen studies have demonstrated a heritable predisposition. A number of studies have attempted to delineate the precise causes of inguinal hernia formation; however, the best-characterized risk factor is weakness in the abdominal wall musculature (Table37-4). Congenital hernias, which make up the majority of pediatric hernias, can be considered an impedance of normal development, rather than an acquired weakness. During the normal course of development, the testes descend from the intra-abdominal space into the scrotum in the third trimester. Their descent is preceded by the gubernaculum and a diverticulum of peritoneum, which protrudes through the inguinal canal and becomes the processus vaginalis. Between 36 and 40 weeks of gestation, the processus vaginalis closes and eliminates the peritoneal opening at the internal inguinal ring. Failure of the peritoneum to close results in a patent processus vaginalis (PPV), hence the high incidence of indirect inguinal hernias in preterm babies. Children with congenital indirect inguinal hernias will present with a PPV; however, a patent processus does not necessarily indicate an inguinal hernia (Fig.37-3). In a study of nearly 600 adults undergoing general laparoscopy, bilateral inspection revealed that 12% had PPV. None of these patients had clinically signiicant symptoms of a groin hernia. In a group of 300 patients undergoing unilateral laparoscopic inguinal hernia repair, 12% were found to have a contralateral PPV, which was associated with a fourfold 5-year incidence of inguinal hernia. (See Schwartz 10th ed., able 37-3 and Figure 37-10, pp. 1500 and 1502.)

Answer 118

Answer: C Other chronic pain syndromes include local nerve entrapment, meralgia paresthetica, and osteitis pubis. At greatest risk of entrapment are the ilioinguinal and iliohypogastric nerves in anterior repairs and the genitofemoral and lateral femoral cutaneous nerves in laparoscopic repairs. Clinical manifestations of nerve entrapment mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthetica, a condition characterized by persistent paresthesias of the lateral thigh. Initial treatment of nerve entrapment consists of rest, ice, NSAIDs, physical therapy, and possible local corticosteroid and anesthetic injection. Osteitis pubis is characterized by inflammation of the pubic symphysis and usually presents as medial groin or symphyseal pain that is reproduced by thigh adduction. Avoiding the pubic periosteum when placing sutures and tacks reduces the risk of developing osteitis pubis. CT scan or MRI excludes hernia recurrence, and bone scan is confirmatory or the diagnosis. Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought or possible bone resection and curettage. Irrespective of treatment, the condition often takes 6 months to resolve. (See Schwartz 10th ed., p. 1515.)

Answer 119

Answer: A The incidence of recurrence is the most-cited measure of postoperative outcome following inguinal hernia repair. In evaluating the various available techniques, other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various approaches to inguinal hernia repair. Among tissue repairs, the Shouldice operation is the most commonly performed technique, and it is most frequently executed at specialized centers. A 2012 meta-analysis from the Cochrane Database demonstrated significantly lower rates of hernia recurrence (odds ratio [OR] 0.62, confidence interval [CI] 0.45–0.85) in patients undergoing Shouldice operations when compared with other open tissue-based methods. In experienced hands, the overall recurrence rate or the Shouldice repair is about 1%. Although it is an elegant procedure, its meticulous nature requires significant technical expertise to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4 to 2.5% after surgeons performed the repair six times. Compared with mesh repairs, the Shouldice technique resulted in significantly higher rates of recurrence (OR3.65,CI1.79–7.47); however, it is the most effective tissue-based repair when mesh is unavailable or contraindicated. Hernia recurrence is drastically reduced as a result of the Lichtenstein tension-free repair. Compared with open elective tissue-based repairs, mesh repair is associated with fewer recurrences (OR 0.37, CI 0.26–0.51) and with shorter hospital stay and faster return to usual activities. In a multi- institutional series, 3019 inguinal hernias were repaired using the Lichtenstein technique, with an overall recurrence rate of 0.2%. Among other tension-free repairs, the Lichtenstein technique remains the most commonly performed procedure worldwide. Meta-analysis demonstrates no significant differences in outcomes between the Lichtenstein and the plug and patch techniques; however, intra-abdominal plug migration and erosion into contiguous structures occurs in approximately 6% of cases. The Stoppa technique results in longer operative duration than the Lichtenstein technique. Nevertheless, postoperative acute pain, chronic pain, and recurrence rates are similar between the two methods. Perhaps the most compelling advantage of the Lichtenstein technique is that nonexpert surgeons rapidly achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilateral inguinal hernias as the preferred open technique. (See Schwartz 10th ed., p. 1516.)

Answer 120

Answer: B Inguinal hernias may compress adjacent nerves, leading to generalized pressure, localized sharp pain, and refferred pain. Pressure or heaviness in the groin is a common complaint, especially at the conclusion of the day or following prolonged activity. Sharp pain tends to indicate an impinged nerve and may not be related to the extent of physical activity performed by the patient. Neurogenic pain may be referred to the scrotum, testicle, or inner thigh. Questions should be directed to elicit and characterize extrainguinal symptoms. A change in bowel habits or urinary symptoms may indicate a sliding hernia consisting of intestinal contents or involvement of the bladder within the hernia sac. (See Schwartz 10th ed., p. 1503.)

Answer 121

1. (E) Inguinal hernias in infancy are almost always congenital and indirect and are often bilateral. Bilateral exploration is recommended, except when the surgery is performed for incarceration.

Answer 122

(A) Hernias, which present in **adult life** are most often **direct and aquired**, rather than indirect. They protrude through the transversalis fascia, which forms the medial half of the posterior wall of the inguinal canal and is located medial to the deep inguinal ring and deep epigastric vessels. Strangulation of direct inguinal herniae is uncommon, probably because the neck of the sac tends to be wide, rather than narrow and constricting.

