Norman Wool, M.D., José M. Velasco, M.D.
1 Components of the Hesselbach triangle have included the following anatomic landmarks except:
A Femoral vein
B Medial border of the rectus sheath
C Cooper ligament
D Inguinal ligament
E Inferior epigastric vessels
Ref.: 1-3
Comments
The inferior epigastric vessels serve as the superolateral border of the Hesselbach triangle. The medial border of the triangle is formed by the rectus sheath, and the inguinal ligament serves as its inferior border. Physical examination often cannot accurately distinguish between direct and indirect inguinal hernias. Hernias occurring within the Hesselbach triangle are considered direct hernias, whereas hernias occurring lateral to the triangle are indirect hernias. The original description of the Hesselbach triangle defined the inferior border as the ligament of Cooper (pectineal ligament). The borders were subsequently modified, with the inguinal ligament being substituted for the Cooper ligament to allow easier identification of the area by surgeons who use the traditional anterior approach for herniorrhaphy.
Answer
A
2 Which of the following statements is false regarding the iliopubic tract?
A Extends from the anterior superior iliac spine to the pubis
B Is a condensation of the transversalis fascia
C Is of anatomic interest but has little clinical significance
D Runs underneath the shelving portion of the Poupart ligament
E Many branches of the lumbar plexus run inferior to the iliopubic tract
Ref.: 1-3
Comments
The transversalis fascia is the portion of the endoabdominal fascia that underlies the transversus abdominis muscle. It has several thickenings, the most important of which is the iliopubic tract, which arises from the iliopectineal arch, inserts on the anterior superior iliac spine, and extends over the femoral vessels to the pubis. Proper utilization of the transversalis fascia during repair of an inguinal hernia is important to the success of operations not using prosthetic material. The iliopubic tract has particular significance because of its importance as a landmark to laparoscopic surgeons. Many of the branches of the lumbar plexus run inferior to the tract, and damage to these nerves may be the result of aggressive dissection or the placement of tacks or staples to affix a prosthesis below this structure.
Answer
C
3 Which of the following statements is false regarding the incidence of abdominal wall hernias?
A Two thirds of all inguinal hernias are classified as indirect.
B Femoral hernias are more common in females than in males.
C Indirect hernias are common in females.
D Hernias generally occur with equal frequency in males and females.
E Premature babies have a 10% incidence of inguinal hernia.
Ref.: 1-3
Comments
Approximately three fourths of all abdominal wall hernias occur in the inguinal region, and roughly two thirds of them are indirect inguinal hernias. Groin hernias are considered to be at least 25 times more common in males than in females. The incidence of inguinal hernias is increased by prematurity. The most common hernia in each gender is an indirect inguinal hernia. Femoral hernias are rare in men and direct hernias are uncommon in women. It has been estimated that inguinal hernias develop in 25% of males and 2% of females during their lifetime. Hernias therefore constitute a significant economic problem in terms of loss of time from work.
Answer
D
4 According to the Nyhus classification of groin hernias, which of the following statements are true?
A A type II indirect hernia has a dilated internal ring and extends into the scrotum.
B A type IIIa hernia is a classically described indirect hernia.
C A femoral hernia is classified as type IIIc.
D Type IV hernias are pantaloon-type hernias.
E Type V hernias are spigelian hernias.
Ref.: 2
Comments
Groin hernias may be primary or recurrent. They are classified as inguinal and femoral, with inguinal hernias being further subdivided into direct and indirect hernias. The Lloyd Nyhus classification further subdivided groin hernias according to their characteristics. Type I hernias are indirect hernias with a normal-size internal ring and typically occur in infants, children, and small adults. Type II hernias are indirect hernias with a dilated internal ring and an intact posterior wall and do not extend into the scrotum. Type III hernias are posterior wall defects. Type IIIa hernias are direct hernias regardless of size. Type IIIb consists of indirect hernias with a dilated internal ring encroaching on the Hesselbach triangle (massive scrotal, sliding, or pantaloon type). Type IIIc hernias are femoral hernias. Type IV consists of recurrent hernias of the direct, indirect, femoral, or a combined type. There are no type V hernias according to the Nyhus classification.
Answer
C
5 Which of the following statements is false regarding direct inguinal hernias?
A The most likely cause is destruction of connective tissue as a result of physical stress.
