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?

Accepted Answer

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?

Accepted Answer

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:

Accepted Answer

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?

Accepted Answer

Patients with incarcerated hernias may have signs of intestinal obstruction, such as vomiting, abdominal pain, and distention. The greatest danger of an incarcerated hernia is that it may become strangulated.

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?

Accepted Answer

The Bassini repair procedure was introduced in 1887 and was formerly the standard of repair. In this procedure the conjoined tendon and the shelving edge of the inguinal ligament are sutured together up to the internal ring. The major difference with this repair is that the superior transversalis fascia is sutured to the inguinal ligament with no attempt made to approximate it to the inferior portion of the transversalis fascia or the Cooper ligament. Critics of this procedure claim that it is not anatomically correct because layers that normally are not integrated (transversalis fascia and inguinal ligament) now are approximated.

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.

Accepted Answer

Indirect hernias may be either congenital, representing a persistence of the processus vaginalis, or acquired. In a congenital hernia, the hernia sac has a small neck, is thin-walled, and is closely bound to the cord structures. In an acquired indirect hernia, the neck is wide and the sac is both short and thick-walled. When both direct and indirect hernias are present, the defect is called a pantaloon hernia after the French word for "pants," which this situation suggests.

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.

Accepted Answer

The anterolateral abdominal wall consists of an arrangement of muscles, fascial layers, and muscular aponeuroses lined interiorly by peritoneum and exteriorly by skin . The roof of the inguinal canal is formed by the external oblique aponeurosis, and the floor is formed by the transversalis aponeurosis and fascia. Essential to an understanding of inguinal hernia repair is an appreciation of the central role of the transversalis fascia as the major supporting structure of the posterior inguinal floor. The inguinal canal is covered by the aponeurosis of the external abdominal oblique muscle, which forms a roof .

Question 8

Femoral hernias occur more frequently in which group of individuals?

Accepted Answer

Femoral hernias occur much more frequently in females, and only 2% of females will develop inguinal hernias in their lifetime.

Question 9

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

Accepted Answer

The mesh-plug technique has been recommended for the treatment of primary and recurrent direct and indirect inguinal hernias. The various hernia types as classified by Gilbert have a corresponding relationship to the use of mesh plugs type I through type VII. Femoral hernias are classified as type VII. Regardless of the hernia type, the mesh-plug technique is performed on an ambulatory basis, through a small incision, often laparoscopically. In femoral hernias, a small- or medium-size plug is secured in position after the sac has been reduced.

Question 10

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

Accepted Answer

The weak places or intervals in the abdominal aponeurosis are (1) the inguinal canal, (2) the femoral rings, and (3) the umbilicus.

Question 11

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

Accepted Answer

A successful herniorrhaphy is measured by the percentage of recurrence, the number of complications, the total costs, and the ability to return to normal activities of daily living.

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:

Accepted Answer

In a strangulated hernia, the blood supply of the trapped sac contents becomes compromised and eventually the sac contents necrose. When bowel is strangulated in such a hernia, resection of necrotic bowel, in addition to repair of the hernia defect, becomes necessary. This is a surgical emergency.

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:

Accepted Answer

Open repair was associated with significantly higher complication rates and longer hospital stays, as well as longer surgical times than laparoscopic repair. There was no statistical difference in surgical site pain or recurrence rates. The researchers concluded that laparoscopic repair of incisional hernias is a safe, feasible, and effective alternative to open repair techniques.

Question 14

What composes the lining of a herniated abdominal sac?

Accepted Answer

A hernia is a sac lined by peritoneum that protrudes through a defect in the layers of the abdominal wall. Hernias can occur in several places in the abdominal wall, with protrusion of a portion of the parietal peritoneum and often a part of the intestine. Generally, the hernia mass is composed of covering tissues, a peritoneal sac, and any contained viscera.

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:

Accepted Answer

A reducible hernia is an abdominal hernia whose contents of the hernia sac can be returned to the normal intra-abdominal position and are not trapped in the extra-abdominal sac (incarcerated). The conditions preventing the return of the hernia contents to the abdomen (nonreducible) can result from (1) adhesions between the contents of the sac and the inner lining of the sac, (2) adhesions among the contents of the sac, or (3) narrowing of the neck of the sac.

Question 16

Select the triad of the boundaries of the Hesselbach triangle.

Accepted Answer

The boundaries of the Hesselbach triangle are deep epigastric vessels laterally, inguinal ligament inferiorly, and rectus abdominis muscle medially.

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?

Accepted Answer

Approaches that reestablish the integrity of the transversalis fascia and simultaneously reestablish and strengthen the posterior inguinal floor are favored. A surgical repair in which transversalis fascia is sewn to the Poupart ligament accomplishes this goal. A McVay or Cooper ligament repair approximates transversalis fascia superior to the inferior insertion of the transversalis fascia along the Cooper ligament.

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.

Accepted Answer

Although hernias occur most often in males, the most common hernia in both males and females is the indirect inguinal hernia. Hernias occur more commonly on the right side than on the left.

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.

Accepted Answer

Laparoscopic repair was associated with a faster return to usual activities and less persisting pain and numbness. There also appeared to be fewer cases of wound infection and hematoma formation. However, operative times were longer, and there appears to be a higher rate of serious complications (e.g., bowel, bladder, and vascular injuries) with laparoscopic methods. Mesh infection is very uncommon, with similar rates noted among the surgical approaches. There is no apparent difference in the rate of hernia recurrence. The increased adoption of laparoscopic techniques may allow patients to return to usual activities faster. Economic savings in the form of fewer days of work missed and reduced workers' compensation have been reported.

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?

Accepted Answer

TEP provides access to the preperitoneal space without entering the peritoneal cavity. The TAPP uses intraperitoneal trocars and the creation of a peritoneal flap over the posterior inguinal region.

Quiz 4: Repair of Hernias