Hernias

Question 0

28-year-old presents with pain in groin. Interpretation if:

1. Several 1 cm tender lymph nodes
2. Acutely tender testicle that began suddenly
3. Acutely tender testicle that began insidiously
4. Acutely tender epididymis

Answer 0

1. Lymphadenitis likely from malignancy in groin/leg/foot
2. Torsion of testes.
3. Viral orchitis or epididymitis
4. Epididymitid

Question 1

28-year-old man presents with pain in groin. Likely cause if physical exam reveals:

1. Firm, tender mass in medial portion of groin
2. Tender area in the lateral portion of the groin and impulse the travels down inguinal canal when coughing
3. Firm, tender mass below inguinal ligament
4. Firm, tender mass with nausea, vomiting, and abdominal distention
5. Large, soft mass in scrotum, separate from the testicle, with fullness in inguinal canal
6. Large, soft mass and scrotum, separate from the testicle, with the fullness in the inguinal canal that can be pushed back into abdomen
7. Firm, tender mass with fever, leukocytosis, and acidosis

Answer 1

1. Direct inguinal hernia
2. Indirect hernia
3. Femoral hernia
4. Incarcerated or strangled intestine and hernia
5. Bowel in scrotum
6. Reducible Indirect hernia that has extended into scrotum
7. Strangulated segment of bowel

Question 2

Types of hernias that are most likely to be strangulated?

Characteristic of a hernia that increases risk of strangulation?

Answer 2

Femoral hernias >indirect hernias >direct hernias

Narrow neck

Question 3

Direct versus indirect hernia?

Answer 3

Weakness in floor of the canal, originates medially to inferior epigastric vessels

Versus

Intact posterior surface, originates at the internal ring and traverses down inguinal canal

INdirect hernia into INguinal canal

Question 4

Conditions that can lead to a hernia?

Answer 4

Anything that increases intra-abdominal pressure – COPD, ascites, obesity, BPH/bowel obstruction (increased straining)

Question 5

Types of open repairs for hernia?

Answer 5

1. Bassini repair – reconstruction of posterior inguinal canal and suturing of superior abdominal wall to inguinal ligament
2. McVay (Cooper’s ligament) repair – suture transversalis fascia to Cooper’s ligament (periosteum of the pubic ramus)
3. Shouldice Repair - attach reinforced transversalis fascia to inguinal ligament in two layers
4. Liechtenstein repair – uses prosthetic mesh to approximate superior abdominal wall structures to inguinal ligament

Question 6

Cooper’s ligament repair – most useful for?

Major weakness of the Bassini repair?

Answer 6

Femoral hernias and attenuated inguinal ligaments

Increased Tension – likely to fail with poor tissue

Question 7

Principal complication of hernia repair? Likelihood?(What specifically affected ?)

Answer 7

Nerves or nearby structures

1-10%

Genitofemoral, ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves

Question 8

During hernia surgery – most important structures to identify and preserve?

Answer 8

Ilioinguinal nerve and spermatic cord

Question 9

Pediatric versus adult inguinal hernia?

Answer 9

1. Usually due to Persistent patent processes vaginalis
2. High incidence of bilaterality
3. Involve no defect in the floor of the inguinal canal

Question 10

Femoral hernia Borders?

Answer 10

Anterior – iliopubic tract (reflection of inguinal ligament)
Posterior – Cooper’s ligaments
Medial – pubic tubercle
Lateral – femoral vein

Question 11

Sliding hernia? Most commonly seen with what type of hernia? Common organs involved?

Answer 11

Hernias involving other structures

indirect hernias

Bladder, cecum, sigmoid colon

Question 12

Richter hernia?

Littré hernia?

Answer 12

Extrusion of intestinal wall into hernial sac

Protrusion of medical diverticulum into hernia sac