Deck 4: Repair of Hernias

Question 1

Charles Wilkins had a laparoscopic hernia repair with good results and an uneventful recovery. Weeks later, as he reviewed his hospital bill, he noted that he had been charged for a very expensive preperitoneal distention balloon, polypropylene mesh, an endomechanical stapler, and three endosurgical trocars. What hernia repair technique was probably performed on Charles?

A)TAPP repair
B)Laparoscopic Bassini repair
C)TEP repair
D)Mesh-plug insertion repair

Answer 1

C
The totally extraperitoneal patch (TEP) laparoscopic hernia repair technique was used on Charles. Access to the posterior rectus sheath is gained by trocar insertion in the periumbilical region. A balloon dissector is placed on the anterior surface of the posterior rectus sheath and inflated, thereby creating an optical cavity. The proximal peritoneal sac is closed with loop ligature to prevent pneumoperitoneum from occurring. A piece of polypropylene mesh is inserted; unfolded to cover the direct, indirect, and femoral spaces and rest over the cord structures; and carefully secured with a tacking stapler.

Question 2

While direct and indirect hernias both protrude into the inguinal canal and represent tears in the transversalis fascia, which one of the two occurs within the Hesselbach triangle?

A)Direct inguinal hernia
B)Indirect inguinal hernia
C)Both options occur within the triangle
D)Neither option occurs within Hesselbach's triangle

Answer 2

A
The triangle formed by the deep epigastric vessels laterally, the inguinal ligament inferiorly, and the rectus abdominis muscles medially is referred to as the Hesselbach triangle. Hernias that occur within the Hesselbach triangle are called direct inguinal hernias. Indirect inguinal hernias occur laterally to the deep epigastric vessels. Both direct and indirect hernias represent attenuations or tears in the transversalis fascia. Direct hernias protrude into the inguinal canal but not into the cord, and therefore rarely into the scrotum.

Question 3

Contributing factors to hernia formation include age, gender, previous surgery, obesity, nutritional status, and pulmonary and cardiac disease. The formation of the hernia at a site of weakness is due to any number of conditions that cause:

A)impaired healing and defective collagen formation.
B)thinning and stretching of muscle fibers.
C)increased pressure within the abdomen.
D)loss of tissue elasticity.

Answer 3

C
Any number of conditions causing increased pressure within the abdomen can contribute to the formation of a hernia. Loss of tissue turgor occurs with aging and from chronic debilitating diseases. Current evidence suggests that adult male inguinal hernias are likely associated with impaired collagen metabolism and weakening of the fibroconnective tissue of the groin. Smoking has also been noted as a contributing factor to hernia formation.

Question 4

Hernia-entrapped viscera, typically loops of small intestine, will result in intestinal obstruction with resulting pain, vomiting, and distention. What is the appropriate descriptive diagnosis of this condition?

A)Nonreducible hernia
B)Incarcerated hernia
C)Torsion of the hernia sac
D)Gangrenous bowel

Question 5

Of the open hernia procedures listed below, which classic hernia procedure is considered, by some surgeons, to not be anatomically correct because the superior transversalis fascia is sutured to the inguinal ligament instead of to the inferior portion of the transversalis fascia or the Cooper ligament?

A)Shouldice repair
B)Bassini repair
C)McVay repair
D)Cooper repair

Question 6

Ryan has an indirect hernia that is characterized by a small neck, thin walls, and close attachment to the cord structures. Marc has a hernia with a short, wide neck, and a thick-walled sac. Based on this description, Ryan has a(n) ____________ hernia and Marc has a(n) __________ hernia.

A)acquired; congenital
B)reducible; nonreducible
C)congenital; acquired
D)pantaloon; sacular

Question 7

The anterolateral abdominal wall consists of an arrangement of muscles, fascial layers, and muscular aponeuroses lined interiorly by peritoneum and exteriorly by skin. The key landmark of the _____________ designates the roof of the inguinal canal and the key landmark of the __________ designates the floor of the inguinal canal.

A)external oblique aponeurosis; transversalis aponeurosis and fascia
B)lateral rectus abdominis; transversalis aponeurosis and fascia
C)external oblique aponeurosis; Poupart ligament
D)transversalis aponeurosis and fascia; Cooper ligament aponeurosis

Question 8

Femoral hernias occur more frequently in which group of individuals?

A)Postoperative obese patients
B)Newborns
C)Weight lifters
D)Females

Question 9

The mesh-plug open hernia repair technique is indicated for which type(s) of hernias?