B Direct hernias should be repaired promptly because of the risk for incarceration.
C A direct hernia may be a sliding hernia involving a portion of the bladder wall.
D A direct hernia may pass through the external inguinal ring.
E An indirect hernia may be present as well.
Ref.: 1-3
Comments
Destruction of connective tissue as a result of the physical stress of intraabdominal pressure, smoking, aging, connective tissue disease, and systemic illnesses reduces the strength of the transverse aponeurosis and fascia. Direct inguinal hernias, therefore, are acquired from the “wear and tear” of daily life, including straining to urinate or defecate, chronic coughing, and heavy lifting. A decrease in the content of hydroxyproline in the aponeurosis of patients with hernias has been demonstrated, as well as alterations in the ultrastructure of collagen. Large direct hernias may weaken the floor of the Hesselbach triangle and result in a functional direct component. Because there is generally diffuse weakness in the area of the Hesselbach triangle without a narrow-necked sac, the risk for incarceration is low. Rarely, incarceration results when the direct hernia passes through the external ring posterior to the cord structures. Involvement of the urinary bladder as a sliding component on the medial wall of a direct hernia sac does not usually cause a problem because the sac can simply be reduced unopened. The spermatic cord should be explored to rule out the presence of an indirect sac.
Answer
B
6 A sliding inguinal hernia on the left side is likely to involve which of the following?
A Ileal mesentery composing the lateral wall of the sac
B Ovary and fallopian tube in a female infant
C Omentum
D Bladder composing the posterolateral wall of the sac
E Cecum composing the anteromedial wall of the sac
Ref.: 1-3
Comments
A sliding hernia is one in which the visceral peritoneum of an organ makes up part of the wall of the hernia sac. If the hernia is indirect, it most commonly involves the cecum on the right or the sigmoid colon on the left. The urinary bladder may also be a sliding component. In females, especially infants and children, portions of the female genital tract are often involved. Although most sliding hernias are indirect, they may also be femoral or direct. Recognition of the presence of a sliding hernia and the position of the visceral component is important to avoid injury to the involved organs during repair.
Answer
B
7 Which of the following statements is true regarding femoral hernias?
A Femoral hernias should not be repaired through an infrainguinal approach.
B Femoral hernias are more common in males than in females.
C Femoral hernias are more common than inguinal hernias in females.
D Large femoral hernias should always be repaired by the insertion of prosthetic material.
E Femoral hernias could lead to bowel obstruction, frequently as a Richter type of hernia.
Ref.: 1-4
Comments
Although femoral hernias are found more often in females than in males, inguinal hernias are still more common than femoral hernias. Femoral hernias with small orifices in women are repaired from below the inguinal ligament with a few sutures or plugged with a cone of polypropylene mesh because they are rarely associated with hernias above the inguinal ligament. Large femoral hernias can be repaired with the McVay Cooper ligament procedure or even better with a preperitoneal permanent prosthesis placed either laparoscopically or from an open preperitoneal approach. Femoral hernias should be repaired promptly because incarceration is common. Viability of the intestine must be ensured since incarceration of the antimesenteric border of the intestine (Richter hernia) could result in infarction. The presence of bloody fluid in an otherwise empty sac mandates careful examination of the intestine to rule out ischemia. The McVay repair may be preferred with incarcerated femoral hernias to avoid infection of prosthetic mesh.
Answer
E
8 Correct statements regarding the management of an incarcerated groin hernia include all of the following except:
A Immediate or urgent surgical repair is always required for incarcerated groin hernias.
B Evaluation of the contents of the hernia sac is a step required in the repair of an incarcerated hernia.
C The contents within an incarcerated hernia can be omentum, intestine, or an ovary.
D A hydrocele may mimic an incarcerated hernia.
E Inadvertent reduction of incarcerated hernia contents during induction of anesthesia does not ensure bowel viability.
