Whole Chapter

Question 1

Name the hernias in this image superiorly to inferiorly

Answer 1

Epigastric
Umbilical/paraunbilical hernia
Spigelian Hernia
Left: Inguinal hernia Right: Femoral Hernia

Question 2

Define a hernia

Answer 2

Abnormal protrusion of an organ or part of an organ through increased abdominal pressure, weakened abdominal wall, and/or congenital defects

Question 3

Hernias can be present in the Groin, flank, pelvic region, and anteriorly/ventral.

State the types within these categories

List the categories in order of decreasing incidence

Answer 3

Listed in decreasing order
Groin: Inguinal, Femoral, Pantaloon
Ventral: Umbilical, Paraumbilical, Parastomal, Spigelian, Gastroschisis, Omphalocele
Pelvic: Obturator, sciatic
Flank: Lumbar

Question 4

What is the most common type of hernia

Answer 4

Inguinal hernia (75%)

Question 5

What are the main causes of hernias

Answer 5

Primary:
Increased intra-abdominal pressure: Obesity, smoking, lifting, chronic cough

Weakened abdominal wall: Aging, post-menopause, steroid use, CTD (Marfan’s, Ehler Danlos)

Secondary:
Incision
Infection

Question 6

There are 3 uncommon hernias which are:
Richter’s Hernia:
Sliding Hernia:
Pantaloon Hernia:

Briefly explain what each is

Answer 6

Richter’s Hernia: Partial thickness of bowel trapped within sac leading to small bowel obstruction (picture)
Sliding Hernia: Peritoneal covered structure (colon bladder) slides extraperitoneally
Pantaloon Hernia: Direct + indirect hernia simultaneously

Question 7

A hernia causing bowel obstruction is called

Answer 7

Incarcerated hernia

Question 8

An inguinal hernia most typically occurs in males 50+. What is the relation of an inguinal hernia to the pubic tubercle?

Answer 8

Above and medial to pubic tubercle

Question 9

What are the different types inguinal hernias

Answer 9

Direct
Indirect
Pantaloon

Question 10

what is the pathogenesis of a direct inguinal hernia?

Answer 10

Protrudes through the transversalis fascia in Hasselbach’s triangle

Question 11

What is the path of an indirect inguinal hernia

Answer 11

Deep ring -> inguinal canal -> superficial ring +/- Spermatic cord

Question 12

Direct and indirect hernias can anatomically be identified on either side of a vessel. What is that vessel and what is the location of each type of inguinal hernia to it?

Hint: This vessel forms a boundary of Hasselbach’s triangle

Answer 12

Direct Inguinal hernia lies medial to the inferior epigastric vessels (and hence within the triangle)

Indirect inguinal hernia lies lateral to the inferior epigastric vessels

Question 13

What are the boundaries to the Hasselbach triangle?

What type of hernia passes through it?

Answer 13

Direct inguinal hernia

Medial: Rectus muscle
Lateral: Inferior epigastric vessels
Inferior: Inguinal ligament/pubic bone (Inguinal hernias lie above and medial to the pubic tubercle)

Extra:
Anterior: Transverse facia

Question 14

Direct and indirect hernias are associated with congenital abnormalities including Ehler danlos and marfan’s syndrome. There is another congenital abnormality that predisposes a person to an indirect hernia specifically. What is it?

Also, which part of the path of the inguinal hernia does it apply to?

For reference:
Deep ring -> inguinal canal -> superficial ring +/- Spermatic cord

Answer 14

Congenital persistent processus vaginalis

Superficial ring

Question 15

An indirect hernia may enter the spermatic cord causing increased sx. What are the contents of the spermatic cord (sorry)

Answer 15

3 vessels:
Testicular artery and vein
Vas deferens artery and vein
Cremesteric Artery and vein

3 Others:
Lymphatics
Spermatic cord (Cremesteric)
Vas Deferens

3 Fascia:
External spermatic fascia
Internal spermatic fascia
Cremesteric muscle and fascia

4 nerves:
Nerve to cremaster
Sympathetic nerves
Ilioinguinal nerve
Genitofemoral nerve

Question 16

Inguinal hernias may be associated with some discomfort and pain. What exacerbated it?

Answer 16

Worse with prolonged standing

Question 17

How can an inguinal hernia present?

Answer 17

Most commonly asymptomatic and due to appearance of a lump

Actual presentation
Lump
Pain worse with prolonged standing -> Severe pain with strangulation
+/- obstruction (nausea, vomiting, constipation)

Question 18

Is an inguinal hernia typically reducible?

Answer 18

Yes but can be irreducible (associated with incarceration)

Question 19

An inguinal hernia presenting with acute pain is an indication of?

Answer 19

strangulation

Question 20

A patient presents with a hernia which you identify as an inguinal hernia. What investigations will you perform to correctly diagnose it?

Answer 20

Bedside: clinical examination to confirm it (superior and medial to pubic tubercle)

Bloods: Routine FVS, CRP, lactate

Imaging: Groin Us (typically not needed as it is a clinical diagnosis)

Question 21

A 65 year old male patient presents with a lump and is disturbed of its appearance. He is otherwise well. What is the management you will provide to this patient?

Answer 21

Routine referral to surgical repair

Question 22

A 65 year old male patient presents with a lump and is disturbed of its appearance. He is otherwise well. You refer them to routine surgical repair. In general, what are the options you have?

How will you decide between them?

