Abdominal Wall Flashcards
A 53-year-old female presents to your clinic with complaint of abdominal bulge and occasional discomfort. She tells you that the bulge is worse when she stands and causes pain throughout the day and when she is active, and it seems to be getting bigger over the past year. She has no obstructive symptoms at this time. She has a history of a midline laparotomy for trauma when she was younger. She had a ventral hernia repair 6 years ago and thinks they put a synthetic mesh in at that time.
She had an episode of cellulitis 1 year after the hernia repair that was treated with antibiotics. She has diabetes, which is controlled by oral medications but is otherwise healthy.
On exam she has a large palpable defect, and on CT scan she has a 6cm defect in the midline containing omentum and small bowel as well as two additional 1cm defects superior to the larger hernia without evidence of obstruction.
- What grade would this hernia be considered based on The Ventral Hernia Work Group (VHWG) classification?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
C
A grading system was created to help identify the risk of morbidity from a ventral hernia repair and to help decide which type of mesh, biologic or synthetic, would be best utilized.
This patient would be considered a Grade 3 because of her history of previous infection despite not requiring mesh removal. If there was no previous infection then she would be considered a Grade 2.
VHWG Classification:
Grade 1 (low risk) would mean no comorbidities (i.e., a young healthy individual).
A Grade 2 (comorbid) consideration means finding comorbidities (e.g., smoking, diabetes, or malnutrition) that increase the risk of surgical site infections (SSIs). There was no evidence of wound
contamination or active infection.
Grade 3 (potentially contaminated) shows evidence of wound contamination (e.g., seroma, violation of the GI tract, or history of wound infection). This includes patients with active or suspected wound contamination.
Grade 4 (infected) would be considered if active infections such as infected synthetic mesh or a septic dehiscence was found.
Regarding ventral hernia which of the following is correct?
A. Primary suture repair has the same recurrence rate as does mesh repair.
B. The type of suture used for closure of a midline incision has been clearly defined as a determinant of postoperative hernia.
C. Secondary ventral hernias are thought to be related to an abnormal ratio of type I and III collagen.
D. Ventral hernia repair is the most common procedure performed by general surgeons.
C.
It has long been established that direct suture repair for ventral hernia has an unacceptably high recurrence rate with the exception of small 1 to 2 cm primary hernias.
There has been speculation that at the time of primary operation the type of suture used for closure correlates with rate of incisional hernia formation; however, there is no conclusive evidence to support this notion.
Primary ventral hernias are thought to have a genetic predisposition, while secondary or incisional hernias are likely related to abnormal ratios of Type I and III collagen as well as the amount of metallopreotease expression.
An average of 150,000 to 250,000 ventral hernias are performed each year making it the fifth most common procedure.
Of the following positions of mesh placement for hernia repairs, which has the highest rate of recurrence?
A. Underlay repair
B. Onlay repair
C. Retro-rectus inlay repair
D. Interpositional repair
D.
Interpositional repair where the mesh is sutured
directly to the fascial edge in a bridging fashion has largely been abandoned due to the extremely high recurrence rates.
Onlay mesh repair places the mesh above the rectus sheath.
There are several types of inlay repair. In the retrorectus repair, the mesh is placed between the rectus abdominis muscle and the posterior rectus sheath.
Alternatively the mesh can be placed pre-peritoneal between the posterior rectus sheath and the preperitoneal fat.
An intraperitoneal or underlay type repair places the mesh underneath the peritoneum. This type of repair is used for laparoscopic repairs. Because the mesh is placed under the peritoneum, intraperitoneal repair is thought to have higher rates of adhesions and erosion of the mesh into the bowel.
In general, the type of repair is surgeon preference.
Advances in mesh products such as composite mesh with anti-adhesive barriers have been developed to decrease complications.
Onlay type mesh repairs have more potential for seroma formation because a large subcutaneous dissection is required and is also more susceptible to contamination from infection because of its superficial location.
Inlay mesh repairs are generally preferred because of their ability to distribute intraabdominal wall pressure and decrease overall tension.
Also underlay and retrorectus repairs have been shown to have the lowest recurrence rates of all types of mesh repair with the highest being interposition and onlay.
Regarding complications of hernia repair, which of the following is true?
A. Surgical site infection rates range from 0% to 12% for clean cases and up to 34% for clean- contaminated and contaminated cases.
B. The Centers for Disease Control (CDC) defines mesh infections as occurring up to 6 months after implantation of prosthetic mesh.
C. Seroma formation is common postoperatively
despite drain placement and therefore drains
should be removed within 1 to 2 weeks to prevent
retrograde infection.
D. The most common organisms identified in mesh infections are gram-negative organisms such as Klebsiella and Proteus spp.
A.
Surgical site infections are common after ventral
hernia repair and are defined as superficial, deep, and organ space infections.
Intraoperative level of wound contamination based on CDC criteria include clean, clean-contaminated, contaminated and dirty correlates with rate of surgical site infections.
Clean cases have an infection rate of 0% to 12% while clean-contaminated and contaminated have infection rates at high as 34%.
The CDC defines mesh infections as occurring up to 1 year after implantation of prosthetic mesh.
The most common organism cultured from infected mesh is staphylococcus aureus and is seen in up to 81% of cases.
This suggests a possible skin flora contamination at the time of mesh implantation.
While gram-negative organisms are presents in mesh infections, they only occur about 17% of the time.
Seromas are common after ventral hernia and drains are recommended to decrease the dead space. While they can cause retrograde bacterial contamination, there is no definitive recommendation of time for removal and are often necessary for up to 4 to 6 weeks.
