13a

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Hernias Questions 977. a. b. c. d.

Hernia occurring through triangle of Petit: (AMU 94) Superior lumbar hernia Inferior lumbar hernia Obturator hernia Femoral hernia

978. a. b. c. d.

Howship-Romberg sign is most specific finding in: (Delhi 90) Superior lumbar hernia Inferior lumbar hernia Obturator hernia Femoral hernia

979. a. b. c. d.

Clinically, a saphena varix is likely to be confused with: (Kar 2002) Baker’s cyst Femoral hernia Spermatocele Varicocele

980. a. b. c. d.

Spigelian hernia occurs through: (Kerala 2001) Medial border of rectus abdominis Lateral border of recti Epigastrium Lumbar triangle

981. a. b. c. d.

Richter’s hernia is commonly associated with: (UPSC 2001) Direct inguinal hernia Femoral hernia Indirect inguinal hernia Obturator hernia

982. a. b. c. d. e.

True about hernia: (PGI 2000 Dec) Direct hernias are usually acquired Femoral is most common hernia to strangulate Extraabdominal hernia are more common 50 % old people suffer from direct type of hernia Treatment of choice for indirect inguinal hernia is surgery

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Surgery

983. Relation of hernial sac to spermatic cord in direct inguinal hernia is: (BIHAR 99) a. Sac is anterior to cord b. Sac is posterior to cord c. Sac is medial to cord d. Sac is lateral to cord 984. a. b. c. d.

Femoral artery begins at: (Maha 2000) Midinguinal Point Femoral ring Mid point of inguinal ligament Any of the above

985. a. b. c. d.

Deep inguinal ring is present in: (Maha 2000) Internal oblique muscle Lacunar ligament Fascia transversalis Transverses abdominis

986. a. b. c. d.

Medial border of femoral canal is formed by: (DNB 2004) Inguinal ligament Pectineal ligament Lacunar ligament Femoral Vein

987. a. b. c. d.

All are true about femoral hernia except: (Manipal 2006) More common in females More risk of strangulation Surgery should be performed as soon as possible Conservative management — truss can be fitted

988. a. b. c. d.

True about femoral hernia: (Delhi 2005) Commoner in males Least likely to strangulate Litter’s hernia is its variant None

989. True about the inguinal canal: (PGI 2005) a. The internal ring lies midway between the symphysis pubis and anterior superior iliac spine b. The internal ring lies medial to the inferior epigastric vessels c. The external oblique aponeurosis forms the anterior boundary d. The inguinal ligament forms the inferior boundary e. The conjoint tendon forms the lateral part of the posterior wall

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990. While operating for obstructed inguinal hernia the sac is opened at: (AIIMS 1996) a. Fundus b. Neck c. Body d. Base 991. The diagnostic feature of congenital diaphragmatic hernia on prenatal ultrasonography is: (AIIMS 2001 MAY) a. A cyst behind the left atrium b. Mediastinal shift with normal heart axis c. Peristalsis in the thoracic cavity d. Absence of gas bubble under the diaphragm 992. What is not true regarding Bochdalek hernia? (AIIMS JUNE 2000) a. Early respiratory distress leading to early diagnosis and treatment are good prognostic signs b. Stomach and transverse colon are commonest contents to herniate c. Diagnosed prenatally by ultrasound d. Common on left posterior side 993. Which of the following is a contraindication for Bag and mask ventilation: (PGI 2002; AIIMS 2000) a. Septicemia b. Tracheoesophageal fistula c. Meconium aspiration d. Diaphragmatic hernia 994. a. b. c. d.

Sliding constituent of a large direct hernia is: (PGI 97) Bladder Sigmoid colon Caecum Appendix

995. The most common content of ‘hernia en glissade’/sliding hernia is: (AI 1988) a. Sigmoid colon b. Caecum c. Appendix d. Urinary bladder 996. The most important and essential step in repair of indirect inguinal hernia is: (UP 2000) a. Isolation and excision of sac b. Narrowing of the internal ring c. Division of the cord d. Strengthening of the posterior wall of the canal

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Surgery

997. a. b. c. d.

