Ventral/Epigastric/Random Hernias

Question 1

Which of the following is NOT categorised as a ventral hernia, which is a herniation in the anterior abdominal wall.

1 - paraumbilicial/umbilical hernia
2 - direct inguinal hernia
3 - epigastric hernia
4 - incisional hernia

Answer 1

2 - direct inguinal hernia

• these are the most common forms of ventral hernias

Question 2

Where does a paraumbilicial/umbilical hernia occur?

1 - defect in deep inguinal ring
2 - linea semilunaris
3 - midline defect in linea alba
4 - rectus abdominus

Answer 2

3 - midline defect in linea alba

• close to umbilicus

Question 3

What % of the adult population will experience a ventral hernia?

1 - 0.2-0.5%
2 - 2-5%
3 - 20-50%
4 - >60%

Answer 3

2 - 2-5%

Question 4

Which of the following is NOT a common risk factor for a paraumbilical/umbilical hernia?

1 - increased abdominal pressure (pregnancy/ascites)
2 - male gender
3 - obesity

Answer 4

2 - male gender

• 3:1 more common in females

Question 5

Are congenital or acquired paraumbilical/umbilical hernias more common?

Answer 5

• 10% are congenital
• 90% are acquired
• involution of umbilical vessels is most common cause of congenital hernia

Question 6

Which of the following is NOT a common presentation of an paraumbilical/umbilical hernias?

1 - pain
2 - palpable/visible lump
3 - tenderness
4 - respiratory distress

Answer 6

4 - respiratory distress

Question 7

When is a paraumbilical/umbilical hernia a medical emergency?

1 - incarcerated
2 - pain
3 - change in bowel habits
4 - strangulated

Answer 7

1 - incarcerated
- can be chronic or asymptomatic
- normally involves abdominal wall fat

4 - strangulated
- can involve large bowel
- cause a bowel obstruction

Question 8

Malignancy of which lymph node is commonly linked with being a differential diagnosis for an paraumbilical/umbilical hernia?

1 - popliteal node
2 - virchows lymph node
3 - sister josephs node
4 - cloquet node

Answer 8

3 - sister josephs node

• 50% are GI malignancy
• 25% are gynaecological cancer

Question 9

In addition to the sister mary joseph lymph node as a differential for paraumbilical/umbilical hernia is divarication of the rectus muscles. What is this?

1 - linea alba becomes stiff and ruptures
2 - abdominal muscles do not form in development
3 - stretched and weakened linea alba

Answer 9

3 - stretched and weakened linea alba

• distance between rectus abdominus becomes larger
• also referred to as diastasis

Question 10

In patient who have divarication of the rectus, also known as diastasis which is a seperating of the linea alba is not typically treated surgically due to poor results. Which of the following is typically NOT a risk factor for diastasis?

1 - increasing age
2 - obesity
3 - increased abdominal pressure
4 - gender

Answer 10

4 - gender

Question 11

Paraumbilical/umbilical hernias are commonly treated only when the patient becomes symptomatic or the opening enlarges. What size are Paraumbilical/umbilical hernias commonly?

1 - <0.1cm
2 - <1cm
3 - <2cm
4 - <4cm

Answer 11

2 - <1cm

• generally repaired laparoscopically
• either mesh or just repair
• always a risk of infection and/or chronic pain

Question 12

What is the definition of an epigastric hernia?

1 - defect in linea alba between pubic symphysis and xiphoid process
2 - defect in linea alba between
arcuate line and xiphoid process
3 - defect in linea alba between umbilicus and xiphoid process

Answer 12

3 - defect in linea alba between umbilicus and xiphoid process

Question 13

What % of hernias in adults are accounted for by epigastric hernias?

1 - 0.2-0.3%
2 - 2-3%
3 - 22-33%
4 - >50%

Answer 13

2 - 2-3%

• relatively rare

Question 14

Which of the following is NOT typically a risk factor for an epigastric hernia?

1 - gender
2 - obesity
3 - pregnancy
4 - older age

Answer 14

1 - gender

Question 15

Are epigastric hernias more common in men or women?

Answer 15

• men are 4 times more likely

Question 16

Epigastric hernias are not commonly large defects in the linea alba and generally only contain abdominal fat. What stops the bowel being present in epigastric hernias?

1 - xiphoid process
2 - rectus abdominus
3 - falciform ligament
4 - pancreas

Answer 16

3 - falciform ligament

Question 17

Epigastric hernias can be symptomatic of asymptomatic, depending on the size of the defect. If a patient presents with symptoms, which of the following is NOT a common symptom?

