Surgery EOR Review Questions with 100%
Verified Correct Answers
how do ventral (incisional) hernias present
bulge at previous incision site, may be tender, mass gets larger with coughing or sneezing
dx is clinical; CT can be used to assess extent
definitive treatment is surgical repair; mesh
sensation of swelling or fullness at affected site → this will WORSEN with increased
intra-abdominal pressure (ex: valsalva maneuver)
hernia
describe incarcerated hernia
painful mass that is irreducible
when tissue (bowel) is trapped, becomes incarcerated, fluid and pressure accumulate, can
lead to necrosis (strangulation) - then signs of systemic toxicity, change in overlying skin
incarcerated hernias require urgent surgical intervention - the contents are trapped in the
hernia sac
strangulated hernias require emergent surgical intervention - ischemia or necrosis
if have nonreducible hernia --> pt gets emergent surgical consult
,indications for surgical repair of hernias
asymptomatic - can be electively repaired
complicated (strangulated, bowel obstruction, incarcerated) - urgent/emergent surgery
all femoral hernias need surgery (higher risk of issues like strangulation)
inguinal hernia with groin pain, unable to do daily activities, irreducible
if strangulated hernia and if intervention delayed, may need bowel resection if necrotic
describe obturator hernia
deep structures, cannot see externally, more in older women age 70-90, high mortality rate
most common presentation is resulting small bowel obstruction; cramping abdominal pain
and distention
Howship-Romberg sign - pain extends down medial aspect of thigh with movement of knee
surgical emergency
80yo F, cramping abdominal pain and vomiting x 1 day, high pitched tinkling bowel
sounds and abdominal distention, diffuse tenderness of abdomen, positive Howship-
Romberg sign, palpable proximal thigh mass
obturator hernia
what is a hiatal hernia
,common condition - the proximal portion of the stomach protrudes through the diaphragm
into the esophageal space
2 types: sliding (most common) and paraesophageal
contrast sliding vs paraesophageal hiatal hernia
1. Sliding - most common, 95% of hiatal hernias, the proximal stomach (gastric cardia)
herniates proximally through diaphragm in the direction of the esophagus, displaces the
phrenoesophageal membrane - leads to the level of the gastroesophageal junction now being
ABOVE the diaphragm
**more associated with GERD symptoms - heartburn, difficult swallowing, regurgitation
2. Paraesophageal - more rare, the superior lateral aspect of stomach (gastric fundus)
herniates through defect in phrenoesophageal membrane ADJACENT to the esophagus, does
not displace the memrane, gastroesophageal junction remains at the level of the diaphragm
**more associated with substernal pain, nausea, vomiting
causes of hiatal hernia
can happen with just normal wear and tear over time; excessive swallowing, trauma, reflux,
vomiting, congenital malformations, GERD, acidification, post-op complications --> leads to
damage of the phrenoesophageal membrane, then stomach herniates proximally
pt with long standing GERD, presents for preop workup, reports heartburn, occasional
difficulty swallowing, frequent regurgitation for the past year; endoscopy shows
protrusion of proximal stomach into the chest cavity
hiatal hernia
, symptoms of hiatal herias
most are asymptomatic
if have symptoms - heartburn, difficulty swallowing, regurgitation; may have
nausea/vomiting, postprandial pain
how to diagnose a hiatal hernia
gold standard is barium swallow
but note that most are diagnosed incidentally on CXR, endoscopy, or manometry
management for hiatal hernias
small asymptomatic hernia - expectant management (nothing yet)
treat reflux with PPIs if present
surgery - rarely done for sliding hiatal hernias, but is an option if patient has symptomatic
paraesophageal hiatal hernia
if hernia is compromised (gastric volvulus, obstruction, strangulation, etc.) then do emergent
repair
so if sliding - do conservative if asymptomatic, if symptomatic treat GERD with PPI
if paraesophageal - if asymptomatic do conservative, if symptomatic do surgery