Answer 123

(A) **Direct hernias** are more common in **older patients**. There is an increased incidence in patients with a **chronic cough** and **prostatic obstruction**. They are rarely encountered in children and women. This type of hernia does not extend to the scrotum and rarely undergoes strangulation.

Answer 124

(A) Indirect inguinal hernia sacs are found less commonly in female patients. They are formed by the **unobliterated processus vaginalis of the peritoneum** and allow for the entry of intraperitoneal viscera, such as loops of small intestine, omentum, and the likes. Compromise of blood supply by constriction leads to strangulation.

Answer 125

(A) Traditional hernia repair is performed under local or general anesthesia. Laparoscopic repair, in general, is performed under general anesthesia. Combinations of local anesthesia and intravenous sedation are in routine use. Orchiectomy, though occasionally used in special circumstances, is by no means a routine part of hernia repair. Exploration of the opposite groin, though recommended in infants, does not apply to adults.

Answer 126

(E) In **Richter’s hernia**, **part of the bowel wall** is entrapped in the hernia sac. This results in a partial occlusion of the lumen and bowel movement remains possible, despite strangulation and gangrene of the entrapped portion. Evaluation at surgery, of the viability of the full-bowel wall must always be carried out before returning the entrapped segment to the peritoneal cavity.

Answer 127

(C) The term **sliding** refers to the *peritoneum that slides along with the hernia* in its passage along the cord (Fig. 8–4). The viscus forms part of the wall of the sac. The peritoneum should not be removed from the bowel wall, because devascularization may occur.

Answer 128

(A) Any of these nerves may be divided, crushed, or entrapped by suture or mesh during repair of a groin hernia. The **lateral femoral cutaneous nerve** is vulnerable especially during laparoscopic hernia repair.

Answer 129

(A) All are normal and constant anatomic structures of the inguinal canal.

Answer 130

(B) The **femoral vein** lies **immediately lateral to the femoral canal.** Careful attention to this structure is essential in repair of femoral herniae.

Answer 131

(D) Unexplained recent onset of swelling in the groin, that is not reducible, should be considered to be a strangulated inguinal or femoral hernia until proved otherwise. Needle aspiration may cause fecal perforation and forceful manual reduction may result in the return of gangrenous bowel to the peritoneal cavity

Answer 132

(E) Strangulated **femoral hernia is located below and lateral to the pubic tubercle** and is more common in **females**. Inguinal hernias occur in similar frequency in females, but compared to femoral hernias, they are less likely to undergo strangulation.

Answer 133

(D) This patient has a strangulated femoral hernia. **Emergency surgery** after appropriate resuscitation is the correct treatment. Gangrene of strangulated bowel may be present. No attempt at manual reduction should be made, because gangrenous bowel may be returned to the peritoneal cavity.

Answer 134

(E) As many as **90% of umbilical herniae up to 1.5 cm** in diameter **will not be clinically evident by the age of 5 years.**

Answer 135

(A) Strangulation of a bowel loop may occur at the **obturator fossa**, **classically following weight loss**, which results in loss of the fat pad that covers the area, superiorly, where the obturator membrane is deficient. This allows entry and strangulation of a bowel loop. Compression of the obturator nerve causes the pain down the medial side of the thigh. CT scan with contrast may show the level of obstruction.

Answer 136

(E) **Epigastric hernia** is a **defect in the linea alba between the umbilicus and the xiphisternum.** It usually contains preperitoneal fat rather than omentum or bowel. It may cause pain and is commonly encountered in older patients. Sometimes it is located on either side of the midline. **Spigelian hernia** occurs **lateral to the linea semilunaris.**

Answer 137

(A) Repair can be performed laparoscopically, under general anesthesia, following adequate preoperative medical preparation. Patients are more comfortable following adequate repair. Modern mesh is of much improved quality and recurrence has become much less common.

Answer 138

(E) The **lateral femoral cutaneous nerve** is visible in the laparoscopic approach to hernia repair. This nerve can be injured in **placement of the mesh** used for repair, especially if staples are used. Great care must be taken to avoid this injury, which causes **severe burning pain and paresthesia of the thigh** and is very disabling. Injury is not likely if staples are not inserted lateral to the deep inguinal ring.

Answer 139

(D) In omphalocele (see Fig. 8–5), the swelling is covered by a membrane formed by the peritoneum, Wharton’s jelly, and amnion. The membrane is transparent, and underlying intestine can be seen. The other features listed are characteristic of gastroschisis. In gastroschisis, the protrusion is not covered by a membrane and the other features listed apply.

Answer 140

(D) **Spigelian hernia** occurs at the **semilunar line, which extends along the lateral border of each rectus abdominis muscle.** The posterior rectus sheath is deficient **at the level of the arcuate line (semicircular line)** about one-third of the distance between the umbilicus and the pubic symphysis; this is the **most common site for Spigelian hernia** to occur through the linea semilunaris. It occurs in **both sexes**. The Bassini technique refers to inguinal hernias only. A hernia that involves part of the bowel wall is known as a Richter’s hernia. The appendix may or may not form part of the contents of the sac.

Answer 141

(B) Patients who have symptoms suggestive of **change in bowel habits** will require a b**arium enema or colonoscopy.** It is important **not to overlook an underlying carcinoma**, which could cause the patient to strain and induce a hernia. Carcinoma and/or polyps may be overlooked if this approach is ignored.