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Question 1

Hernia

Answer 1

Hernias are abnormal protrusions of a viscus (or part of it) through a weak normal or abnormal opening in a cavity that involves it, e.g., the abdomen.

Question 2

Factors leading to hernia include:

Answer 2

Increased pressure, e.g., from lifting heavy weights, constipation, pregnancy, etc.
• Weakness in the walls of the cavity, e.g., due to aging, congenital diseases like Marfan syndrome and Ehlor-Danlos syndrome (both connective tissue diseases), trauma, surgery, etc.

Question 3

Types of hernia: in general

Types of hernia :(location)

Answer 3

Congenital and Acquired

Umbilical, paraumbilical, Spigelian, epigastric, lumbar, inguinal (most common), incisional, femoral.

Question 4

extending between the deep inguinal ring and superficial inguinal rings

Answer 4

Inguinal canal

deep inguinal ring (a hole in the transversalis fascia) and superficial inguinal rings (a hole in the aponeurosis of the external oblique)

Question 5

is an oval opening in the fascia transversalis.

It is the beginning of the inguinal canal and is at a point midway between the ASIS and the pubic symphysis; it is just above the inguinal ligament and immediately lateral to the inferior epigastric vessels.

Answer 5

Deep inguinal ring

Question 6

inguinal ring is a triangular (with the apex pointing above and the base being below)

defect in the EOA immediately above and medial to the pubic tubercle, and is composed of medial and lateral crus joined together by intercrural fibers.

Answer 6

Superficial inguinal ring

Question 7

lie just medial to the deep inguinal ring

Answer 7

Inferior epigastric vessels

Question 8

The inferior epigastric vessels lie just medial to the deep inguinal ring, passing from the iliac vessels to rectus abdominis

Answer 8

they’re used as a landmark to classify inguinal hernia types

Question 9

The inguinal canal contains

Answer 9

the spermatic cord in males and the round ligament in females (and it also contains the ilioinguinal nerve, L1)

Question 10

During development, independently from descent of the testis, the peritoneum of the abdominal cavity forms an evagination,, on each side of the midline into the ventral abdominal wall.

Answer 10

called the processus vaginalis,

Question 11

Inguinal hernias can be categorized into two types These two basic types are fundamentally different

Answer 11

anatomy, causation and complications.

Question 12

deep inguinal ring

This type is more common.

congenital inguinal hernia

the processes vaginalis should obliterate under hormonal control

Inguinal hernia in neonates and young children

muscles around the deep inguinal ring can prevent a hernia from developing until later in life, when, under the constant positive abdominal pressure, the deep inguinal ring and muscles are stretched and a hernia becomes apparent

oblique in its path

Answer 12

Indirect inguinal hernia

Question 13

weakness in the posterior wall of the canal, termed Hesselbach’s triangle

Answer 13

Direct inguinal hernia

Question 14

medial to the inferior epigastric vessels

acquired

stretching and weakening of the abdominal wall just medial to the inferior epigastric (IE) vessels.

is more likely in elderly patients

broadly based and therefore unlikely to strangulate.

Answer 14

Direct inguinal hernia

Question 15

the names “indirect” and “direct” come from how the hernia is

Answer 15

Reduced

Question 16

examination can differentiate the two types of swelling

Answer 16

Can you get above the swelling?

Question 17

Possibly get above the swelling

Answer 17

Hydrocele

Question 18

which is used to distinguish direct and indirect hernia.

Answer 18

Occlusion test

Question 19

an inch above the inguinal ligament

above and medial to the pubic tubercle

below and lateral to the pubic tubercle.

Answer 19

Deep inguinal ring
Superficial inguinal ring
Femoral ring

Question 20

Do occlusion test!!!!!

Answer 20

1) The patient is asked to lie down (supine) and reduce the hernia
2) After reduction, the thumb is placed over deep ring to occlude it and the patient is asked to cough.

Deep inguinal ring blocked and swelling appeared – Direct inguinal hernia
• Deep inguinal ring locked and swelling did not appear – indirect inguinal hernia

Question 21

is done to differentiate between direct, indirect, or femoral hernia

Answer 21

Zeimans test (three finger test)

Question 22

Do zeimans test

Answer 22

The hernia should be reduced first. The examiner stands on the side of the hernia and puts their index, middle and ring finger over the deep ring, superficial ring, and femoral region respectively. The patient is asked to cough and impulse is felt:
• At index finger à indirect
• At middle finger à direct
• At ring finger à femoral

Examine inguinal lymphnode as well as the lesion might be scrotal swelling

Question 23

Examination of inguinal hernia technique

Question 24

How hernia is managed

Answer 24

Surgically

Open surgery or laparscopy

Question 25

Herniotomy
 Herniorrhaphy:
 Hernioplasty:

Answer 25

Herniotomy: removal of the hernial sac only
 Herniorrhaphy: herniotomy plus repair of the posterior wall of the inguinal canal
 Hernioplasty: herniotomy plus reinforcement of the posterior wall of the inguinal canal with a
synthetic mesh

Question 26

The most common adverse events following hernia repair with mesh

Answer 26

pain, infection, hernia recurrence, adhesion, and bowel obstruction.

Question 27

Symptoms of inguinal hernia

Answer 27

 A painless reducible bulging.
 Indirect inguinal hernia may be congenital and appear in infancy or childhood (patent processus vaginalis)
 Groin discomfort or pain. The discomfort may be worse on bending or lifting. Relieved with lying down
 Heaviness in groin and scrotum
 Irreducible bulging without obstruction(adhesion)  Obstruction of the contents of the sac:
sudden pain, nausea, and vomiting

Symptoms of an inguinal hernia-continue
 (strangulation) if the blood supply compromised lead to ischemia of the contents with severe pain, tenderness, fever and tachycardia plus signs and symptoms of intestinal obstruction.
 Inflammation of hernia contents like appendicitis and salpingitis  Direct hernia sac rarely descend to scrotum
 Direct inguinal hernia is always acquired

Question 28

Strangulation symptoms

Answer 28

if the blood supply compromised lead to ischemia of the contents with severe pain, tenderness, fever and tachycardia plus signs and symptoms of intestinal obstruction.

Question 29

Howww is Diagnosis of herniaa

Answer 29

 Clinical history and examination is sufficient for almost all cases  In rare cases when diagnosis can not be done clinically
- Ultrasound by an expert if still not obvious - MRI with Valsalva
- Herniography (a contrast study)
Note: Herniography and MRI are rarely done, even if the clinical features are not obvious and US isn’t helpful. Investigations are rarely used, aside from ones used to prepare for surgery

Question 30

With this technique, you use one port that has all three openings.)

Answer 30

NOTES