ABSITE HERNIA ACTUAL Exam
Questions and CORRECT Answers
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 - CORRECT ANSWER - Urgent
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 - CORRECT ANSWER - Ultrasonography 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 - CORRECT ANSWER - Iliohypogastric 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.
Questions and CORRECT Answers
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 - CORRECT ANSWER - Urgent
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 - CORRECT ANSWER - Ultrasonography 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 - CORRECT ANSWER - Iliohypogastric 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.