Ref.: 1-3
Comments
Incarceration with potential resultant strangulation of small bowel is a serious complication of groin hernias. If the patient has an incarcerated inguinal hernia and strangulation is not suspected, an attempt at reduction by using sedation, Trendelenburg positioning, and gentle sustained pressure over the groin mass is appropriate. Reduction en masse refers to the persistent nature of incarcerated tissue frequently through the external ring despite an apparently successful reduction. If there is any indication of strangulation, reduction should not be attempted preoperatively. Rather, the sac should first be opened before reduction to inspect the viability of the contents. The presence of bloody fluid in the peritoneal cavity should raise the question of intestinal viability. Delayed repair following successful reduction may permit resolution of edema. A hydrocele can mimic an incarcerated hernia. Should physical examination fail to establish the diagnosis, a hydrocele will transilluminate clearly but a hernia will not. Ultrasound can confirm the presence of a hydrocele. The contents of an incarcerated inguinal hernia may be omentum, intestine, or an ovary. In patients with a suspected strangulated hernia, spontaneous reduction of the hernia’s contents could occur. However, the surgeon should not assume that the bowel is viable. Examination of the abdominal contents is thus mandatory.
Answer
A
9 Which of the following statements about the management of inguinal hernias in infants and children is true?
A Repair should be delayed until a child reaches school age since most inguinal hernia defects close spontaneously.
B Repair usually requires a Bassini procedure.
C The distal sac should be removed to prevent the formation of a secondary hydrocele.
D Contralateral inguinal exploration is indicated routinely because of the high risk for bilaterality.
E Intubation of the clinically apparent hernia sac with a laparoscope is one method of examining the contralateral side.
Ref.: 1-3
Comments
Inguinal hernias in infants and children are nearly always indirect and result from failure of obliteration of the processus vaginalis. Effective treatment requires only high ligation and transection of the sac with or without excision of the distal component. Repair need not be delayed unless the infant has associated medical problems. In fact, bowel obstruction and gonadal or intestinal infarction as a result of strangulation are most likely to occur during the first 6 months of life. Therefore, repair should be performed soon after the diagnosis is made. Exploration of the opposite side in children with a unilateral inguinal hernia is controversial. The incidence of a contralateral hernia following unilateral inguinal herniorrhaphy in children has been reported to be 10% to 30%. Contralateral exploration should be performed routinely in the subset of patients most likely to have a clinically occult hernia: children younger than 2 years, girls younger than 3 years (higher bilateral rate), patients with ventriculoperitoneal shunts, and children younger than 2 years with a left-sided hernia. This last recommendation is based on the fact that most (60%) pediatric hernias are right sided. Intubation of the clinically apparent hernia sac with a laparoscope is one method of examining the contralateral side.
Answer
E
10 Which of the following statements is false regarding the preperitoneal or posterior approach to repair of groin hernias?
A It may be appropriate for repair of both direct and indirect hernias.
B It may be appropriate for repair of femoral hernias.
C It is the preferred approach for repair of obturator hernias.
D The preperitoneal approach is not indicated for bilateral or recurrent hernias.
E Laparoscopic hernioplasty is an extension of the preperitoneal approach.
Ref.: 1-3
Comments
The preperitoneal approach, which involves a transverse skin incision three fingerbreadths above the pubic tubercle, has been especially successful in the repair of femoral hernias. Both direct and indirect inguinal hernias can also be approached in this manner, although many surgeons have reported higher recurrence rates for direct hernias when using this approach. Cooper ligament repair is carried out in the same way as for an anterior approach. The ligament is approximated to the transversus abdominis aponeurosis medially with a transition suture between the transversus aponeurosis, the iliopubic tract, and the Cooper ligament, with completion laterally by approximation of the iliopubic tract and transversus aponeurosis. This approach as originally described has not achieved widespread use, largely because of increased recurrence rates believed to be due to tension. Modifications of the preperitoneal approach consisting of the use of prosthetic material have made it more popular, particularly for repair of bilateral, obturator, and recurrent hernias. General or regional anesthesia is necessary. Postoperative paralytic ileus is not infrequent. Laparoscopic hernioplasty is an extension of the preperitoneal concept. In most laparoscopic repairs, the prosthesis is placed in the preperitoneal space.
Answer
D
11 Which of the following statements is true regarding mesh-plug hernioplasty?
A It cannot be performed with the patient under local anesthesia with intravenous sedation.
B It is associated with a 7% to 10% recurrence rate.
C It may be appropriate for indirect, direct, femoral, and recurrent hernias.
D A 21-day recovery period is necessary before patients can assume normal daily activities.
