Inguinal Hernias

Question 1

A hernia is when an organ or body part protrudes through a muscle or wall that normally contains it. Which type of the following hernias are more common?

1 - incisional hernia
2 - inguinal hernia
3 - femoral hernia
4 - umbilical hernia

Answer 1

2 - inguinal hernia

• 70,000 of the total hernias are inguinal per year

Question 2

Do hernias increase or decrease with age?

Answer 2

• increase

Question 3

Are inguinal hernias more common in men or women?

Answer 3

• men = 27% lifetime risk
• women = 3% lifetime risk

Question 4

Which of the following is NOT a typical risk factor for an inguinal hernia?

1 - age
2 - patent processus vaginalis
3 - connective tissue variations
4 - body mass index
5 - smoking
6 - lifting and standing

Answer 4

5 - smoking

Question 5

What is the relationship between BMI and inguinal hernias in a BMI <35?

1 - high BMI = higher risk
2 - high BMI = lower risk
3 - BMI not linked to risk
4 - high and low BMI increase risk

Answer 5

2 - high BMI = lower risk

• a lower BMI increases risk of inguinal hernia
• BUT BMI >35 increases risk

Question 6

From the outside of the abdomen/groin area there are a number of layers. Organise the layers below from inside to outside?

1 - aponeurosis of the external oblique muscle
2 - transversalis fascia
3 - peritoneum
4 - transversalis muscle
5 - external oblique muscle
6 - peritoneum fat
7 - internal oblique muscle

Answer 6

1 - peritoneum
2 - peritoneum fat
3 - transversalis fascia
4 - transversalis muscle
5 - internal oblique muscle
6 - external oblique muscle
7 - aponeurosis of the external oblique muscle

Question 7

The aponeurosis of which muscle forms the inguinal ligament?

1 - transversalis muscle
2 - internal oblique muscle
3 - external oblique muscle
4 - rectus abdominus

Answer 7

3 - external oblique muscle

• rolls up forming the inguinal canal as well

Question 8

The external oblique muscles form the aponeurosis that attaches the muscle to the pelvis forming the inguinal ligament. Which 2 of the following are the important attachment sites for the inguinal ligament?

1 - pubic symphysis
2 - pubic tubercle
3 - anterior superior iliac spine
4 - posterior superior iliac spine

Answer 8

2 - pubic tubercle
3 - anterior superior iliac spine

Question 9

The inguinal ligament, formed by the external oblique muscles rolls up and forms the inguinal canal, which allows spermatic cord (from the scrotum to the pelvis) in males and in females, it contains the round ligament of the uterus and the ilioinguinal nerve. Label the roof, floor, anterior and posterior walls of the inguinal canal using the labels below:

• aponeurosis of the external oblique (reinforced by internal oblique muscle laterally)
• inguinal ligament
• transversalis fascia, internal oblique, and transversus abdominis
  – transversalis fascia

Answer 9

• anterior wall = aponeurosis of the external oblique (reinforced by internal oblique muscle laterally)
• posterior wall = transversalis fascia
• roof = transversalis fascia, internal oblique, and transversus abdominis
• floor = inguinal ligament

Question 10

During development there is a ligament that is important for dragging male and female organs down into the posterior aspect of the groin. What is the name of this ligament?

1 - round ligament
2 - falciform ligament
3 - gubernaculum ligament
4 - cardinal ligament

Answer 10

3 - gubernaculum ligament

Question 11

During development the gubernaculum ligament is important for dragging male and female organs down into the posterior aspect of the groin. What does this then become in males?

1 - round ligament
2 - falciform ligament
3 - gubernaculum testis ligament
4 - cardinal ligament

Answer 11

3 - gubernaculum testis ligament

• eventually forms the gubernaculum testis (“scrotal ligament”
• attaches testes to scrotum

Question 12

During development the gubernaculum ligament is important for dragging male and female organs down into the posterior aspect of the groin. What does it become in females?

1 - round ligament
2 - ovarian ligament
3 - gubernaculum testis ligament
4 - cardinal ligament

Answer 12

1 - round ligament
2 - ovarian ligament

• ovarian connects ovaries to side of uterus
• round connects uterus to labia majora

Question 13

As the gubernaculum moves down through the inguinal canal thanks to a physiological herniation of the abdominal wall, called what?