Answer 22

1) Open mesh repair (tension free) - First-line
2) Non-mesh repair (tissue approximation) - In the presence of an infection
3) Laparoscopic Herniorrhaphy - In the case of bilateral or recurrent hernias

Question 23

You are asked what an open mesh repair of an inguinal hernia is by your examiner

Answer 23

First line surgical treatment of an inguinal hernia. It utilizes non-absorbable mesh to strengthen the posterior wall of the deep ring/inguinal canal under local anaesthesia and sedation

Question 24

A laparoscopic herniorrhaphy is used to treat bilateral or recurrent inguinal hernias.
What are the 2 types?
What is it?

What are the contraindications?

Answer 24

TEP - Totally extraperitoneal repair
TAPP - Transabdominal pre-peritoneal repair

It is a more intensive mesh-based (both types) surgical procedure to repair recurrent or bilateral inguinal hernias via a tension force under GA

contraindications:
Infection
Ascites
GA intolerance
Previous pre-peritoneal surgery (total abdominal hysterectomy, C-section)

Question 25

What are the complications of surgical repair of a hernia?

Answer 25

General: Infectious: Wound site infection, sepsis, UTI (catheter use during surgery), pneumonia Bleeding: Post-op bleeding, haematoma Thromboembolic: DVT, PE, stroke Cardiovascular: MI, arrhythmia, A.fib, stroke Anaesthetics: Atelectasis/barotrauma from intubation, GA intolerance, if spinal, LP (traumatic, incorrect) Other: Chronic pain, delayed wound healing, Adhesions!! Specific: Urinary retention Scrotum: Paraesthesia (labia majora in women), haematoma, atrophy Recurrence

Question 26

A 65 year old male patient presents with a lump and is disturbed of its appearance. He is otherwise well. You refer them to routine surgical repair and they ask you if there is anything they should know for after the surgery. What will you tell them?

Answer 26

Avoid heavy lifting for 6-8 weeks post-procedure

Question 27

A 65 year old male patient presents with a lump and is disturbed of its appearance. He is otherwise well. You refer them to routine surgical repair. On followup, they are noted to experience 2 complications of the surgery which are testicular atrophy and paraesthesia in the scrotum. What are the causes of these?

Answer 27

Both due to damage to the spermatic cord Paraesthesia in the scrotum or labia majora are due to damage to the ilioinguinal nerve Testicular atrophy due to damage to the testicular artery

Question 28

What is the location of the femoral hernia compared to the pubic tubercle?

Answer 28

Below and lateral to the pubic tubercle (inferolateral)

Question 29

What is the typical presentation of a femoral hernia?

Answer 29

60% present with a lump (in a female typically >70) 40% present as emergency due to high risk of stangulation

Question 30

Why does a femoral hernia have a higher risk of strangulation than an inguinal hernia?

Answer 30

Due to the narrow neck

Question 31

Does a femoral hernia typically have a cough impulse?

Answer 31

no

Question 32

Femoral hernias What are the components of the Femoral triangle? What are the contents of the femoral triangle? What are the contents of the femoral canal?

Answer 32

Lymphatics + fat

Question 33

What is the management for a femoral hernia?

Answer 33

All should be surgically required due to high risk of strangulation

Question 34

What is Saphena Varix? Where is the saphena varix located? How would you examine it?

Answer 34

A saphena varix is a venous swelling caused by dilation of the saphenous vein at the SFJ (3cm inferolateral to pubic tubercle - same as femoral hernia) Inspection: Blue lump in groin, disappears when supine (unlike femoral hernia), cough impulse Palpation: Empties with pressure Tourniquet and Trendelenburg test

Question 35

Explain both the Tournquet and Trendelenburg test?

Answer 35

Tourniquet test: Lie patient flat, perform straight leg raise and put on shoulder. Milk empty veins by massaging blood back towards the groin and apply the tourniquet around the upper thigh. Get patient to stand up and observe leg for refilling: Rapid refilling on standing before tourniquet = incompetence below the SFJ No refilling on standing and rapid filling on tourniquet release = SJF incompetence Trendelenburg test is the same but use fingers to occlude SFJ (3 cm inferolateral to pubic tubercle)

Question 36

What are the 2 types of umbilical hernias? Give their etiology How will you manage each?

Answer 36

True: Always congenital -> Typically closes spontaneously by 3 years. if not, surgical repair Periumbilical: Always acquired -> Elective surgical repair, urgent if symptoms

Question 37

What are the 2 main RFs for an acquired umbilical hernia (periumbilical)

Answer 37

multiparity pregnancy obesity

Question 38

Incisional hernias are relatively common. They present typically as a lump/defect. How does size affect prognosis? Give 4 RFs What is the main indication for surgical repair?

Answer 38

Smaller is worse as it has an increased risk of strangulation RFs: Post-op infection Multiple operations in same site Abdominal obesity Poor muscle quality (smoking, anaemia) Poor choice of incision Inadequate closure technique Surgical repair if symptomatic/strangulated

Question 39

What is a spigelian hernia? How will you diagnose it? How will you manage it?

Answer 39

Herniation through a defect between the lateral border of the rectus abdominus and the linea semiulnaris Diagnosis is difficult clinically => requires US/CT Management is direct surgical repair

Question 40

An obturator hernia is a defect through the obturator canal. What is the presentation of it? How is it diagnosed and managed?

Answer 40

Compression of the obturator nerve => Motor: Hip adduction -> Trendelenburg gait Sensory: Pain and paraesthesia in medial thigh and knee joint Dx: CT required like for spigelian Mx: High risk of strangulation => direct surgical repair (also like spigelian)