Which of the following is the most common location for recurrence at reoperation following laparoscopic repair of an inguinal hernia?
The most common location for recurrence following laparoscopic hernia repair is the medial aspect of the mesh. This relates to failure to secure the mesh medially and using a piece of mesh that is too small. With a large direct defect, it is important to have adequate coverage anteriorly or the mesh can prolapse into the hernia defect.
A 55-year-old female presents with a tender mass below the inguinal ligament. During repair of the femoral hernia through an inguinal approach you are unable to reduce the bowel. Which of the following is the next best step?
A. Push up on the bowel inferiorly while pulling up on the bowel superiorly
B. Perform a small segmental bowel resection
C. Divide the inguinal ligament
D. Make a small contralateral inguinal incision to place a laparoscope
If you are unable to reduce the bowel during a femoral hernia repair through an inguinal approach, the next best step is to incise the inguinal ligament. Make sure to control the neck of the hernia so that you can ensure viability of the bowel and then repair the hernia and inguinal ligament.
Which of the following is the most common presentation of an obturator hernia?
D. Paresthesias of the lateral thigh
Obturator hernias are very rare but occur more frequently in multiparous elderly women. They can be associated with the Howship-Romberg sign, which is pain on internal rotation of the thigh. An obturator hernia occurs through a weakened obturator membrane. The defect is usually narrow in diameter, which predisposes to small bowel incarceration and strangulation.
In which of the following patients is laparoscopic hernia repair indicated?
A. 65-year-old male with bilateral inguinal hernias with a prior radical retropubic prostatectomy
B. 37-year-old pregnant female in the second trimester with an incarcerated left inguinal hernia with a previous caesarean section
C. 45-year-old female with bilateral recurrent inguinal hernias after laparoscopic repair who recently underwent pelvic radiation
D. 27-year-old male with a history of laparoscopic cholecystectomy with bilateral inguinal hernias
Laparoscopic inguinal hernia repair has advantages in the setting of bilateral and/or recurrent hernias. Contraindications include patients who have had prior laparoscopic hernia repair, prior preperitoneal pelvic surgery or previous lower midline incision, prior pelvic radiation, or cannot tolerate general anesthesia.
Which of the following is the most likely cause of ischemic orchitis following inguinal hernia repair?
A. Ligation of the testicular artery
B. Complete excision of a large scrotal hernia sac
C. Inadvertent torsion of the testicular cord during the repair
D. Reconstruction of an internal ring that causes compression of the testicular cord
Extensive dissection of the spermatic cord is the most common risk factor in the development of ischemic orchitis following inguinal hernia repair. Ischemic orchitis likely results from testicular venous congestion from thrombosis of the pampiniform venous plexus. To help prevent this, the spermatic cord should not be dissected past the pubic tubercle and the hernia sac can be ligated and divided leaving the distal sac in place. Ligation of the testicular artery is usually well tolerated, as evidenced by the 2-stage Fowler-Stevens orchiopexy for high undescended testis, because the testicle has a rich collateral blood supply from the cremasteric artery (branch of inferior epigastric artery) and the artery to the ductus deferens (branch of inferior vesical artery).
A 52-year-old chronic alcoholic male, who has never been to a hospital, presents with slow oozing of clear fluid through thin skin at the apex of his large umbilical hernia. He has a shifting dullness on physical examination. Which of the following is the next best step in management?
A. Immediate umbilical hernia repair with mesh
B. Perform paracentesis, primarily repair the skin defect, and place an abdominal binder
C. Treat with salt and fluid restriction, oral antibiotics, and place a negative pressure wound dressing over the skin defect
D. Aggressive diuresis, IV antibiotics, and bed rest followed by hernia repair during the same hospital admission
Umbilical hernia repair in cirrhotics with uncontrolled ascites has a high morbidity and mortality rate. Optimal therapy includes aggressive diuresis and sodium/fluid restriction to control ascites, IV antibiotics to combat possible bacterial peritonitis, bed rest to reduce stress on the hernia and leaking site, followed by repair of the hernia after the ascites is controlled.
Which of the following nerves is not at risk during a laparoscopic repair of an inguinal hernia?
B. Femoral branch of the genitofemoral nerve
C. Lateral cutaneous nerve of the thigh
D. Intermediate cutaneous branch of the anterior branch of the femoral nerve
The pudendal nerve is not at risk of injury during laparoscopic hernia repair. To help reduce the incidence of nerve injury during laparoscopic hernia repair, placing tacks lateral to the epigastric vessels is avoided.
Which of the following statements regarding umbilical hernia is true?
A. Early repair of umbilical hernias in infants should be performed because of the risk of incarceration
B. Umbilical hernias are more common in white infants than in African-American infants
C. Repair of umbilical hernias in adults is usually indicated
D. Umbilical hernias in infants usually require surgery
Umbilical hernias in adults should usually be performed promptly because of the risk of incarceration. Umbilical hernias are rarely incarcerate and most surgeons will defer surgery until about 4 to 5 years of age because the majority of umbilical hernias in infants will close spontaneously by 2 years of age. Umbilical hernias are about 8 times more common in African-American children than in white children.
Which of the following is the best choice for repairing a unilateral indirect inguinal hernia in a 5-month-old-male infant?
B. High ligation of the hernia sac
C. Laparoscopic TEP hernia repair
D. Cooper ligament (McVay) repair
Inguinal hernia in infants results from a patent processus vaginalis and not from a weakness in the floor of the inguinal canal. High ligation of the hernia sac is usually all that is required except in the instance of a large defect, which may require tightening of the internal ring or reconstruction of the inguinal floor.
Which of the following statements is true regarding hernias?
A. Femoral hernias are more common in males than in females
B. Inguinal hernias occur more frequently in females than in males
C. Indirect inguinal hernias account for two-thirds of all inguinal hernias
D. Indirect hernias are a rare occurrence in women
Indirect inguinal hernias account for two-thirds of inguinal hernias. Femoral hernias account for approximately 5% of abdominal wall hernias and occur more frequently in women. Inguinal hernias are approximately 25 times more common in men than in women. The most common hernia in both men and women is an indirect inguinal hernia.