E Manual labor is restricted for 6 weeks postoperatively.
Ref.: 4, 5
Comments
In the 1990s, I. M. Rutkow and A. W. Robbins introduced the mesh-plug hernioplasty. In more than 3000 reported hernioplasties, a 1% overall recurrence rate has been documented for all varieties of inguinal hernias. Although Rutkow and Robbins perform the mesh-plug hernioplasty with epidural anesthesia, subsequent reports have described the procedure being performed with local anesthesia and intravenous sedation. In more than 1000 mesh-plug hernioplasties reported by K. W. Millikan and coworkers, a 0.1% recurrence rate was documented, with 96% of patients returning to normal activities within 3 days. In this series, all manual laborers returned to work without restriction on postoperative day 14. During the last decade, mesh-plug hernioplasty has become the most popular prosthetic hernia repair in the United States.
Answer
C
12 All of the following statements concerning the Lichtenstein repair are true except:
A It is performed with local anesthesia in an outpatient setting.
B Polypropylene is the most common prosthetic material used for repair.
C The medial edge of the mesh is sutured to the transversalis fascia, and the lateral edge is sutured to the inguinal ligament.
D To reduce recurrence rates, the most cephalad tails of the mesh should extend 2 to 4 cm beyond the internal ring.
E To reduce recurrence rates, the most caudal aspect of the mesh should extend at least 2 cm over the pubic tubercle.
Ref.: 1-3, 6
Comments
As commonly performed, the open herniorrhaphy technique is the tension-free repair popularized by Irving L. Lichtenstein and colleagues. The Lichtenstein repair is routinely performed in an outpatient setting with local anesthesia. Polypropylene mesh is most commonly sutured medially to the transversus abdominis arch, with the internal oblique being overlapped by approximately 2 cm. The latter edge of the mesh is sutured to the inguinal ligament. To reduce recurrence rates, Parviz Amid has described overlapping the mesh at least 2 cm over the pubic tubercle and 2 to 4 cm lateral to the internal ring. Lichtenstein encouraged patients to resume activities rapidly. The Lichtenstein repair was one of the first prosthetic repairs to achieve approximately an overall 1% or lower recurrence rate in the United States.
Answer
C
13 Which of the following is false with regard to the McVay Cooper ligament repair?
A It is appropriate for indirect and direct hernias but not for femoral hernias.
B Exposure of the Cooper ligament and the medial border of the femoral sheath is accomplished by incising the transversalis fascia.
C A relaxing incision is mandatory.
D The conjoined tendon is sutured to the Cooper ligament from the pubic tubercle laterally to the femoral canal.
E With a transition stitch, the surgeon sutures the conjoined tendon to the inguinal ligament lateral to the femoral canal.
Ref.: 1-3
Comments
Cooper ligament hernioplasty is used to repair the three most vulnerable areas for herniation in the myopectineal orifice—the deep ring, the Hesselbach triangle, and the femoral canal—and is therefore indicated for the three common types of hernia of the groin. In the McVay repair, the conjoined tendon is sutured to the Cooper ligament laterally. Exposure of the Cooper ligament is accomplished by incising the transversalis fascia and entering the preperitoneal space. A relaxing incision is mandatory because there is otherwise too much tension on the suture line. A transition stitch is necessary to suture the conjoined tendon to the inguinal ligament beyond the femoral canal. The internal inguinal ring is recreated with adequate laxity to allow easy passage of the tip of a Kelly clamp adjacent to the cord structures.
Answer
A
14 Which of the following hernias is most likely to recur after primary repair?
A Epigastric hernia
B Spigelian hernia
C Indirect hernia
D Femoral hernia
E Incisional hernia
Ref.: 1-3
Comments
Primary repair of incisional hernias can be associated with a 30% to 50% or higher recurrence rate, depending on the size of the hernia. Except for small incisional hernias, prosthetic mesh is necessary to reduce recurrence rates to 10% or possibly less. Patients with incisional hernias usually have predisposing factors, such as obesity, chronic debilitating illness, diabetes, advanced age, and smoking. The predisposing factors also play a role in the failure of primary repair. Recurrence rates after the other listed hernia repairs should all be 5% or less.