Which of the following is true with respect to biologic and synthetic mesh materials?
A. Use of biologic mesh material in a contaminated field has around a 30% surgical site infection rate.
B. Recurrence rates after biologic mesh can be as high as 30% in contaminated fields.
C. Advanced age is associated with an increased
risk of complications after abdominal wall reconstruction.
D. Synthetic mesh infections have been successfully treated using a vacuum-assisted closure (VAC) technique without the need for mesh explantation.
D.
Prolonged operative time and American Society of Anesthesiologists (ASA) > 2 have been associated with major operative complications, but advanced age has not been shown as a predictor of morbidity.
Particular comorbidities identified were obesity, smoking, hypertension, diabetes and anemia.
Berrevoet et al. showed that use of vacuum-assisted closure (VAC) techniques can be successful in treating surgical site infections, including synthetic mesh infections.
A meta-analysis by Bellows et al. including 60 studies showed a 17% surgical site infection and 15% recurrence rate in Grade 3 contaminated
fields after biologic mesh repair.
A 44-year-old male presents to the emergency department. He has had complaints of abdominal pain over the last several days. Today he was bending over to pick up something off of the floor and he felt a sudden sharp pain at his belly button. He states the area is now very tender and achy. He has felt some nausea for the last hour or two. No change in bowel habits prior to this episode. His past medical history is significant for an umbilical hernia, hypertension and cirrhosis. Past surgical history is for an appendectomy when he was 27.
He smokes % ppd and has 2-3 drinks per day. He denies any drug use. When pressed he states that his doctors told him his liver problems are because he “drinks too much”
Vital signs are: HR 105, BP 140/91, RR 18, Pulse Ox
98%on RA. On exam there is no evidence of jaundice. He is noted to have tenderness directly at the umbilicus with a protuberant abdomen. It is dull to percussion. There are skin changes noted at the umbilicus, specifically an area of ulceration and a non-reducible hernia is noted.
Labs:
WBC: 13.1;Hgb/Hct: 13.5/40; Platelets: 202
Na: 138; K: 3.7; BUN/Cr: 23/1.4; TBili: 1.7; INR: 1.6
Which of the following negatively affects the
patient’s perioperative mortality risk specifically
due to his cirrhosis?
A. White blood cell count of 13.1
B. Hypertension
C. Alcohol consumption
D. Smoking
E. INR
E.
In a cirrhotic patient, the extent of the cirrhosis
affects the perioperative mortality; but the etiology of cirrhosis does not have to be taken into consideration.
To determine the patient’s 90-day mortality, the Model for End Stage Liver Disease (MELD) score can be used. The MELD score is calculated by the equation:
MELD = 3.78 x ln[serum bilirubin (mg/dL)] + 11.2
x ln[INR] + 9.57 x ln[serum creatinine
(mg/dL)] + 6.43
As such, the patient’s bilirubin, INR, and creatinine affect his survival chances.
This system was developed to determine outcomes for patients having undergone transjugular intrahepatic portosystemic shunt (TIPS) procedures. It has now become the standard for determination of severity of liver disease (having replaced the Childs Classification) and
based on the new criteria as outlined by the United Network for Organ Sharing (UNOS), frequency of dialysis was applied to the formula.
In addition the etiology of the cirrhosis (or end-stage liver disease) was not found to be a significant prognostic indicator and was removed from the original MELD score.
In our particular patient the MELD score is 17, which correlates with a 6% 3-month mortality.
MELD Scores
40 or more: 71.3% mortality 30–39: 52.6% mortality 20–29: 19.6% mortality 10–19: 6.0% mortality < 9: 1.9% mortality
Which of the following factors is associated with increased incidence of abdominal wall hernias in
patients with cirrhosis?
A. Increased clotting time
B. Single episode of ascites formation
C. Rising creatinine
D. Recanalized umbilical vein
E. Decreased mobility
D.
Patients with liver cirrhosis and ascites have a risk of developing an umbilical hernia that approaches 20%.
A single episode of ascites is not highly associated with abdominal wall hernia formation. However as the number of episodes of ascites increases,
so does the incidence of hernia formation, such that by the third episode about 70% of patients will have developed an umbilical hernia.
The other factors, which include increased intra-abdominal pressure, muscle wasting and weakening of the abdominal fascia related to malnutrition and recanalization of the umbilical vein, are all contributing factors to the development of umbilical hernias in the cirrhotic patient.
The decreased functional status, rising creatinine from kidney dysfunction, and the increased platelet dysfunction due to uremia do not influence the development of a hernia.
Which of the following relates to worse outcomes in the setting of emergent repair of an umbilical hernia in the cirrhotic patient?
A. Mesh insertion
B. Smoking
C. Omentectomy
D. Small bowel resection
E. Anemia
E.
In the setting of emergent repair of abdominal
wall/umbilical hernia in the cirrhotic patient, preoperative anemia was the only preoperative predictor of complicated outcome.
The other factors that were found to be statistically significant and related to major complications were age greater than 65 and higher Model for End Stage Liver Disease (MELD) score.
Additionally the authors in this study noted that small bowel obstruction in this setting had a ninefold increase in risk for postoperative complications.
However, smoking, omentectomy, mesh insertion and small bowel resection were not found to be significant factors in the development of postoperative complications.
Best management of an umbilical/ventral hernia in
a patient with cirrhosis and ascites would include which of the following?