A)Femoral hernias
B)Indirect inguinal hernias
C)Direct inguinal hernias
D)All of the options are correct

Question 10

Identify the triad of anatomic sites of abdominal wall weakness with a potential for hernias.

A)Groin, ventral line, umbilicus
B)Inguinal rings, femoral canal, incision
C)Inguinal canal, femoral rings, umbilicus
D)Ventral line, aponeurosis, inguinal canal

Question 11

An example of a common postoperative complication related to inguinal hernia surgery is:

A)delayed return to activity.
B)delayed healing.
C)postoperative adhesions.
D)hernia recurrence.

Question 12

Morris Bettelman, an 86-year-old retired plumber, states that he has suffered from a groin hernia all of his adult life; he states, "as far back as I can remember." Sometimes he has to push the bulge back into his abdominal muscle and then he is fine until he has a coughing spell. This morning the bulge was large and tender when he woke up and he could not reduce it. As the pain increased, he felt weak and nauseous. His daughter took him to the emergency department. Morris was diagnosed with a strangulated incarcerated hernia and scheduled for emergency surgery. If the contents of Morris' hernia sac become compromised, with strangulation of the bowel, the probable label on his surgical specimen will be:

A)compromised bowel.
B)strangulated bowel.
C)necrotic bowel.
D)intestinal obstruction.

Question 13

A group of United Kingdom (UK) researchers undertook an analysis of several research studies comparing the outcomes of laparoscopic versus open incisional hernia repair of patients who had prior laparotomies. They examined surgical time, duration of hospital stay, perioperative complications, postoperative surgical site pain, and recurrence rates in 183 patients whose incisional hernias were repaired by the open approach and 183 repaired by the laparoscopic approach. Based on the results of this study, an appropriate risk reduction strategy for patients with incisional hernias would be to repair incisional hernias:

A)laparoscopically.
B)through an open approach.
C)using either open or laparoscopic approaches for equally good patient outcomes.
D)with the open approach to decrease surgical time.

Question 14

What composes the lining of a herniated abdominal sac?

A)Fascia
B)Peritoneum
C)Muscularis
D)Rectus abdominis muscle

Question 15

Depending on their location, hernias are classified as direct inguinal, indirect inguinal, femoral, umbilical, incisional, or epigastric. Hernias in any of these groups are either reducible or nonreducible. The characteristic "reducible" hernia can best be described as a hernia:

A)that does not require surgical repair.
B)that is an emergent diagnosis.
C)with visceral contents that can be returned to the abdomen.
D)with a narrow sac neck that is closed with adhesions.

Question 16

Select the triad of the boundaries of the Hesselbach triangle.

A)Inguinal ligament, rectus abdominis muscle, deep epigastric vessels
B)Rectus abdominis muscle, Cooper ligament, aponeurosis
C)Scarpa's fascia, deep epigastric vessels, external oblique muscle
D)Inguinal ligament, inguinal canal, Cooper ligament

Question 17

Which two similar hernia repair approaches reestablish the integrity of the transversalis fascia and simultaneously reestablish and strengthen the posterior inguinal floor by sewing the transversalis fascia to the Poupart ligament?

A)The Shouldice and the McVay ligament repair
B)The Bassini and the Shouldice repair
C)The McVay and the Cooper ligament repair
D)The Shouldice and the Cooper ligament repair

Question 18

Select the most common hernia that occurs in both males and females and name the side on which it would most likely occur.

A)Direct femoral hernia on the left
B)Indirect inguinal hernia on the right
C)Indirect femoral hernia on the left
D)Direct inguinal hernia on the right

Question 19

A study was conducted that compared laparoscopic and open-mesh methods of inguinal hernia repair and also compared TEP and TAPP techniques for cost and patient outcome effectiveness. Some of the factors measured included patient's return to prior activities, persisting pain and numbness, infection, length of operation time, and complications. The researchers discovered several compelling findings and many differences between the two approaches. Select two statements that reflect true findings from the study.

A)TEP and TAPP techniques were of similar cost to the patient.
B)Mesh infection rate was low with both techniques.
C)There was no significant difference in complication rates.
D)There was no apparent difference in the rate of hernia recurrence.
E)Return to work and activity was similar for the two techniques.f. TEPP and open-mesh techniques shared equal costs to the patient.

Question 20

The transabdominal preperitoneal patch (TAPP) hernia repair and the totally extraperitoneal patch (TEP) repair differ in the manner in which access is gained to the preperitoneal space. Which of the two provides access to the preperitoneal space without entering the peritoneum?

A)The TEP technique
B)The TAPP technique
C)Both techniques require access into the peritoneal compartment
D)Neither technique enters the peritoneal compartment