Answer
E
15 Which of the following developments has not led to a decrease in recurrence rates after groin hernia repair?
A Modifications of the Bassini repair
B Routine use of prosthetic material
C Widespread acceptance of the “tension-free” concept
D Use of the preperitoneal space for hernia repair
E Use of laparoscopy in hernia repair
Ref.: 1-3
Comments
Recurrence rates for groin hernias vary from less than 1% to 30%. True recurrence rates are difficult to establish because of inadequate patient follow-up. The Bassini repair and its modifications (Shouldice and McVay) all create tension at the suture line and have been found to have recurrence rates between 10% and 30% when performed outside specialized centers. Several developments in the latter half of the twentieth century have significantly influenced the currently accepted level of a recurrence rate of less than 5%. The routine use of prosthetic material to perform a tension-free hernia repair became accepted by surgeons after being popularized by Lichtenstein in the 1980s. Others, such as Rutkow, Robbins, R. D. Kugel, A. Gilbert, G. Wantz, R.E. Stoppa, and Nyhus, have used multiple prosthetic materials and approaches to continue to reduce the recurrence rate to below 1%. The most popular prosthetic materials are polypropylene, polyester fiber mesh, and polytetrafluoroethylene. Use of the preperitoneal space also helped lower recurrence rates by allowing larger pieces of prosthetic material to be used and incorporating intraabdominal pressure to aid in keeping the mesh in place. Laparoscopy by itself has not helped lower recurrence rates below those achieved with open tension-free mesh repairs, but it has given the surgeon another option for accessing the preperitoneal space.
Answer
A
16 Which of the following is not true regarding laparoscopic hernia repair?
A Local anesthesia with sedation is the most common form of anesthesia used.
B It could lead injury to the genitofemoral nerve and the lateral femoral cutaneous nerve.
C Transabdominal preperitoneal or total extraperitoneal approaches are commonly used.
D Fixation devices for the mesh should not be placed below the iliopubic tract.
E It is best suited for recurrent and bilateral hernias.
Ref.: 1-3, 7
Comments
Laparoscopic techniques for repair of inguinal hernias were introduced in the 1990s and have gained mild to moderate acceptance, with less than 10% of all inguinal hernia repairs being performed via these approaches. The repairs are usually performed with the patient under general anesthesia, and cost is considerably higher than an open approach with local anesthesia and sedation. Although there is controversy regarding its use for unilateral, newly diagnosed hernias, it seems ideally suited for recurrent and bilateral hernias, where the disability and technical difficulty associated with open (conventional) repairs cannot be overlooked. Laparoscopy can be performed totally extraperitoneally by dissecting within the preperitoneal space or transabdominally. In either case, a preperitoneal repair is performed. Mesh fixation devices placed below the iliopubic tract risk injury to the genitofemoral nerve and the lateral femoral cutaneous nerve. Placement of fixation devices is also avoided below the internal inguinal ring in an area known as the “triangle of doom.“ This triangle is bordered laterally by the spermatic vessels and medially by the vas deferens. Located within this triangle are the external iliac artery and vein and the femoral nerve.
Answer
A
17 Indications for preperitoneal laparoscopic repair of groin hernias include all of the following except:
A Pregnancy
B Irradiation
C Prior open mesh repair
D American Society of Anesthesiologists Physical Status II (ASA II)
E Bilaterality
Ref.: 1, 8
Comments
Pregnancy is a contraindication to elective laparoscopic repair of a groin hernia. Irradiation of the lower abdominal wall is a relative contraindication to preperitoneal repair. A previous low midline incision from prostate or bladder surgery or irradiation may make it difficult to enter and dissect the preperitoneal space. The latter two contraindications may dictate an open anterior approach. Bilaterality and failed open mesh repair are indications for laparoscopic preperitoneal repair. Even though laparoscopic repair could be performed with the patient under local or regional anesthesia, it is usually best done under general anesthesia. Therefore, patients with severe risk factors are not candidates for it.
Answer
A
18 Which of the following is a true statement regarding umbilical hernias?
A They are the embryonic equivalent of a small omphalocele.
B Repair in infants is usually deferred until approximately 1 years of age.
C Repair in adults is generally indicated.
D The “vest-over-pants” type of repair is stronger than simple approximation of fascial margins.
E They are most common in white infants.