A. Elective repair rather than emergent management
B. Preoperative ascites control only
C. Postoperative ascites control only
D. Primary repair of the hernia
E. Intra-operative drain placement only
A.
In a randomized controlled trial of 80 patients
having repair with or without mesh by Ammar, the
author found that primary repair of an umbilical/
ventral hernia in the setting of cirrhosis and ascites
has a significantly higher recurrence rate than when a mesh repair is performed (14.2% vs 2.7%, p< 0.05).
Most authors now advocate for more aggressive elective repair of hernias in patients with cirrhosis and ascites even in the setting of Class B and C cirrhosis.
In the study by Carbonell et al they found that elective surgical morbidity in cirrhotics was no different from non-cirrhotics (15.6% vs. 13.5%; p = 0.18).
Emergent surgery morbidity was statistically significant between the 2 groups (17.3% vs. 14.5%; p = 0.04).
While differences in elective surgical mortality in cirrhotics approached significance (0.6% vs. 0.1%; p = 0.06), mortality was 7-fold higher in emergency surgery (3.8% vs. 0.5%; p < 0.0001).
In addition the opportunity to utilize laparoscopy in the elective setting in this patient population has the ability to mitigate postoperative complications and decrease length of hospitalization.
Medical diuresis, postoperative paracentesis and drain placement at time of surgery are all factors
that improve the postoperative course after hernia
repair in these patients.
Odom et al noted a significant increase in major complications when no invasive measure was used to control the ascites.
An otherwise healthy 31 -year-old male presents with a painless bulge in his right groin. Although it does not bother him or limit his daily activities, he notices fluctuation in its size, from being absent when he lies flat for a few minutes, to a golf-ball sized mass upon coughing or strenuous exercises. Physical examination confirms the presence of a right inguinal hernia. No abnormalities were noted on the contralateral side.
- Regarding the management and indications for
surgical intervention of asymptomatic inguinal
hernias, which of the following is correct?
A. Observation is not recommended, as the incidence of inguinal hernia strangulation is greater than 10% after 5 years.
B. Elective surgical repair is advised for otherwise healthy patients, as procedure is fairly low-risk and post-operative complications are always minor, if any.
C. Both watchful waiting and surgical repair are
safe as treatment options, however most patients
will develop symptoms over time and require an
operation.
D. The type of inguinal hernia, whether direct
or indirect, heavily dictates the management
approach, as incarceration is at least ten times
more often in the case of direct hernias.
E. As emergency and elective inguinal hernia
repairs share similar morbidity and mortality
rates, watchful waiting is always considered a
safe option.
C. As one of the naturally weak points in the abdominal wall, the groin area is prone to the protrusion of peritoneal sac.
When this occurs in the presence of minor symptoms or in the absence of symptoms altogether, the condition is known as asymptomatic inguinal hernia.
One-third of patients with inguinal hernias fall within this category, presenting with a non-tender bulge in the area.
The inferior epigastric vessels, as well as the internal and external inguinal rings, provide anatomic landmarks that help in distinguishing direct and indirect inguinal hernias.
The sac of a direct hernia protrudes outward and forward, medial to the internal inguinal ring and the inferior epigastric vessels.
On the other hand, indirect hernias pass from the
internal ring obliquely toward the external ring, lateral to the vessels.
A pantaloon-type hernia occurs when both of these features are present.
Regardless, the anatomic distinction between these is of little importance given the similarities in the approach for operative repair.
More traditional descriptions of inguinal hernias are made on the basis of its contents (e.g., sliding, Richterk, Littre’s), or the status of the contents (e.g., sliding, incarcerated, strangulated).
With more than 20 million operations performed
annually around the world, inguinal hernia repair is
the most common elective procedure performed in the United States and Europe. There is a well-documented debate as to what the best management is for asymptomatic inguinal hernias, that being between the operative and the watchful waiting approach.
The rationale of repairing all inguinal hernias, whether symptomatic or not, lies on their risk of incarceration and strangulation.
Elective repairs are considered relatively safe with low short-term morbidity, mortality, and recurrence rates.
This is different from emergent operations, which carry higher morbidity and mortality rates given the additional risks of gangrene, perforation, and infection of the peritoneal cavity.
Nonetheless, watchful waiting spares the patient from the complications of elective surgery such as surgical site infection, hematoma, urinary retention, and more in the long-term, chronic groin pain, neuralgia and recurrence.
Studies by Fitzgibbons et al. and O’Dwyer et al.
have been key in addressing the differences between elective surgery and watchful waiting.
Although they both show no difference in terms of discomfort and pain across groups, there is a rate of conversion driven mainly by pain of 54% and 72% after 5 and 7.5 years, respectively, in those managed non-operatively.
A more recent systematic review of the evidence byMizrahi et al. (Arch Surg 2012;147:277-81) shows
that the rate of strangulation in those who do not
pursue surgery is quite low at less than 1 % after a two-and a four-year follow-up period.
On the other hand, the range of operative complications in those undergoing elective surgery goes from 0% to 22.3%, with a
recurrence rate of 2.1%
Both treatment options are thus considered safe, although most patients will progress to develop symptoms and eventually require an operation.
Which of the following is considered the most common early complication after open inguinal hernia repair?
A. Surgical site infection
B. Hematoma/seroma
C. Urinary tract infection
D. Small bowel obstruction
E. Recurrence
B. The overall risk of complications following open
inguinal hernia repair is low, and fortunately, these
are oftentimes transient and easy to manage.
Several factors play a role in the occurrence of complications, including the surgical technique, surgeon experience, and anesthetic choices.
