ABSITE - HERNIAS- QUESTIONS AND
ANSWERS 100% SOLVED!
You are evaluating a 55-year-old female for a painful lump in her right groin for several
days. She denies fever, chills, nausea or emesis, has been having normal bowel and
bladder function, and is in otherwise excellent health. Physical examination reveals a
solitary 3-cm tender, firm, round mass in her right groin below the inguinal ligament with
no skin discoloration. She has a pre-paid vacation scheduled in three days. At this point,
you would recommend:
A. Observation with reevaluation after her vacation
B. Urgent hernia repair
C. Elective hernia repair following her vacation
D. Analgesics and attempted reduction of the mass
E. Aspiration of the mass with ultrasound guidance - ANSWERSUrgent hernia repair
Correct.
The patient's history and physical examination are consistent with an incarcerated
femoral hernia, which requires immediate operation to avoid progression to
strangulation, ischemia and perforation of involved bowel. Complications are highly
likely in this setting. Although attempted reduction under analgesia and sedation is
reasonable, this is not recommended for femoral hernias. There is no role for needle
aspiration of a groin mass when a hernia is suspected.
A healthy 40-year-old man is consulting with you for evaluation of intermittent left groin
discomfort (4 out of 10 on pain scale) which has been present for the past three weeks.
These symptoms have caused him to miss work on occasion. He denies any
constitutional symptoms, and has no other complaints at this time. On physical
examination, you cannot detect a hernia, even with provocative maneuvers (i.e.,
Valsalva, cough). Your recommendation at this time would be:
A. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous
contrast for further evaluation
B. Diagnostic laparoscopy
C. Contrast herniography (peritoneography)
D. Left groin exploration with possible inguinal hernia repair
E. Ultrasonography of the left groin - ANSWERSUltrasonography of the left groin
Correct.
This patient may have an occult inguinal hernia which is not detectable on physical
examination. Ultrasonography, herniography and CT are all useful diagnostic studies,
with ultrasound being the least invasive, less costly, and with high sensitivity and
specificity. In this patient with minimal symptoms, there is no indication for immediate
laparoscopy or groin exploration.
, A 60-year-old male presents with persistent pain over his right lower abdomen six
months after a bilateral TEPP laparoscopic inguinal hernia repair. There is no evidence
of hernia recurrence, seroma or infection on physical examination. As part of your
investigation, you obtain a plain abdominal radiograph, which reveals multiple bilateral
spiral tacks across the lower abdomen. You obtain the operative report, and confirm
your suspicion that the surgeon used permanent spiral tacks for mesh fixation. Injury to
which of the following nerves is the most likely cause for his persistent pain?
A. Ilioinguinal nerve
B. Iliohypogastric nerve
C. Genital branch of the genitofemoral nerve
D. Lateral femoral cutaneous nerve
E. Femoral nerve - ANSWERSIliohypogastric nerve
Correct.
Post-herniorrhaphy neuralgia has been reported to occur in up to 20% of cases. Injury
to any of the nerves mentioned can result in post-herniorrhaphy neuralgia. Given the
location of the patient's symptoms and the method used for mesh fixation, the
iliohypogastric nerve is the most vulnerable to injury during laparoscopic mesh fixation.
A 67-year-old man presents with vomiting and abdominal distension. An abdominal x-
ray reveals air/fluid levels suggesting small bowel obstruction. On exam, her abdomen
is distended with diffuse tenderness and there is a tender mass in the right groin. At
operation, you resect a strangulated 6-cm segment of small intestine and there is
moderate contamination with bowel contents. What should you do for the hernia?
A. Complete the operation and plan a subsequent hernia repair.
B. Perform a repair using polypropylene mesh.
C. Perform a repair using biologic mesh.
D. Perform a tissue-based repair. - ANSWERSPerform a tissue-based repair.
Correct.
It is important to repair the hernia defect at operation to avoid the risks of early recurrent
intestinal obstruction. With contamination during the bowel resection, the safest option
is to perform a tissue-based repair. Permanent mesh should be avoided in this situation
because of the risk of infection. Use of biologic mesh is associated with almost certain
hernia recurrence. It may be necessary to perform the hernia repair through a separate
groin incision.
A 33-year-old man has a symptomatic recurrent inguinal hernia following a totally
extraperitoneal (TEP) repair two years ago. Which of the following is the best approach
for reoperation?
A. TEP repair
B. Trans-abdominal pre-peritoneal (TAPP) repair
C. Open inguinal repair
D. Open trans-abdominal repair - ANSWERSOpen inguinal repair
Correct.
Most experts would recommend an open repair in this circumstance. It is important to
avoid using the same approach as previously done to minimize the risk of nerve injury
or other complications due to scarring. The open inguinal approach is the best answer.