Ref.: 1-3
Comments
Umbilical hernias are the result of a patent umbilical ring, whereas an omphalocele is the result of failure of abdominal wall closure in the midline during early intrauterine life. Umbilical hernias are said to be present in 40% to 90% of African-American infants. Incarceration is rare in infants. Unless the defect is large, most surgeons defer repair until the child is approximately 4 years of age because spontaneous closure does occur. In adults, however, repair should be carried out promptly because of the risk for incarceration. There is no convincing evidence that a “vest-over-pants” type of repair is structurally superior to simple approximation of the fascial margins. Repair in adults may benefit from the use of prosthetic material, such as polypropylene, if the fascial defect is large or tension is present. There are several variations of mesh repairs with no evidence-based consensus of choice at this time.
Answer
C
19 Which of the following hernias represent incarceration of a limited portion of the small bowel?
A Spigelian hernia
B Grynfeltt hernia
C Petit hernia
D Richter hernia
E Littre hernia
Ref.: 1-3
Comments
Spigelian, Grynfeltt, and Petit hernias are abdominal or lumbar hernias in unusual anatomic locations. A spigelian hernia occurs at the lateral border of the rectus at the linea semicircularis. A Petit hernia occurs at the inferior lumbar triangle bordered by the latissimus dorsi, external oblique, and iliac crest. A Grynfeltt hernia occurs at the superior lumbar triangle where the internal oblique inserts on the twelfth rib. Richter and Littre hernias represent incarceration of a limited portion of the small bowel. A Littre hernia has an incarcerated Meckel diverticulum or the appendix as its contents. A Richter hernia is characterized by noncircumferential incarceration of the small bowel, usually only the antimesenteric portion. It is important to recognize Richter and Littre hernias because vascular compromise may occur without evidence of intestinal obstruction.
Answer
D
20 Which of the following statements is false with regard to the Kugel mesh repair for inguinal hernias?
A Less than a 1% recurrence rate has been documented.
B The mesh is placed in the preperitoneal space.
C The mesh is usually sutured to the conjoined tendon and the inguinal ligament.
D The repair can be performed on all varieties of inguinal hernias.
E The procedure is best performed with the patient under local anesthesia.
Ref.: 9
Comments
The minimally invasive Kugel mesh hernia repair is a preperitoneal hernia repair. The procedure is usually performed with local or epidural anesthesia through an oblique skin incision approximately 2 to 3 cm above the internal ring. A pocket is developed in the preperitoneal space, and oval mesh with a semirigid ring is placed so that it covers the femoral, direct, and indirect defects of all varieties of inguinal hernias. The mesh is not usually sutured in place, but occasionally a suture may be placed in the Cooper ligament for large direct hernias. In a series of 808 repairs, Kugel reported a 0.62% recurrence rate over a 54-month period. This repair has not gained as wide use as the Lichtenstein or plug-and-patch technique.
Answer
C
21 Which of the following items represents the optimal convalescent period required before returning to manual labor after inguinal mesh herniorrhaphy?
A 6 to 8 weeks
B 4 to 5 weeks
C 2 to 3 weeks
D 1 week
E Less than 1 week
Ref.: 1-4
Comments
Traditionally, patients who engage in strenuous activities have been allowed periods of 6 to 8 weeks to recuperate after traditional open herniorrhaphy. Studies have shown that collagen maturation and tensile strength in a hernia wound require months to reach maximal states. Tension-free repair using prosthetic material has allowed patients to return to normal activities sooner. These repairs, including the mesh-plug, Kugel, and laparoscopic procedures, have allowed patients to perform any activity that they choose as soon as they feel comfortable, which is usually within 2 to 3 weeks. In a study of mesh-plug repairs, 465 manual laborers returned to work without restriction on postoperative day 14. Studies have demonstrated longer recovery when workers’ compensation is involved.
Answer
C
22 Which of the following statements is not true with regard to incisional ventral hernias?
A Primary repairs are associated with a 30% to 50% recurrence rate.
B The incidence of incisional hernias is between 2% and 11% after laparotomy.
C Prosthetic mesh repairs have reduced the recurrence rate to 20% or less.
D Bilayer mesh can be placed safely in the intraabdominal cavity.
E Comorbid conditions, such as diabetes, hypertension, and obesity, are uncommon in patients with incisional hernias.