Wound and scrotal hematomas are amongst the most common early postoperative complications, with reported rates of 6.1% and 4.5%, respectively.
Neumayer L et al. compared open mesh versus laparoscopic inguinal hernia repair and reported a combined incidence of hematoma or seroma of 13.6% in open cases, and 16.4% in those performed laparoscopically.
Other less common adverse events seen in the immediate postoperative period include urinary retention, orchitis, pain, and urinary tract and wound infections.
As for long-term complications, chronic pain tops the list, with a reported rate of 14% to 19% following open repairs with some series reporting frequencies as low as 6%or as high as 75.5%.
The risk is lower following laparoscopic cases,
with rates ranging between 9.8% to 13.8% Orchitis,
infection, and hernia recurrence are amongst other
common late complications.
Which of the following is true regarding laparoscopic inguinal hernia repair?
A. It is generally less expensive than the open repair.
B. Potential complications are similar, or less severe, to those seen with open repair.
C. Procedure is limited to the repair of only one
detect in the inguinal region given poor visualization of the anatomy.
D. Although patients have a faster return to daily activities, they are associated with greater persistent pain and numbness compared to the open approach.
E. It is usually the favored approach in special situations such as in recurrent or bilateral inguinal
hernias.
E. The approach and operative technique for the
repair of inguinal hernias has evolved throughout
the years.
Repairs can be either done open or laparoscopically.
The open approach can be either a tissue repair or a prosthetic (tension-free) repair.
Although the former might be of historical interest, there are some situations in which these may be indicated such as in a contaminated field, in pediatric patients, or in those places where access to prostheses is limited.
By identifying increased tension as the main cause
of recurrence, Lichtenstein popularized the use of a synthetic mesh to bridge the hernia defect and provide a tension-free repair.
This approach is the gold standard of open hernia repairs, as it has proven to decrease the rates of postoperative discomfort, duration of hospital stay, and recurrence.
The laparoscopic approach also offers a tension-free repair.
Those who support this technique emphasize the quicker time to recovery, less pain, better visualization of the anatomy, and the ability to repair all the defects in the inguinal region.
On the other hand, critics insist on the longer operative times, technical challenges, risk of recurrence, and increased costs.
A meta-analysis study by Voyles et al. (Am J Surg. 2002;184:6-10) compared the two approaches and showed that both provide equivalent outcomes, with open repairs being lower in cost, and entailing a lower risk of severe postoperative complications.
Those unique to the laparoscopic approach include small bowel obstruction, internal hernia, bladder perforation, infarcted omentum, and port-site hernia.
Special situations may favor the use of the laparoscopic approach. In the setting of bilateral inguinal hernias, the ability to use the same access sites evidently translates into faster recovery and less postoperative pain.
However, whether done open or laparoscopically, the simultaneous repair of bilateral hernias does not increase the risk of re-operation for recurrence.
Another typical challenge for the surgeon is that of recurrent hernias. These may be caused by either technical problems (e.g., knot slipped, crushed suture, inadequate bites of fascia), or patient factors such as malnutrition, steroid use, and smoking.
A second groin exploration entails cutting through
scar tissue that in itself adds a certain degree of difficulty and additional trauma with increased risk of damage to the testicular blood supply and sensory nerves.
Access through virgin territories through a posterior approach explains the advantage of laparoscopic repairs in these situations.
After an open inguinal hernia repair, which symptom is likely to appear as a result of the most commonly injured nerve in this type of approach?
A. Numbness on ipsilateral upper lateral thigh
B. Numbness on ipsilateral medial thigh
C. Hyper response of the cremasteric reflex
D. Hypersthesia of the ipsilateral hemiscrotum
E. Numbness of the suprapubic region
B. Depending on the approach used, specific nerves in the area will be more prone to injury. For example, in open hernia repairs, the ilioinguinal nerve can be most commonly injured at the external ring where it runs on top of the cord.
This results in loss of the cremasteric reflex and numbness to the ipsilateral penis, scrotum, and thigh.
On the other hand, the posterior approach used in laparoscopic surgery can result in injuries to the lateral femoral cutaneous, femoral branch of the genitofemoral (sensory, upper lateral thigh), and rarely, the femoral nerves.
Hypersthesia of the hemiscrotum and numbness of the suprapubic region are not complications of nerve injury from inguinal hernia repairs.
Which of the following is true regarding femoral hernias?
A. Watchful waiting or surgical repair are both reasonable options to consider in otherwise healthy patients diagnosed with asymptomatic femoral hernia.
B. The mesh plug repair is the preferred approach in emergent cases.
C. Rate of incarceration and strangulation is reported as greater than 40%.
D. Men are more likely than women to experience this type of hernia.
E. Its sac protrudes through the femoral canal, bounded medially by the femoral vein.
C. Rate of incarceration and/or strangulation is reported to be greater than 40%.
Another potential defect where hernias can occur is that of the femoral canal, bounded superiorly by the iliopubic tract, inferiorly by the lacunar ligament, laterally by the femoral vein, and medially by the junction of the iliopubic tract and lacunar ligament.
Its difficult diagnosis and treatment pose a challenge to even the more experienced surgeon.
Added to this, a large proportion of patients with this type of hernia present late to medical care, oftentimes requiring emergent interventions that translate in higher risk of adverse postoperative events.
Women are more likely to experience this type of hernia than men, comprising about 30% of their groin hernias (versus only 2% in men).
As they are usually associated with incarceration and strangulation (reported rates between 44% and 86%), the most adequate treatment once diagnosed is surgery.