Hernia most often overlooked is: (TN 98) Femoral hernia Inguinal hernia Incisional hernia Paraumbilical hernia

998.

In children, umbilical hernia is best operated after age: (DNB 2001) 9-12 months 1-2 years 3-4 years 10-12 years

a. b. c. d.

999. A 25-year-old male presents with reducible right inguinal swelling present since 2 years with history of irreducibility since 10 hrs. On examination, there is distension of abdomen, hyperperistaltic bowel sounds, the swelling is tense and tender, red with absent cough impulse and patient has tachycardia. Most likely diagnosis in such patient is: (SGPGI 98) a. Strangulation b. Obstruction c. Irreducibility d. Sliding Hernia 1000. Best possible treatment of a congenital indirect uncomplicated inguinal hernia in a 10-year-old boy is: (TN 99) a. Herniotomy b. Herniorrhaphy c. Hernioplasty d. Truss 1001. A 75-year-old male patient has asymptomatic right-sided direct inguinal hernia since 10 years. Patient has bronchial asthma with IHD, arrhythmias and poor left ventricular function best possible plan of management will be: (Bihar 2000) a. Observation only b. Herniorrhaphy c. Hernioplasty d. Truss 1002. Prevention of injury to ilioinguinal nerve is an important step during inguinal hernia operation while: (UPSC 1997) a. Incising the subcutaneous tissue b. Incising the external oblique aponeurosis c. Incising the cremasteric fascia d. Isolating the sac

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1003. Which of the following is content of Littre’s hernia? (DNB 2004) a. Urinary bladder b. Meckle’s diverticulum c. Circumference of intestinal wall d. Appendix 1004. Richter’s hernia involves: (MP 2003) a. Meckle’s diverticulum b. Hernia with hydrocele c. Abdominal organ especially on posterior wall d. Circumference of intestine 1005. A patient operated for direct inguinal hernia developed anesthesia at the root of the penis and adjacent part of the scrotum. The nerve likely to be injured is: (AIIMS 2001 nov) a. Genital branch of genitofemoral nerve b. Femoral branch of genitofemoral nerve c. Iliohypogastric nerve d. Ilioinguinal nerve

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Hernias Answers 977. Ans. b (Inferior lumbar hernia) (Ref. CSDT 11th ed. 794) LUMBAR HERNIA The superior and inferior spaces or triangles are sites of flank herniation. The superior lumbar triangle (triangle of Grynfeltt) is bordered by the 12th rib superiorly, the internal oblique muscle anteriorly, and the erector spinal muscle posteriorly. The inferior lumbar triangle (triangle of Petit) is bordered by the external oblique muscle anteriorly, the latissimus dorsi muscle posteriorly, and the iliac crest inferiorly. These hernias are rare, often presenting as a bulge in the flank. Hernia contents can include bowel, retroperitoneal fat, kidney, or other visceral organs. Incarceration and strangulation do occur (in about 10% cases). Barium studies are helpful when bowel is contained in the hernia; however, computed tomography is most useful in determining location and contents of lumbar hernias. Repair is by mobilization of the nearby fascia and obliteration of the hernial defect by precise fascia-to-fascia closure. The recurrence rate is very low. 978. Ans. c (Obturator hernia) (Ref. CSDT 11th ed. 795) OBTURATOR HERNIA Obturator hernias are uncommon and difficult to diagnose. The peritoneal sac and its contents herniate through the obturator canal in the superolateral aspect of the obturator foramen alongside the obturator vessels and nerves, and come to lie between the obturator externus and pectineus muscles or between the layers of the obturator membrane. This is primarily a hernia of elderly females commonly containing bowel, but it may also contain appendix, omentum, bladder, uterus, or adnexal tissue. Incarceration is almost certain. The hernia sac may be palpable on rectal or vaginal examination. Howship-Romberg sign is specific of obturator hernia, in which the pain extends down the medial aspect of the thigh with abduction, extension, or internal rotation of the knee. Plain films or barium studies may demonstrate bowel obstruction with a fixed loop containing gas or contrast in the obturator region. 578