1 - processus vaginalis
2 - round ligament
3 - labia majora
4 - vas deferens

Answer 13

1 - processus vaginalis

• developmental out pouching of the parietal peritoneum

Question 14

The processus vaginalis is a developmental out pouching of the parietal peritoneum. The gubernaculum moves down through the processus vaginalis into the inguinal canal and to where the male and female reproductive organs are located. If the processus vaginalis does not seal properly in development it can lead to all of the following except which one?

1 - hydrocele
2 - hematocele
3 - direct inguinal hernia
4 - testicular torsion
5 - indirect inguinal hernia

Answer 14

3 - direct inguinal hernia

Question 15

The inguinal canal has 2 openings, the deep and superficial inguinal ring. Which of the following is the anatomical marker for locating the deep inguinal ring?

1 - mid inguinal point
2 - 2cm medially to pubic symphysis
3 - 2cm laterally to pubic tubercle
4 - midpoint of inguinal ligament

Answer 15

4 - midpoint of inguinal ligament

Question 16

The midpoint of inguinal ligament is the location of the deep inguinal ring and is often confused with the mid inguinal point. What important structure can be located at the mid inguinal point?

1 - femoral vein
2 - femoral artery
3 - femoral nerve
4 - femoral lymphatics

Answer 16

2 - femoral artery

Question 17

When we talk about inguinal hernias they can be direct or indirect. In an indirect inguinal hernia where does the problem occur?

1 - inguinal canal
2 - deep inguinal ring
3 - Hasselbachs triangle
4 - superficial ring

Answer 17

2 - deep inguinal ring

• normally due to in-proper closure of the processus vaginalis
• protrusion can also pass through superficial ring

Question 18

When we talk about inguinal hernias they can be direct or indirect. In a direct inguinal hernia where does the problem occur?

1 - inguinal canal
2 - deep inguinal ring
3 - Hasselbachs triangle
4 - superficial ring

Answer 18

3 - Hasselbachs triangle

• protrusion can also pass through superficial ring

Question 19

Hasselbachs triangle, also known as the inguinal triangle contains not contain any clinical structures of importance, so why is this triangle important?

1 - locate femoral artery
2 - locate deep inguinal ring
3 - area of potential abdominal weakness
4 - strongest part of abdomen)

Answer 19

3 - area of potential abdominal weakness

Question 20

Hasselbachs triangle, also known as the inguinal triangle is an area of potential abdominal weakness. Which of the following is NOT part of the medial, lateral or inferior borders?

1 - lateral border of the rectus abdominis muscle.
2 - inferior epigastric vessels
3 - femoral artery
4 - inguinal ligament

Answer 20

3 - femoral artery

Question 21

Is a direct or indirect hernia more common?

Answer 21

• indirect accounts for 75% of inguinal hernias
• generally congenital due to poor closure of the processus vaginalis

Question 22

Although inguinal hernias can be asymptomatic, which of the following is NOT a common symptom?

1 - Groin pain
2 - bulge/lump in the groin (reducible (or not)
3 - referred pain to testicle or thigh
4 - can be worse after physical activity
5 - can cause bowel or bladder symptoms
6 - hematuria
7 - reduction may provide temporary relief of symptoms

Answer 22

6 - hematuria

Question 23

Why do we examine the groin with patients standing and lying?

1 - to assess mobility
2 - to see if any masses may reduce spontaneously
3 - to assess patients pain levels

Answer 23

2 - to see if any masses may reduce spontaneously

Question 24

Which of the following is NOT part of a groin examination if a hernia is inspected?

1 - ask patient to stand and lie down
2 - reduce or ask patient to reduce hernia
3 - biopsy
4 - ask patient to cough
5 - apply pressure to deep inguinal ring

Answer 24

3 - biopsy

Question 25

When trying to differentiate between a direct and indirect inguinal hernia we can apply pressure over the deep inguinal ring to see if the hernia can be controlled here. Where would we apply pressure for this?

1 - mid inguinal point
2 - 2cm medially to pubic symphysis
3 - 2cm laterally to pubic tubercle
4 - midpoint of inguinal ligament

Answer 25

4 - midpoint of inguinal ligament

• direct inguinal hernias cannot be controlled like this

Question 26

When we look at hasselbachs triangle in the image here, can the direct or indirect inguinal hernia be located medially or laterally to the epigastric artery?

Answer 26

• direct = medially and inferior
• indirect - laterally

Question 27

Which of the following is NOT a common differential for an inguinal hernia?

1 - femoral hernia
2 - testicular pathology
3 - lymph node
4 - merkels diverticulum
5 - malignancy
6 - vascular abnormality
7 - psoas abscess

Answer 27

4 - merkels diverticulum

Question 28

There is a lymph node located very close to inguinal canal that can often be mistaken for an inguinal hernia. What is this lymph node called?