All femoral hernias should be repaired, and in the presence of incarcerated contents, the sac should be assessed for viability.
Delayed diagnosis will lead to higher morbidity and mortality.
Different repair techniques are available and mainly depend on the clinical presentation.
Many consider the mesh plug repair as the technique of choice in elective and non-infected cases.
In contrast, the tissue repair (i.e., McVay operation) should be preferred in strangulated cases in which severe infection is present.
A 65-year-old female is seen in your clinic for a “lump” in her groin. She states the lump has been present for a few years and intermittently becomes larger in size. On exam, there is no evidence of adenopathy or venous thrombosis. A reducible hernia is palpated. You perform an uncomplicated McVay repair and she is seen in follow up one year later with a recurrence.
- Regarding femoral hernias, which of the following is true?
A. It is an acquired defect.
B. It has a male preponderance.
C. It is more common than inguinal hernias.
D. The incidence of incarceration is lower than
inguinal hernias.
A.
Femoral hernias are acquired hernias and NOT of
congenital origin. They are more common in females and more common in older women who are multiparous, as laxity of the abdominal wall and stretching of the femoral ring with aging or pregnancy is felt to be an etiology.
Given the mostly fixed, confined spaces of the femoral canal, these hernias are notorious for incarcerating leading to emergent/urgent hernia repair.
A study from the Swedish Hernia Register showed an incidence of 2 to 4 percent of all groin hernias over a 14 year period.
Of these hernias, 35.9% of femoral hernias were found to present as an emergency (incarceration) needing surgery, and of these, 22.7% required bowel resection.
This is compared to only 4.9% needing emergency surgery in the inguinal group. It is seen more commonly in women, roughly 2:1 female:male.
Regarding the McVay technique for hernia repair,
which answer choice displays the key steps in order?
A. Expose Coopers ligament, suture transversus abdominus aponeurosis to Cooper’s ligament beginning at the pubic tubercle towards the femoral sheath, place transition stitch containing transversus abdominus. Cooper’s ligament, femoral sheath medial to femoral vein, and inguninal ligament (iliopubic tract), approximate the conjoint tendon to the inguinal ligament laterally to the internal ring.
B. Expose Cooper’s ligament, make relaxing incision on anterior rectus sheath, suture transversus abdominus aponeurosis to Cooper’s ligament beginning at the pubic tubercle towards the femoral sheath, place transition stitch containing transversus abdominus, Cooper’s ligament, femoral sheath medial to femoral vein, and inguinal ligament (iliopubic tract), approximate the conjoint tendon to the inguinal ligament laterally to the internal ring.
C. Expose Cooper’s ligament, make relaxing incision on anterior rectus sheath, suture transversus abdominus aponeurosis to Cooper’s ligament beginning at the pubic tubercle towards the femoral sheath laterally to the internal ring.
D. Expose Cooper’s ligament, suture transversus
abdominus aponeurosis to Cooper’s ligament beginning at the pubic tubercle towards the femoral sheath laterally to the internal ring.
B.
The McVay repair, aka the Cooper’s Ligament repair, is a tissue repair that is effective in repair of all three groin hernias (indirect, direct, and femoral).
It is performed with non-absorbable sutures in an interrupted fashion.
Sutures are placed to sew the transversus abdominus aponeurosis to Cooper’s ligament beginning at the pubic tubercle towards the femoral sheath. Once this is reached, place a transition stitch containing transversus abdominus, Coopers ligament, femoral sheath medial to femoral vein, and inguinal ligament (iliopubic tract), then approximate the transversus abdominal aponeurosis to the inguinal ligament laterally to the internal ring.
Exposure of Cooper’s ligament is done prior to suturing. Additionally, to avoid tension, a curvilinear relaxing incision is made through the anterior rectus sheath starting 1cm cephalad of the pubic tubercle to near its lateral border.
Regarding recurrence of this patient’s hernia, which of the following is the most likely etiology?
A. Congenital collagen disorder
B. Wound infection
C. Tension on suture line
D. Postmenopausal
C.
Tension on the suture line is felt to be the most common cause of hernia recurrence in general and especially in tissue repairs. This is why an adequate relaxing incision is necessary in the McVay repair. Most likely, there was some tension on the repair despite the relaxing incision.
A shift has been made to tension free repairs with the usage of mesh. Tissue vs mesh repair was compared in a large meta-anaylsis containing over 11,000 patients specifically looking at recurrence rates after hernia surgery.
Findings of this show the odds of developing a recurrent hernia with mesh repairs were reduced by about half, though recurrence rates were relatively small with each repair.
Other factors can contribute to recurrence such as wound infection, but are not the primary/most common cause.
Congenital collagen disorder is a rare disorder and is not likely to be seen in this patient.
Regarding repair of groin hernias, which of the following techniques will fix a femoral hernia?
A. Bassini repair
B. Marcy repair
C. Shouldice repair
D. Preperitoneal repair
E. Lichtenstein tension free with mesh repair
D.
Lichtenstein tension free hernia repair with mesh is the most common hernia repair done at most institutions. It requires little suturing, does not need a relaxing incision, and does not need general anesthesia.
Unfortunately, the drawback of this repair is that it does not close, nor cover, the femoral ring. Therefore, it is not used for repair of femoral hernias.
The Marcy repair only repairs the deep inguinal ring and is mostly used in pediatric patients. The Bassini and Shouldice repairs only repair the inguinal floor and will not treat a femoral hernia.