Ref.: 3, 10, 11
Comments
In the United States, approximately 2 million laparotomies are performed each year, with a reported incisional ventral hernia rate of between 2% and 11%. The population of patients in whom wound dehiscence occurs tends to be obese and they frequently might have one or more of the following: comorbidities of a smoking history, hypertension, and diabetes. Primary incisional ventral hernia repairs have been associated with recurrence rates of up to 50%. Prosthetic mesh repairs have lowered the recurrence rates to less than 10%. Recently, it has been found that a bilayer prosthesis composed of both polypropylene and polytetrafluoroethylene can be placed safely in the abdominal cavity without the development of bowel obstruction or enterocutaneous fistulas. Intraabdominal placement of the mesh allows the greatest underlay of the fascial defect, thereby enabling the greatest amount of tissue ingrowth to occur. When polypropylene alone is placed in the intraabdominal cavity, bowel obstruction, enterocutaneous fistula, and difficult reentrance to the abdomen occur with an unacceptable frequency.
There is increasing evidence of less recurrence with laparoscopic incisional hernia repair with mesh. This is typically an inlay with considerable overlap over the fascial defect. Postoperative discomfort and local wound problems seem to be decreased. Lighter synthetic mesh is gaining in popularity. Again, expertise and experience in this advanced laparoscopic procedure are necessary to achieve low recurrence rates and avoid serious complications. A frequent but easily treated complication of laparoscopic repair is seroma, which can occur in up to 30% to 50% of patients. It is usually self-limited. The use of drains to avoid seroma formation is controversial, and it has not been associated with a decrease in its incidence. Aspiration of seromas is best accomplished under image guidance if they are symptomatic or concern about infection exists.
Answer
E
23 Inguinal hernias:
A Are best treated with laparoscopic techniques
B Should always be repaired
C Benefit from the use of mesh in reducing recurrence later
D Are associated with a high incidence of strangulation
E Are rare in females
Ref.: 11, 12
Comments
Open anterior mesh repairs are the most frequently used repairs for inguinal hernias, with plug-and-patch and Lichtenstein repairs being the most common. The benefit of laparoscopic repair is still controversial, however. Most recurrence rates are slightly higher for laparoscopic repair and are more dependent on surgeon expertise and experience. Laparoscopic repair requires general anesthesia. Most agree that laparoscopic approaches are preferred for recurrence of hernias treated by anterior mesh repair and for bilateral hernias.
A recent study by Fitzgibbons prospectively studied the nonoperative management of small, asymptomatic hernias. The overall results were comparable in those in the nonoperative group who ultimately underwent repair later. Although defending surgery may make subsequent repair of larger hernias more difficult, implantation of mesh, infection, and chronic pain are avoided as well and have minimized morbidity in the asymptomatic group. The incidence of strangulation in inguinal hernias is 1% to 2%, and that in femoral hernias is as high as 20%.
Inguinal hernias are the most common hernias in females, although direct inguinal hernias are rare.
Answer
C.
24 The separation-of-components technique:
A Is best for hernias with fascial defects of 3 cm or less
B Has a recurrence rate of approximately 10%
C May be used when there is contamination or bowel surgery is required
D Is contraindicated for recurrent incisional hernias
E Ideally it avoids the use of mesh
Ref.: 13
Comments
Although primary suture repair with mesh has acceptable recurrence rates for small incisional hernias, recurrence rates are disappointing when these techniques are used for very large hernias. In addition, more complications are associated with mesh repair of very large hernias either by open or by laparoscopic technique.
The separation-of-components technique has demonstrated improved results in the repair of massive incisional hernias, with recurrence rates of approximately 20%. This technique can be used when there is contamination or bowel surgery is required, thereby avoiding the dreaded complication of mesh infection.
The separation-of-components technique can be used for failed mesh repairs. In selected cases the addition of soft synthetic mesh has improved success with the technique.
Answer
C
25 A 75-year-old man is seen in the emergency department with a 2-hour history of incarcerated femoral hernia. He takes warfarin for a past history of atrial fibrillation and has an international normalized ratio (INR) of 3.1. Which of the following are correct treatments:
A Admit the patient for correction of the INR and repair the hernia in the morning.