what is intussusception
Verified Correct Answers
how do ventral (incisional) hernias present
bulge at previous incision site, may be tender, mass gets larger with coughing or sneezing
dx is clinical; CT can be used to assess extent
definitive treatment is surgical repair; mesh
sensation of swelling or fullness at affected site → this will WORSEN with increased
intra-abdominal pressure (ex: valsalva maneuver)
hernia
describe incarcerated hernia
painful mass that is irreducible
when tissue (bowel) is trapped, becomes incarcerated, fluid and pressure accumulate, can
lead to necrosis (strangulation) - then signs of systemic toxicity, change in overlying skin
incarcerated hernias require urgent surgical intervention - the contents are trapped in the
hernia sac
strangulated hernias require emergent surgical intervention - ischemia or necrosis
if have nonreducible hernia --> pt gets emergent surgical consult
,indications for surgical repair of hernias
asymptomatic - can be electively repaired
complicated (strangulated, bowel obstruction, incarcerated) - urgent/emergent surgery
all femoral hernias need surgery (higher risk of issues like strangulation)
inguinal hernia with groin pain, unable to do daily activities, irreducible
if strangulated hernia and if intervention delayed, may need bowel resection if necrotic
describe obturator hernia
deep structures, cannot see externally, more in older women age 70-90, high mortality rate
most common presentation is resulting small bowel obstruction; cramping abdominal pain
and distention
Howship-Romberg sign - pain extends down medial aspect of thigh with movement of knee
surgical emergency
80yo F, cramping abdominal pain and vomiting x 1 day, high pitched tinkling bowel
sounds and abdominal distention, diffuse tenderness of abdomen, positive Howship-
Romberg sign, palpable proximal thigh mass
obturator hernia
what is a hiatal hernia
,common condition - the proximal portion of the stomach protrudes through the diaphragm
into the esophageal space
2 types: sliding (most common) and paraesophageal
contrast sliding vs paraesophageal hiatal hernia
1. Sliding - most common, 95% of hiatal hernias, the proximal stomach (gastric cardia)
herniates proximally through diaphragm in the direction of the esophagus, displaces the
phrenoesophageal membrane - leads to the level of the gastroesophageal junction now being
ABOVE the diaphragm
**more associated with GERD symptoms - heartburn, difficult swallowing, regurgitation
2. Paraesophageal - more rare, the superior lateral aspect of stomach (gastric fundus)
herniates through defect in phrenoesophageal membrane ADJACENT to the esophagus, does
not displace the memrane, gastroesophageal junction remains at the level of the diaphragm
**more associated with substernal pain, nausea, vomiting
causes of hiatal hernia
can happen with just normal wear and tear over time; excessive swallowing, trauma, reflux,
vomiting, congenital malformations, GERD, acidification, post-op complications --> leads to
damage of the phrenoesophageal membrane, then stomach herniates proximally
pt with long standing GERD, presents for preop workup, reports heartburn, occasional
difficulty swallowing, frequent regurgitation for the past year; endoscopy shows
protrusion of proximal stomach into the chest cavity
hiatal hernia
, symptoms of hiatal herias
most are asymptomatic
if have symptoms - heartburn, difficulty swallowing, regurgitation; may have
nausea/vomiting, postprandial pain
how to diagnose a hiatal hernia
gold standard is barium swallow
but note that most are diagnosed incidentally on CXR, endoscopy, or manometry
management for hiatal hernias
small asymptomatic hernia - expectant management (nothing yet)
treat reflux with PPIs if present
surgery - rarely done for sliding hiatal hernias, but is an option if patient has symptomatic
paraesophageal hiatal hernia
if hernia is compromised (gastric volvulus, obstruction, strangulation, etc.) then do emergent
repair
so if sliding - do conservative if asymptomatic, if symptomatic treat GERD with PPI
if paraesophageal - if asymptomatic do conservative, if symptomatic do surgery
what is intussusception