The preperitoneal repair, a variation known as the Kugel repair, involves placing mesh in the preperitoneal space and suturing this from the pubic tubercle to Cooper’s ligament.
Bi-layer mesh repair, in theory is a combined preperitoneal and Lichtenstein repair with mesh and is used for femoral hernia repair.
Plug and patch repair can be utilized to obliterate the femoral canal in femoral hernia repair.
Laparoscopic repair, as with the above repairs, is a described technique for repair of femoral hernias and utilizes the preperitoneal space.
A 35-year-old male presents to clinic three months after an uncomplicated open right inguinal hernia repair with mesh for a chronic, minimally symptomatic, indirect inguinal hernia. During the operation, the ilioinguinal nerve was intentionally divided. He reports continued right sided, sharp, episodic groin pain radiating to his testicle that is worse than the symptoms he had prior to repair. He took ibuprofen and acetaminophen for 6 weeks after the surgery with minimal relief. The pain is beginning to limit his activities at work. He now complains of worsening pain.
- Regarding the pathophysiology of chronic groin
pain after hernia surgery, which of the following is
correct?
A. Most commonly, it is felt to be neuropathic and due to primary nerve injury during the operation.
B. It is felt to be due to inflammatory mechanisms from the operation and healing.
C. It is nociceptive.
D. Tacking mesh to nerves in a laparoscopic repair is an uncommon cause.
E. Secondary nerve injury from either inflammation or nerve degeneration from mesh contact is the most common cause.
A.
Chronic postoperative groin pain is felt to be secondary to neuropathic pain from aberrant
nerve conduction as a result of either primary or
secondary nerve injury.
Typically, it is ongoing pain, which is difficult to manage.
Initial postoperative pain is due to inflammatory cytokine release and nociceptive mechanisms.
Nocioceptive pain is pain felt via neural pathways in which tissue damage surrounding the nerves is the stimulus. This type of pain typically resolves over 6 weeks and is amendable to anti-inflammatory medications such as NSAIDS.
Primary nerve injury is defined as direct nerve injury and can occur during hernia repair in multiple ways.
Regarding the management of chronic groin pain
after hernia surgery, which of the following is
correct?
A. Imaging studies (ultrasound, CT scan, and/or
MRI) are suggested to rule out underlying causes.
B. Peripheral nerve block should be attempted to confirm diagnosis.
C. Referral to a pain management specialist is
recommended.
D. Triple neurectomy is recommended only after
failing less invasive treatments by a pain management specialist.
E. All are correct.
E
Chronic groin pain, or chronic postherniorrhaphy inguinal pain, after hernia surgery is diagnosed by chronic pain at site or region of prior hernia repair that persists postoperatively for over three months that cannot be attributed to another cause.
The prevalence of postoperative chronic groin pain varies from study to study. A large Swedish survey including 2500 patients, noted 14% of patients had lifestyle limiting groin pain, and 30% chronic pain that didn’t hinder their lifestyle. A smaller series noted 1.5% of patients had moderate to severe pain at five years. Interestingly, it is more common in younger patients, with persistent pain in 58% of patients under the age of 40 and only 14% of those older than age 40.
Upon presentation of a patient you suspect has chronic postoperative groin pain, anti-inflammatory treatment should be attempted but usually has little effect on neuropathic pain. In this instance, an ilioinguinal nerve block can help confirm diagnosis and is indicated.
Additionally, nerve ablation with phenol or radiofrequency ablation is used.
Patients who fail less invasive means of treatment should undergo triple neurectomy.
Non-neuropathic pain must be excluded. This is done with history, physical, and imaging studies.
The ideal imaging study has not been determined by randomized trials. In general, ultrasound is the least expensive test with minimal risk to the patient.
However, CT and MRI can provide a better representation of the location of mesh, location of neuronal structures, and presence of recurrent hernias.
Regarding nerve injuries in hernia repair, which of
the following is correct?
A. Injury to the ilioinguinal nerve causes loss of
cremasteric reflex, and numbness to the ipsilateral scrotum, penis, and medial thigh.
B. Injury to the femoral branch of the lateral femoral cutaneous nerve causes loss of sensation to the medial thigh.
C. Tack placement inferior to the iliopubic tract and medial to the spermatic cord is avoided to minimize nerve damage in laparoscopic hernia repair.
D. Injury to the genital branch of the genitofemoral nerve results in loss of sensation of the entire scrotum and lack of cremestric reflex on the contralateral side.
A.
An injury to the femoral branch of the lateral femoral cutaneous nerve causes lack of sensation to the lateral thigh and not the medial thigh as mentioned in the answer.
This nerve is seen in laparoscopic hernia repairs and is not encountered during open inguinal hernia repair.
Other nerves encountered laparoscopically include the lateral femoral cutaneous nerve, the ilioinguinal nerve lateral to the internal ring, the iliohypogastric (which cannot be seen but could be injured with mesh fixation), the genital branch of the genitofemoral nerve, and the femoral nerve.
The so called “triangle of pain”is defined as the iliopubic tract superiolaterally, the spermatic vessels posteriomedially, and the reflected peritoneal edge laterally.
This contains the genitofemoral nerve and the lateral femoral cutaneous nerve. Minimization of nerve injuries laparoscopically is achieved by avoiding tack placement inferior to the iliopubic tract laterally beyond the external iliac artery.
For open inguinal hernia repairs, the ilioinguinal nerve is the most common cause of pain. Injury to this nerve can also cause ipsilateral scrotal, thigh, and penis numbness as well as loss of the cremasteric reflex.