B Perform emergency laparoscopic repair of the hernia.
C Perform emergency open repair of the hernia.
D Attempt a reduction of the hernia in the emergency department after sedation.
E Use of mesh in the repair is recommended.
Ref.: 1, 3
Comments
The risk for strangulation in incarcerated femoral hernias is reported to be as high as 20% to 40%. It is believed that the window for successful treatment to avoid bowel resection is 4 to 6 hours. This clinical condition is considered a surgical emergency, and fresh frozen plasma can be administered just before and during surgery. Laparoscopic repair can be challenging with an incarcerated hernia, and in addition there is concern for increased bleeding in the patient. Laparoscopic repair also requires the use of mesh, which may become infected. Although mesh decreases recurrence in femoral hernias, it is probably not advisable in this setting. An open approach is probably preferred and can be a tissue-to-tissue repair. Any attempt at reduction is probably contraindicated because of the high potential for strangulation. If the bowel drops into the abdomen during an open approach, insertion of a scope into the hernia sac may be useful in evaluating the integrity of the affected bowel.
Answer
C
26 Chronic groin pain following inguinal hernia repair may be the result of:
A Division of the nerves during the surgical procedure
B Postoperative scar tissue
C Use of mesh
D Injury from the use of tacks or staples
E All of the above
Ref.: 1
Comments
Groin pain following inguinal hernia repair is much more common than recurrence and has occurred at incidence as high as 29% to 76% in several series. Transient pain with mild numbness inferior to the incision is common and often transient. Intense pain and loss of sensation that persists suggest nerve injury or entrapment. In open repair, the ilioinguinal, iliohypogastric, or genital branch of the genitofemoral nerve is most commonly involved. Injury to the lateral femoral cutaneous and genitofemoral nerves in laparoscopic repairs may occur from tack placement. Mesh inguinodynia has been reported to result from an inflammatory response to mesh or resultant scar tissue, or both. Although nerve blocks may be diagnostic or therapeutic, exploration may be necessary along with neurectomy, removal of mesh, or tack removal.
Nerve division at the time of the original surgery has not proved to be efficacious.
This frustrating problem is best prevented by meticulous identification and avoidance of entrapment of the aforementioned nerves in open repair and avoidance of tack placement, particularly in the triangle of doom in laparoscopic procedures.
Answer
E
27 A 55-year-old man who runs marathons has a recurrent inguinal hernia. Which statement is correct?
A The previous type of repair has no significance in the treatment plan.
B A Shouldice repair is recommended.
C He will have to stop running marathons after repair.
D Repair can be performed with the patient under local anesthesia with a high likelihood of success.
E Laparoscopic repair, if the previous repair was performed in open manner with mesh, is an evidence-based choice.
Ref.: 11
Comments
Repair of recurrent inguinal hernia can be challenging in terms of preventing recurrence and avoiding morbidity such as chronic pain. Tissue-to-tissue repairs may be repaired with an anterior mesh repair such as the Lichtenstein or plug-and-patch repair. Obtaining a prior operative report is strongly recommended to facilitate selection of the appropriate current repair. Laparoscopic repair for recurrence of a hernia after open anterior mesh repair is supported by prospective trials. The caveat is that such results require expertise and experience in laparoscopic repair. The Shouldice repair is not generally recommended for recurrent hernias. Repair by an expert surgeon should allow resumption of all normal activity and is recommended for active individuals. Repair can be deferred if asymptomatic in selected patients.
Answer
E
28 A 55-year-old man with liver failure and ascites has an enlarging umbilical hernia. The ascites is refracting to diuretic therapy. The correct therapy is:
A Open repair with waterproof mesh
B High-volume paracentesis immediately before repair
C Deferring hernia repair until correction of the ascites by transjugular intrahepatic portosystemic shunting (TIPS) or liver transplantation
D Laparoscopic repair with inlay mesh
E Repair of the hernia and use of abdominal binder after the operation
Ref.: 3
Comments
Repair of any hernia in a patient with ascites is a challenging problem. In general, any consideration of elective repair should be deferred until the ascites is controlled. If there is slow breakdown and leakage of ascites, urgent repair may be necessary to prevent peritonitis. Frequent paracentesis may be helpful in this difficult scenario with assorted high morbidity.
Answer
C
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