1 - popliteal node
2 - virchows lymph node
3 - sister josephs node
4 - cloquet node

Answer 28

4 - cloquet node

• sister josephs node = umbillicus lymph node
• virchows lymph node = supraclavicular lymph node

Question 29

When assessing inguinal hernias there are a number of potential pathologies. Which of the following is NOT commonly associated with the testes?

1 - undescended testicle
2 - epididymal cyst
3 - hydrocele
4 - indirect inguinal hernia
5 - varicocele
6 - lipoma of spermatic cord

Answer 29

4 - indirect inguinal hernia

• a direct inguinal hernia may be present

Question 30

Although diagnosing a hernia is predominantly clinical, or even surgical, which of the following imaging is 1st line choice?

1 - ultrasound
2 - CT
3 - MRI
4 - PET scan

Answer 30

1 - ultrasound

• 10-15% of hernias still missed
• CT and MRI can rule out pathology

Question 31

If a patient has an inguinal hernia and is treated conservatively, what is the distinguishing factor that determines if they undergo surgery or not?

1 - risk of chronic pain following surgery
2 - support belt not available
3 - increased risk of strangulation
4 - unable to continue ADLs

Answer 31

4 - unable to continue ADLs

Question 32

If a patient requires surgery for an inguinal hernia they can undergo a laparotomy or laparoscopic operation. The principles of surgery are:

1 - Isolate sac
2 - reduce the sac contents
3 - reduce or excise sac
4 - close the defect without tension

Answer 32

• can include the use of a mesh
• porcine mesh is most commonly used
• BUT mesh can increase risk of haematoma, seroma and infectio

Question 33

Following surgery for an inguinal hernia, how long are patients advised to avoid heavy lifting or exertion?

1 - 4-6 hours
2 - 4-6 days
3 - 4-6 weeks
4 - 4-6 months

Answer 33

3 - 4-6 weeks

Question 34

If a hernia is strangulates should you try to reduce it?

Answer 34

• no
• it will be very warm, painful and have skin changes

Question 35

What is the recurrence rate of inguinal hernias?

1 - 0.15%
2 - 1.5%
3 - 15%
4 - 75%

Answer 35

3 - 15%

• mesh infection = <1%
• chronic pain <10%
• nerve injury and haematoma can occur

Question 36

A rare but late complication of a hernia repair is chronic groin pain. This is often due to inadvertently trapping which nerve?

1 - ilioinguinal nerve
2 - genitofemroal nerve
3 - sciatic nerve
4 - vagus nerve

Answer 36

1 - ilioinguinal nerve

Question 37

A rare but late complication of a hernia repair is testicular atrophy. This is often due to damage of which artery?

1 - vas deferens artery
2 - cremasteric artery
3 - testicular artery
4 - inferior mesenteric artery

Answer 37

3 - testicular artery

• normally due to narrowing of the deep inguinal ring

Question 38

Inguinal hernias can be asymptomatic, or cause the following clinical presentations: groin pain, bulge/lump in the groin (reducible (or not), referred pain to testicle or thigh, can be worse after physical activity, can cause bowel or bladder symptoms and a reduction may provide temporary relief of symptoms. Which 2 of the following cases are classes as a medical emergency with an inguinal hernia?

1 - incarceration
2 - severe pain
3 - strangulation
4 - fever

Answer 38

1 - incarceration
3 - strangulation

• can lead to obstructions and or ischaemia of bowel
• generally need an operation within 4 hours

Question 39

When we talk about emergency presentations of an inguinal hernia we talk about the sac being incarcerated. What does this mean?

1 - bowels within sac are blocked
2 - sac cannot be reduced, but is not affecting bowel movements or blood flow
3 - blood flow in sac is impaired

Answer 39

2 - sac cannot be reduced, but is not affecting bowel movements or blood flow

• can be painful
• bowel can become obstructed
• if pressure inside sac exceeds venous blood flow can become very dangerous and need surgery

Question 40

When we talk about emergency presentations of an inguinal hernia we talk about the sac being strangulated. What does this mean?

1 - bowels within sac are blocked
2 - sac cannot be reduced, but is not affecting bowel movements or blood flow
3 - blood flow in sac is impaired

Answer 40

3 - blood flow in sac is impaired

• incredibly painful
• irreducible
• bowel obstructed
• systemically unwell
• REQUIRES EMERGENCY PROCEDURE