Hernias

Question 1

Is omentum/fat in a hernia concerning?

Answer 1

No, but can be painful

Question 2

Is an organ stuck in a hernia concerning?

Answer 2

Yes

Question 3

What is the most common type of hernias? What is the men:women ratio?

Answer 3

Inguinal hernias

90% men, 10% women

Question 4

What are the abdominal wall layers in the inguinal canal? (4)

Answer 4

Peritoneum + fat
Transversalis fascia
Transversus abdominis
Internal/external oblique

Question 5

Which muscle is not found in the inguinal canal?

Answer 5

transversus abdominus

Question 6

What are the vessels within the inguinal canal? (3)

Answer 6

Testicular artery
Cremasteric artery
Artery to the vas deferens

Question 7

What are the nerves that run within the inguinal canal? Alongside it?

Answer 7

Genital branch of the genitofemoral nerve

Ilioinguinal nerve runs alongside

Question 8

What are the 3 fascial layers that run through the inguinal canal?

Answer 8

External spermatic
Cremasteric
Internal spermatic

Question 9

What are direct inguinal hernias?

Answer 9

Passing through Hesselbach’s triangle

Question 10

What are the sides of Hesselbach’s triangle?

Answer 10

Rectus abdominus
Inguinal ligament
Inferior epigastric artery

Question 11

What are femoral hernias?

Answer 11

Pass through the femoral space, with the inguinal ligament above, cooper’s ligament below

Question 12

Where are the femoral vessels relative to a femoral hernia?

Answer 12

Laterally (VAN)

Question 13

What is the ligament below femoral hernias? Above?

Answer 13

Below = Cooper's
Above = inguinal

Question 14

What is the Bassini repair?

Answer 14

Single layer reconstruction of the inguinal floor

Question 15

What is the Shouldice repair?

Answer 15

Four-layer reconstruction of the inguinal floor

Question 16

What is the McVay repair? What is significant about this method of repair?

Answer 16

Inguinal floor brought to cooper’s ligament

Closes the femoral space

Question 17

True or false: all tissue repairs are without prosthetic reinforcement

Answer 17

True

Question 18

Why would you perform a tissue repair, without mesh?

Answer 18

Infection risk

Cheaper if without

Question 19

What is a Lichtenstein Mesh repair?

Answer 19

Mesh reconstruction of the inguinal floor

Question 20

What is the standard for hernia repair?

Answer 20

Lichtenstein mesh repair

Question 21

Mesh reconstruction of the inguinal floor = ?

Answer 21

Lichtenstein Mesh repair

Question 22

What is a pre-peritoneal mesh repair?

Answer 22

Placing mesh beneath the fascia to allow for pressure of abdominal contents to better hold the mesh

Question 23

What are the benefits of a pre-peritoneal mesh repair?

Answer 23

Mechanically more sound

Eliminates the need to reconstruct the internal ring

Question 24

What is a transabdominal preperitoneal laparoscopic inguinal hernia repair (TAP)?

Answer 24

Lap + incision into peritoneum + placement of mesh

Question 25

What is a total extraperitoneal preperitoneal lap inguinal hernia repair? (TEP)

Answer 25

Entry into rectus sheath, and dissection of preperitoneal space (no entry into the peritoneum)

Question 26

What are the three indications for laparoscopic repair?

Answer 26

- Bilateral inguinal hernias | - Comorbid umbilical hernias

Question 27

What are the indications for watchful waiting of inguinal hernias?

Answer 27

If pt has CV or pulmonary comorbidities, or lifts a lot for work

Question 28

When is open tissue repair indicated?

Answer 28

If infected field

Question 29

Where is the transversus abdominis muscle?

Answer 29

Deep to the internal oblique

Question 30

What happens to the posterior rectus abdominis sheath as you go inferiorly?

Answer 30

Disappears

Question 31

What are the four types of abdominal wall hernias?

Answer 31

Umbilical Incisional Epigastric Spigelian

Question 32

Where do umbilical hernias occur?