1 - bowel obstruction
2 - palpable lump
3 - pain

Answer 17

1 - bowel obstruction

• bowel not generally involved due to falciform ligament

Question 18

Which of the following is NOT commonly included as a differential in patients with a suspected epigastric hernia?

1 - divarication of the rectus / diastsis
2 - intra-abdominal mass
3 - bowel obstruction
4 - skin lesion

Answer 18

3 - bowel obstruction

Question 19

Generally epigastric hernias are managed conservatively unless they enlarge or become symptomatic

Question 20

How big are epigastric hernias generally?

1 - <0.5cm
2 - <1cm
3 - <2cm
4 - <4cm

Answer 20

1 - <0.5cm

Question 21

What is an incisional hernia?

1 - a patients abdomen is punctured with a sharp object
2 - congenital weakness in linea alba
3 - weakness of abdomen due to previous surgery
4 - defect causes during embryological development

Answer 21

3 - weakness of abdomen due to previous surgery

Question 22

Following surgery to the abdominal wall the strength of the abdominal wall is always reduced. What % of the original wall strength is the abdomen following surgery?

1 - 0.7%
2 - 7%
3 - 37%
4 - 70%

Answer 22

4 - 70%

• sutures can cut through tissue leaving a defect

Question 23

Wounds closed under tension is a risk factor for an incisional hernia. Why does closing under tension increase the risk of an incisional hernia?

1 - damages peritoneum
2 - cause necrosis of tissue and tissue weakens
3 - can damage organs
4 - skin is unable to heal properly

Answer 23

2 - cause necrosis of tissue and tissue weakens

Question 24

In addition to closing a wound under tension, there are multiple risk factors for an incisional hernia. Which of the following is NOT a risk factor?

1 - wound infections
2 - gender
3 - diabetes
4 - immunosuppression (including steroids)
5 - obesity
6 - midline incisions (up to 20% for midline laparotomies)
7 - smoking

Answer 24

2 - gender

• diabetes and immunosuppression (including steroids) can cause poor wound healing and increase risk of infection

Question 25

The majority of incisional hernias are asymptomatic. However, they can be associated with symptoms. but which of the following is NOT common? 1 - bulge or lump at site of previous incision 2 - pain 3 - GI upset 4 - anorexia

Answer 25

4 - anorexia

Question 26

When is an incisional hernia a medical emergency? 1 - incarcerated 2 - pain 3 - change in bowel habits 4 - strangulated

Answer 26

1 - incarcerated 4 - strangulated

Question 27

Although ultrasound is used for smaller incisional hernias, what imaging technique is used for larger incisional hernias? 1 - MRI 2 - PET scan 3 - CT 4 - X-ray

Answer 27

3 - CT - useful for looking at abdominal wall prior to surgery

Question 28

Surgery to treat a patient with an incisional hernia can be simple or complex and be laparoscopic or laparotomy. This can include a parastomal hernia and large midline hernias. Prior to surgery patients are asked to optimise their ability to undergo complex surgery. Which of the following is NOT a common factor patients are asked to engage in? 1 - weight loss 2 - nutrition 3 - optimise medication 4 - improve cardiorespiratory fitness 5 - stop oral contraception

Answer 28

5 - stop oral contraception

Question 29

There are lots of unusual hernias. What is a Littre hernia? 1 - inguinal hernia containing the appendix 2 - herniation of part of the bowel 3 - inguinal hernia containing meckels diverticulum 4 - hernia occurring along the semilunar line

Answer 29

3 - inguinal hernia containing meckels diverticulum

Question 30

There are lots of unusual hernias. What is a Amyands hernia? 1 - inguinal hernia containing the appendix 2 - herniation of part of the bowel 3 - inguinal hernia containing meckels diverticulum 4 - hernia occurring along the semilunar line

Answer 30

1 - inguinal hernia containing the appendix

Question 31

There are lots of unusual hernias. What is a Richters hernia? 1 - inguinal hernia containing the appendix 2 - herniation of part of the bowel 3 - inguinal hernia containing meckels diverticulum 4 - hernia occurring along the semilunar line

Answer 31

2 - herniation of part of the bowel - common in femoral hernias

Question 32

There are lots of unusual hernias. What is a Spigellian hernia? 1 - inguinal hernia containing the appendix 2 - herniation of part of the bowel 3 - inguinal hernia containing meckels diverticulum 4 - hernia occurring along the semilunar line

Answer 32

4 - hernia occurring along the semilunar line

Question 33

There are lots of unusual hernias. What is an obturator hernia? 1 - inguinal hernia containing the appendix 2 - herniation of bowels through the obturatory foreman of pelvis 3 - inguinal hernia containing meckels diverticulum 4 - hernia occurring along the semilunar line

Answer 33

2 - herniation of bowels through the obturator foreman of pelvis