ANSWERS 100% SOLVED!
You are evaluating a 55-year-old female for a painful lump in her right groin for several
days. She denies fever, chills, nausea or emesis, has been having normal bowel and
bladder function, and is in otherwise excellent health. Physical examination reveals a
solitary 3-cm tender, firm, round mass in her right groin below the inguinal ligament with
no skin discoloration. She has a pre-paid vacation scheduled in three days. At this point,
you would recommend:
A. Observation with reevaluation after her vacation
B. Urgent hernia repair
C. Elective hernia repair following her vacation
D. Analgesics and attempted reduction of the mass
E. Aspiration of the mass with ultrasound guidance - ANSWERSUrgent hernia repair
Correct.
The patient's history and physical examination are consistent with an incarcerated
femoral hernia, which requires immediate operation to avoid progression to
strangulation, ischemia and perforation of involved bowel. Complications are highly
likely in this setting. Although attempted reduction under analgesia and sedation is
reasonable, this is not recommended for femoral hernias. There is no role for needle
aspiration of a groin mass when a hernia is suspected.
A healthy 40-year-old man is consulting with you for evaluation of intermittent left groin
discomfort (4 out of 10 on pain scale) which has been present for the past three weeks.
These symptoms have caused him to miss work on occasion. He denies any
constitutional symptoms, and has no other complaints at this time. On physical
examination, you cannot detect a hernia, even with provocative maneuvers (i.e.,
Valsalva, cough). Your recommendation at this time would be:
A. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous
contrast for further evaluation
B. Diagnostic laparoscopy
C. Contrast herniography (peritoneography)
D. Left groin exploration with possible inguinal hernia repair
E. Ultrasonography of the left groin - ANSWERSUltrasonography of the left groin
Correct.
This patient may have an occult inguinal hernia which is not detectable on physical
examination. Ultrasonography, herniography and CT are all useful diagnostic studies,
with ultrasound being the least invasive, less costly, and with high sensitivity and
specificity. In this patient with minimal symptoms, there is no indication for immediate
laparoscopy or groin exploration.
, A 60-year-old male presents with persistent pain over his right lower abdomen six
months after a bilateral TEPP laparoscopic inguinal hernia repair. There is no evidence
of hernia recurrence, seroma or infection on physical examination. As part of your
investigation, you obtain a plain abdominal radiograph, which reveals multiple bilateral
spiral tacks across the lower abdomen. You obtain the operative report, and confirm
your suspicion that the surgeon used permanent spiral tacks for mesh fixation. Injury to
which of the following nerves is the most likely cause for his persistent pain?
A. Ilioinguinal nerve
B. Iliohypogastric nerve
C. Genital branch of the genitofemoral nerve
D. Lateral femoral cutaneous nerve
E. Femoral nerve - ANSWERSIliohypogastric nerve
Correct.
Post-herniorrhaphy neuralgia has been reported to occur in up to 20% of cases. Injury
to any of the nerves mentioned can result in post-herniorrhaphy neuralgia. Given the
location of the patient's symptoms and the method used for mesh fixation, the
iliohypogastric nerve is the most vulnerable to injury during laparoscopic mesh fixation.
A 67-year-old man presents with vomiting and abdominal distension. An abdominal x-
ray reveals air/fluid levels suggesting small bowel obstruction. On exam, her abdomen
is distended with diffuse tenderness and there is a tender mass in the right groin. At
operation, you resect a strangulated 6-cm segment of small intestine and there is
moderate contamination with bowel contents. What should you do for the hernia?
A. Complete the operation and plan a subsequent hernia repair.
B. Perform a repair using polypropylene mesh.
C. Perform a repair using biologic mesh.
D. Perform a tissue-based repair. - ANSWERSPerform a tissue-based repair.
Correct.
It is important to repair the hernia defect at operation to avoid the risks of early recurrent
intestinal obstruction. With contamination during the bowel resection, the safest option
is to perform a tissue-based repair. Permanent mesh should be avoided in this situation
because of the risk of infection. Use of biologic mesh is associated with almost certain
hernia recurrence. It may be necessary to perform the hernia repair through a separate
groin incision.
A 33-year-old man has a symptomatic recurrent inguinal hernia following a totally
extraperitoneal (TEP) repair two years ago. Which of the following is the best approach
for reoperation?
A. TEP repair
B. Trans-abdominal pre-peritoneal (TAPP) repair
C. Open inguinal repair
D. Open trans-abdominal repair - ANSWERSOpen inguinal repair
Correct.
Most experts would recommend an open repair in this circumstance. It is important to
avoid using the same approach as previously done to minimize the risk of nerve injury
or other complications due to scarring. The open inguinal approach is the best answer.