Answer 32

Umbilical stalk

Question 33

What is the prognosis for congenital umbilical hernias in infants? Acquire in Adults?

Answer 33

``` Children = will regress Adults = progress and enlarge ```

Question 34

What are incisional hernias?

Answer 34

Failure of fascial healing

Question 35

What are the risk factors for incisional hernias?

Answer 35

Lifting and straining (6 weeks (2 weeks is weakest time)

Question 36

Why are epigastric hernias repaired much more often than other types?

Answer 36

These are usually painful

Question 37

Why do you need to mark epigastric hernias when pts are awake?

Answer 37

Pt will be too relaxed and it will be hard to find

Question 38

What are Spigelian hernias?

Answer 38

Hernias at vascular perforation of the inferior semilunar line

Question 39

What is the semilunar zone?

Answer 39

Area where there is no longer fascia behind the rectus abdominus

Question 40

What is a primary repair of an abdominal wall hernia? When are these appropriate (2)?

Answer 40

Suture repair of defect. | Good for small hernias and/or contaminated fields

Question 41

What is the problem with primary hernia repairs?

Answer 41

high recurrence rate

Question 42

When are mesh reinforced repair contraindicated?

Answer 42

Contaminated fields

Question 43

What part of the body do you want to scar over the mesh?

Answer 43

Abdominal fascia

Question 44

What is an inlay mesh?

Answer 44

Between borders of herniation

Question 45

What is an overlay mesh?

Answer 45

Lay over the hernia

Question 46

What is an underlay mesh?

Answer 46

Intraperitoneal--behind the hernia

Question 47

What is a retrorectus mesh lay?

Answer 47

Between rectus abdominus and its sheath

Question 48

What is the gold standard for mesh laying?

Answer 48

Retrorectus lay

Question 49

What are the three characteristics of an ideal hernia repair?

Answer 49

1. Prevent recurrence 2. Resist infection 3. Resist intra-peritoneal adhesion

Question 50

What is Diastasis recti? Treatment?

Answer 50

Attenuation and widening of the linea alba Reassure and strengthen

Question 51

What is the appropriate way to reduce the hernia?

Answer 51

Push from sides--not on top

Question 52

True or false: incarcerated hernias are not necessarily a surgical emergency

Answer 52

True, but should be fixed

Question 53

What are strangulated hernias?

Answer 53

Hernias with compromised blood flow

Question 54

What are incarcerated hernias?

Answer 54

Hernias that cannot be reduced

Question 55

What are the ssx of strangulated hernias?

Answer 55

Redness, warmth, TTP

Question 56

True or false: hernias rarely occur through mesh

Answer 56

True

Question 57

When should a BMP be ordered with a hernia? CBC? CT?

Answer 57

``` BMP = If suspect obstruction CBC = infx CT = large or recurrent defects ```

Question 58

What makes up the superior wall of the inguinal canal?

Answer 58

2M Internal oblique Transverse abdominus muscle

Question 59

What makes up the anterior wall of the inguinal canal?

Answer 59

2A | Aponeurosis of external oblique and internal oblique

Question 60

What makes up the floor of the inguinal canal?

Answer 60

2L Inguinal ligament Lacunar ligament

Question 61

What makes up the posterior wall of the inguinal canal?

Answer 61

2Ts Transversalis fascia Conjoint Tendon

Question 62

What is the transverse line that separates where there is and is not a sheath behind the rectus abdominus?

Answer 62

Arcuate line

Question 63

What are the layers of the spermatic cord fascia? List them in order of deep to superficial. (3)

Answer 63

Internal spermatic fascia Cremasteric fascia External spermatic fascia

Question 64

From what structures are the: - Internal spermatic fascia - Cremasteric fascia - External spermatic fascia derived from?

Answer 64

Internal spermatic fascia-Transversalis fascia Cremasteric fascia - Internal oblique External spermatic fascia - External oblique