Injury to the genital branch of the genitofemoral nerve can less commonly cause pain. More commonly, scrotal sensation and lack of cremasteric reflex on the ipsilateral side are seen.
Regarding surgical management of post-herniorrhaphy neuralgia, which of the following is correct?
A. Tailored neurectomy is more effective than triple neurectomy at decreasing symptoms postoperatively.
B. Triple neurectomy is effective at eliminating pain in upwards of 80% of patients, making this the
most effective surgical therapy.
C. Mesh explantation alone is an effective strategy and has been shown to be superior to neurectomy with or without mesh explantation.
D. Patients with pre-existing pain hypersensitization are ideal candidates for neurectomy.
B.
Given the significant morbidity and difficulty of the operation, neurectomy is reserved for patients who fail pain management strategies.
Patients with pre-existing pain syndromes or hyper-sensitization are not ideal surgical candidates.
Of the operative strategies, triple neurectomy of the ilioinguinal, iliohypogastric and genital branch of the genitofemoral nerve has been shown to be the best at a surgical cure.
There have been a few small trials studying success rates for triple neurectomy, the largest looking at 225 patients. Of these, 80% reported resolution of pain, 15% had transient pain, and only 2 patients reported no improvement.
Tailored neurectomy could be beneficial as it is less morbid, leaving the patient with less sensory loss.
Although tailored neurectomy has not been compared to triple neurectomy, and only been studied in small studies, it was found to provide complete pain relief in only 54% of patients, giving partial relief in 24% of patients and leaving 24% with no benefit.
Mesh explantation alone is not likely to be an effective strategy for the treatment of chronic post-herniorraphy neuralia unless secondary nerve injury either by excessive scar formation over the mesh or nerve contact with the mesh not associated with entrapment, or meshoma by imaging is suspected.
No randomized controlled trials have compared triple neurectomy with and without mesh explantation; but if mesh removal alone does not relieve the pain then proceeding with a third operation in the inguinal region may result it a very difficult dissection, inability to identify all 3 nerves, and worsening pain.
Regarding intentional division of the ilioinguinal
nerve at time of initial herniorrhaphy, which of the
following is correct?
A. There is no difference in sensory loss between division and preservation of the nerve.
B. A significant decrease in postoperative chronic pain is seen when the ilioinguinal nerve is intentionally divided during initial surgery.
C. There is no significant difference in decreasing chronic postoperative groin pain.
D. There is less debilitating pain with routine division of the ilioinguinal nerve.
E. There is less pain if the nerve is clipped versus being divided by electrocautery.
C.
Intentional ilioinguinal nerve division during herniorrhaphy has been postulated to decrease chronic groin pain.
Its benefits have been studied in multiple randomized control trials.
It is clear that operative division will decrease sensation along the distribution of the nerve (the groin and hemiscrotum).
However, no statistically significant advantage at decreasing post-herniorrhaphy neuralgia at 1 month, 6 month, and 1 year follow ups has been shown in large studies and meta-analysis of over 1200 patients.
A 63-year-old female presents with a history of gastroesophageal reflux disease (GERD). She takes a PPI twice daily and complains of having more regurgitation over the past 6 months. She has a history for diabetes mellitus and hypertension. She has no history of alcohol or tobacco use. She is otherwise in good health with no other problems. Her BMI is 38 kg/m2.
- What is the most likely cause of her symptoms?
A. Gastroparesis
B. Esophageal cancer
C. Gastric ulcers
D. Hiatal hernia
E. Obesity
- What should be the next appropriate test?
A. CXR
B. Manometry
C. pH monitoring
D. Endoscopy
- D.
Hiatal hernia is quite common in the population with up to 60%of the population having such hernias. Approximately 9% are symptomatic.
Regurgitation can be the only symptom but at times some will have cardiac and pulmonary symptoms.
Esophageal cancer must be on the differential diagnosis with anyone presenting with regurgitation and a history of GERD.
It is unlikely to be cancer as the patient has not had any dysphagia or weight loss.
Gastric ulcers are associated with GERD but will usually present with abdominal pain.
Diabetic neuropathy can affect the intestinal tract and can cause gastroparesis. Patients with this condition can have regurgitation, abdominal fullness, and pain.
This patient has no other symptoms consistent with diabetic periperal neuropathy.
Obesity is a risk factor to reflux disease but the most common cause in this patient is likely a hiatal hernia.
- D.
The workup has to exclude other pathologies.
Endoscopy is essential to the evaluation of patients presenting with GERD, to determine the extent of esophagitis, and to determine the extent of a hiatal hernia, to rule out malignancy.
Manometry can be used to evaluate the LES and look for motility disorders.
pH monitoring is the gold standard for diagnosing and quantifying acid reflux. Impedance pH can also be performed to discern the difference between non-acid and acidic reflux.
Additionally, the use of either CT or a swallow study can be used for evaluation of the motility of the stomach and can help decipher if there is a need for pyloroplasty or pyloromyotomy.
What is the most common type of hiatal hernia?
A. Type I
B. Type II
C. Type III
D. Type IV
A.
Type I (sliding) hernia: Upward herniation
of the cardia in the posterior mediastinum, the GE
junction migrates above the diaphragm. Type I hiatal hernias are the most common at 90%.
Type II (paraesophageal) hernia: The GE junction remains in the normal anatomical position, the fundus herniates through the hiatus.
Type III (mixed) hernia: Characterized by an upward herniation of both the cardia and the gastric fundus.
