Hernias

Question 1

Direct and indirect inguinal hernias

Answer 1

• Direct: directly through the posterior wall of the inguinal canal. Medial to inferior epigastric vessels.
• Indirect: into the inguinal canal through the deep inguinal ring. Lateral to inferior epigastric vessels.

Question 1

Perineal hernias

Answer 1

Question 2

Obturator hernias

Answer 2

• Most common in women, particularly those with a history of recent weight loss
• Palpable in mid-thigh when the hip is flexed, externally rotated, and abducted (lithotomy position)
• Howship-Romberg sign: Positive in 50% of cases of obturator hernias. Pain along the inner thigh produced by the above movement (hip flexion, abduction, external rotation). Effective obturator neuralgia produced by nerve entrapment.

Question 3

Sciatic hernias

Answer 3

Question 4

Lumbar hernias

Answer 4

Question 5

Spigelian hernia

Answer 5

Question 6

Epigastric hernia

Answer 6

Question 14

__ is indicated for all patients with acutely complicated inguinal hernia

Answer 14

Open surgical repair is indicated for all patients with acutely complicated inguinal hernia

Question 15

The vast majority of congenital umbilical hernias . . .

Answer 15

. . . will spontaneously resolve by age 5

Question 16

Presentation of uncomplicated vs incarcerated hernia

Answer 16

• Uncomplicated: “Heaviness”, “discomfort” in an area chronically
• Incarcerated: Acute occurence of pain (the incarceration event)

Question 17

Subtle difference between inguinal and femoral hernias

Answer 17

• The femoral hernia will appear below the inguinal ligament
• The direct inguinal hernia will appear above the inguinal ligament
• The indirect inguinal will appear at the scrotum or labia

Question 18

Littre hernia

Answer 18

• Hernia that contains a Meckel diverticulum
• Congenital
• Aka “persistent omphalomesenteric duct hernias”
  *

Question 19

Amyand’s hernia

Answer 19

When an inguinal hernia contains the appendix

Question 20

De Garengeot’s hernia

Answer 20

When a femoral hernia contains the appendix

Question 21

Richter’s hernia

Answer 21

Herniation of the bowel through any hernia defect

Question 22

The three triangles (Hesselbach’s, Pain, Doom)

Answer 22

Question 23

Sliding hernia

Answer 23

• Indirect inguinal hernia which contains colon (L) or cecum (R)
• High ligation of the sac without knowing its contents can cause ischemic injury to the intestine within the sac

Question 24

Hesselbach’s triangle

Answer 24

Question 25

Femoral canal

Answer 25

Question 26

Which type of inguinal hernia has the highest rate of incarceration/obstruction?

Answer 26

Femoral

Due to the small diameter of the femoral canal and the rigidity of its surrounding structures

That is why watchful waiting is not indicated for femoral hernias

Question 27

Inguinal hernias: Which do you watch and which do you send to the OR?

Answer 27

• Any hernia that is incarcerated: Urgent OR
• Any hernia that is strangulated: Emergent OR
• Femoral hernia: Elective OR
• Moderately symptomatic hernia: Elective OR
• Asymptomatic or minimally symptomatic direct or indirect inguinal henria (NOT femoral): Watch and wait

Question 28

Chronic pain following hernia repiar

Answer 28

• A significant complication of the procedure
• More common in young adults and in women
• Possible etiologies:
  
  • Hernia recurrence (1-5%)
  • Mesh-related pain (tends to be motion-related, treat w/ anti-inflammatories. If severe, remove mesh)
  • Nerve irritation (treat w/ gabapentinoids)
  • Infection

Question 29

If you are going to repair a hernia with mesh, you should also. . .

Answer 29

. . . cut the ilioinguinal nerve, to avoid the likely complication of ilioinguinal neuritis.

Or at least offer this to the patient.

Question 30

Inguinal hernias tend to occur on the __ side, because __

Answer 30

Inguinal hernias tend to occur on the right side, because

Question 31

Telling apart inguinal hernias

Answer 31

You can tell apart femoral from true inguinal, but you *cannot* distinguish direct from indirect inguinal on exam. Both direct and indirect inguinal can go to the groin.

Question 32

Inguinal canal nerves

Answer 32

Ilioinguinal Iliohypogastric Genital branch of genitofemoral

Question 33

Contraindications to inguingal hernia repair

Answer 33

* Pregnancy * Infection * Ascites

Question 34

Nerves in the triangle of pain

Answer 34

Lateral femoral cutaneous nerve (on psoas muscle) Genital branch of genitofemoral

Question 35

Structures in triangle of doom

Answer 35

Iliac vessels

Question 36

Tension free repair

Answer 36

New paradigm for hernia repair If tension is left, it will just tear again!

Question 37

Below the arcuate line, there is no. . .

Answer 37

. . . **posterior sheath**

Question 38

Transverse section of abdominal wall

Answer 38