EXAM #3: HERNIAS

Question 1

What is the general school of thought for the surgical management of hernias?

Answer 1

Repair before they cause problems

Question 2

What is the most common type of all hernias?

Answer 2

Inguinal

Far more common in men

Question 3

Review the abdominal wall layers.

Answer 3

1) Skin
2) Subcutaneous tissue
- Camper’s Fascia (fatty)
- Scarpa’s Fascia (fibrous)
3) External Oblique
4) Internal Oblique
5) Transversus Abdominis m.
6) Transversalis fascia
7) Peritoneum

Question 4

Review the anatomy of the inguinal canal.

Answer 4

N/A

Question 5

What is an indirect inguinal hernia?

Answer 5

• Hernia through the internal inguinal ring
• Lateral to the inferior epigastric vessels
• Within the spermatic cord

MD’s Don’t Lie

Question 6

Where does a direct inguinal hernia pass through?

Answer 6

Hasselbach’s Triangle

Question 7

What is a direct inguinal hernia?

Answer 7

Hernia that occurs

• Adjacent to rectus abdominus
• Medial to inferior epigastirc vessels
• Superior to inguinal ligament

Question 8

What patient’s more commonly have femoral hernias?

Answer 8

Female

Question 9

What is a femoral hernia?

Answer 9

Hernia that passes into the femoral canal, below the inguinal ligament

Question 10

How can an inguinal hernia be repaired with a “tissue repair?”

Answer 10

1) Bassini repair= single layer reconstruction of inguinal floor
2) Shouldice repair= four layer reconstruction of inginal floor
3) McVay repair= inguinal floor brought to Cooper’s Ligament–closes the femoral space

Question 11

What is the best tissue repair for an incarcerated femoral hernia?

Answer 11

McVay b.c is closes the femoral repair

Question 12

Why perform a tissue repair?

Answer 12

1) No mesh available

2) INFECTION

Question 13

What is the current standard hernia repair?

Answer 13

Lichtenstein Mesh Repair

Question 14

What are the key characteristics of a Lichtenstein Mesh Repair?

Answer 14

1) Mesh reconstruction of inguinal floor
2) Tension-free

*Lowest risk of recurrence

Question 15

What is the risk of a Lichtenstein Mesh Repair?

Answer 15

Prosthetic mesh infection

Question 16

What is a Pre-Peritoneal Mesh Repair?

Answer 16

Mesh is placed INSIDE of fascia (vs. outside)

Mesh is between peritoneum and transversus abdominus

Question 17

How do you place pre-peritoneal mesh?

Answer 17

Open or Laparoscopic

Question 18

What are the benefits of Laparoscopic repair for pre-peritoneal mesh repair?

Answer 18

1) Less post-op pain
2) Less infection and hematoma
3) Quicker recovery with fewer work restrictions

Question 19

What are the two approaches to the pre-peritoneal repair?

Answer 19

TAP and TEP

Question 20

What is the TAP approach?

Answer 20

TransAbdominal Preperitoneal Laparoscopic Hernia Repair

Question 21

What is the TEP approach?

Answer 21

Total Extraperitoneal Preperitoneal

Question 22

How does the TEP differ from the TAP?

Answer 22

TAP= standard laprascopic approach

TEP= entry in RECTUS SHEATH

Question 23

What are the evidence-based indications for laprascopic hernia repair?

Answer 23

1) Bilateral inguinal hernias
2) Comorbid umbilical
3) Young healthy individual that wants to return to work earlier

Question 24

What is a Spigelian hernia?

Answer 24

Hernia along the semilunar line

Question 25

What is the difference between an umbilical hernia in a kid and adult?

Answer 25

Kid= frequently regress (congenital) Adult= acquired and progress/enlarge

Question 26

How are umbilical hernias repaired?

Answer 26

1) Primary if 1-2cm | 2) Mesh reinforcement for 2cm+ defects

Question 27

What is an incisional hernia?

Answer 27

Failure of fascia healing

Question 28

What are the risk factors for incisional hernias?

Answer 28

``` Infection Early return to work Obesity Old-age Male Sleep apnea* Emphysema* ``` *Chronic hypoxia states

Question 29

How long should people be lifting restricted to prevent an incisional hernia?

Answer 29

6 weeks

Question 30

What is a unique feature of epigastric hernias?

Answer 30

Small defect above the umbilicus that is PAINFUL *Repaired to alleviate pain

Question 31

What is the proposed etiology of Spigelian Hernias?

Answer 31

Vascular defects of the semilunar lines

Question 32

What is a primary repair for an abdominal wall hernia?

Answer 32

Cut down a simply suture the defect *Note that these are associated with a high recurrence rate

Question 33

When is a primary repair done for a hernia?

Answer 33

1) Strangulation 2) Skin breakdown 3) Bowel resection

Question 34

What is a mesh reinforeced repair for an abdominal wall hernia?

Answer 34

Mesh is placed to help reinforce the defect

Question 35

When is a mesh reinforced repair CONTRAindicated?

Answer 35

Contaminated field/ infection

Question 36

Where is abdominal wall mesh placed most commonly?

Answer 36

"Underlay" i.e. intraperitoneal

Question 37

What is the gold standard for abdominal wall mesh placement?

Answer 37

"Retrorectus" i.e posterior to the rectus sheath

Question 38

Is an incarcerated hernia a surgical emergency?

Answer 38

NO--an incarcerated hernia is one that cannot be reduced *****A STRANGULATED hernia is an incarcerated hernia with compromised blood flow/ infection; this is a surgical emergency*****

Question 39

What are the clinical features of a strangulated hernia?

Answer 39

1) Erythema of the overlying skin 2) Fever 3) Tachycardia 4) Elevated WBC count