Type IV hiatal hernia: An additional organ, usually the colon but could involve the spleen or liver, herniates as well.
Regarding the etiology of hiatal hernias most are?
A. Congenitally acquired
B. Have no familial hereditary pattern
C. Similar to a Bochdalek hernia
D. Result from a weakening of the phrenoesophageal ligament
D.
Cephalad migration of the gastroesophageal junction may result from weakening of the phrenoesophageal ligament.
Depletion of elastin fibers leads to stretching of the ligament and proximal displacement of the gastroesophageal junction.
Most cases of hiatal hernia are acquired rather than congenital.
A small number of cases of familial hiatal hernias have been shown.
Bochdalek hernias are congenital hernias involving the right posterior diaphragm usually found in children, it is extremely rare to find in the adult population with less than 100 published cases.
The patient undergoes an uneventful diaphragm
repair and a Nissen fundoplication. Two years post-operatively the patient presents with a recurrence of her symptoms. On evaluation, it is noted that the Nissen fundoplication is slipped. What is an alternative for repair?
A. Colles gastroplasty
B. Roux-En-Y gastric bypass
C. Ivor-Lewis esophagectomy
D. Esophagomyotomy
B.
A good alternative for tailed fundoplications is a Roux-En-Y Gastric Bypass.
Kim et al. showed that at 11 months, 93.3% of patients were symptom-free.
Colles Gastroplasty is used as a lengthening procedure and has no role in the management of revision on its own.
Esophagectomy has no role in the revision of slipped fundoplication.
Esophagomyotomy is used to treat achalasia to release the pressure on the LES.
A slipped Nissen refers to the stomach that slips under the wrap creating an hourglass shape deformity that can be seen on UGI.
This is different from a recurrence where the stomach re-herniates into the chest.
A 56-year-old female returns to your clinic two weeks following a laparoscopic repair of a ventral hernia with mesh placement. She complains of a bulge along her incision that looks similar to her previous hernia. CT scan reveals the hernia repair is intact, but the patient has developed a seroma into the previous hernia space. Which of the following is the MOST appropriate next step in treatment?
a. Wound exploration, seroma evacuation, and skin closure over a drain
b. Percutaneous drainage of the seroma
c. Reassurance and follow up in 2 weeks
d. Mesh removal and primary repair of the hernia defect
c. Reassurance and follow up in 2 weeks
What are the 9 layers of the abdominal wall?
Skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum.
What is the portion of the external oblique aponeurosls that extends from the anterosuperior iliac spine to the pubic tubercle called?
Inguinal (Poupart) ligament
What directions of the fibers of the external oblique course?
Superolateral to inferomedial
What directions do the fibers of the internal oblique course?
Inferolateral to superomedial
What directions do the fibers of the transversus abdominis course?
Transverse
Where does the aponeurosis, which is originally divided into anterior and posterior lamella that envelops the rectus abdominis muscle, begin to course anteriorly to the rectus abdominis muscle and become part of the anterior rectus sheath?
Semicircular line (of Douglas/arcuate line)
What are the borders of the Hesselbach’s triangle?
Inguinal ligament inferiorly, lateral margin of the rectus sheath medially, and inferior epigastric vessels laterally
What makes up the floor ofthe Hesselbach triangle?
Transversalis fascia
What structures course through the preperitoneal space?
Inferior epigastric artery and vein;
median umbilical ligament (urachus-remnant of fetal allantoic stalk);
medial umbilical ligaments (vestiges of fetal umbilical arteries);
falciform ligament
What are the 9 potential spaces of the abdomen?
Right subphrenic; left subphrenic; right paracolic gutter; left paracolic gutter; subhepatic; supramesenteric; inframesenteric; lesser space; pelvis
What is the function of the peritoneum?
To promote sequestration and removal of bacteria from the peritoneal cavity,
control the amount of fluid in the peritoneal cavity,
and
facilitate the migration of inflammatory cells from the microcirculation into the peritoneal cavity.
What is the most reliable method to help determine the cause of ascites?
The serum-ascites albumin gradient (SAAG)
How do you calculate the SAAG?
Serum albumin concentration – ascites albumin concentration
What does a SAAG <1.1 g/dL signify?
Absence of portal hypertension (biliary ascites, nephrotic syndrome, pancreatic ascites, peritoneal carcinomatosis, post-op lymphatic leak, serositis with connective tissue disease, tuberculous peritonitis)
What does a SAAG >1.1 g/dL signify?
Presence of portal hypertension (alcoholic hepatitis, Budd-Chiari syndrome, cardiac ascites, cirrhosis, fulminant liver failure, massive liver metastasis, myxedema, portal vein thrombosis)
How much albumin should be given for every liter of ascites removed after large-volume paracentesis (>5 L)?
6 to 8 g of albumin/L of ascites removed
Most common malignancy associated with chylous ascites:
Lymphoma
Term for bacterial infection of ascitic fluid in the absence of an intraabdominal, surgically treatable source of infection:
Spontaneous bacterial peritonitis
What is the management of spontaneous bacterial peritonitis?
Third-generation cephalosporin (e.g., ceftriaxone)
Treatment for tuberculous peritonitis:
Antituberculous drugs (isoniazid and rifampin daily for 9 months commonly used)
Initial treatment for peritoneal dialysis-associated peritonitis:
Intraperitoneal administration of antibiotics (usually first-generation cephalosporin)
Treatment for recurrent/persistent peritoneal dialysis-associated peritonitis:
Removal of the dialysis catheter and resumption of hemodialysis