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Computed tomography will depict the hernia sac protruding through the obturator foramen and extending between the pectineus and obturator muscles. This hernia should not be repaired from the thigh approach. The abdominal approach gives the best exposure, however , retropubic approach (Cheatle-Henry operation) may also be used. 979. Ans. b (Femoral hernia) FEMORAL HERNIA Femoral hernias are difficult to diagnose clinically because of their deep location in the femoral canal. They always remain below the inguinal ligament and lateral to the pelvic tubercle and are more prone to incarceration and strangulation than inguinal hernias. This type of hernia occurs more commonly in females and usually contains properitoneal fat, omentum, and/or small bowel. Clinically, saphena varix is its closest differential diagnosis. 980. Ans. b (Lateral border of recti) SPIGELIAN HERNIA Spigelian hernias are caused by a congenital weakness in the posterior layer of transversalis fascia, which allows viscera to prolapse between the lateral abdominal wall muscles and through the linea semilunaris. Thus, it occurs usually at infraumbilical location. Typically, the omentum and short segments of large or small bowel protrude through the hernia defect. Diagnosis of these rare hernias is notoriously difficult. Computed tomography is the imaging modality of choice because it allows visualization of the hernia defect in the rectus sheath and identification of the hernia contents. 981. Ans. b (Femoral hernia) (Ref. Bailey and Love-23rd ed.-1145) Hernias involving only a part of the bowel wall are termed “Richter’s hernias.” Generally, a segment of large bowel is involved. Since only a portion of the intestinal wall is incorporated into the hernia, the lumen remains patent, and there is no obstruction. Incarceration is uncommon. It may be associated with femoral hernia. 982. Ans. a, b, c, e INGUINAL HERNIA Inguinal hernia, the most common abdominal hernia, can be direct or indirect. Indirect inguinal hernia occurs with the greatest frequency, is usually congenital, but may be acquired in older individuals. The processus vaginalis normally closes before birth. In one third of infants and one sixth of adults, the process vaginalis remains patent, persisting as a peritoneal sac into which viscera

580

Surgery may enter. Hernia contents typically include small bowel loops and mobile colon segments such as sigmoid, appendix, cecum and transverse colon. Retroperitoneal organs such as the urinary bladder, distal ureters, or ascending or descending colon may be incorporated into the hernia. Preoperative recognition of retroperitoneal contents in the hernia is essential to avoid injury during surgical repair. The peritoneal sac and viscera protrude lateral and inferior to the inferior epigastric vessels through the inguinal canal and emerge at the external inguinal ring. In males, the hernia can extend along the spermatic cord into the scrotum, whereas in females, the hernia follows the course of the round of ligament into the labia majoris. Bowel obstruction, incarceration, and strangulation are common sequelae of indirect inguinal hernia. Diverticulitis, appendicitis, and primary or metastatic tumors may occur within the hernia. Direct inguinal hernias protrude directly through the lower abdominal wall through a defect in the transversalis fascia, medial to the inferior epigastric vessels. More common in men, they rarely incarcerate.

983. Ans. d (Sac is posterior to cord) (Ref: B and L, Surgery, 23rd ed., 1145; B.D.Chaurasia’s Human Anatomy- Vol. II 3rd ed. 61, 179) An indirect inguinal hernial sac travels down the canal on anterolateral aspect of spermatic cord, while direct hernial sac is posterior to cord. CONTENTS OF SPERMATIC CORD 1. The Ductus deferens 2. Testicular and Cremasteric Arteries and Artery of Ductus Deferens 3. Pampiniform plexus of veins 4. Genital branch of Genitofemoral nerve and Plexus of sympathetic nerves 5. Lymphatic vessel from testes 6. Remnants of Processes Vaginalis. Ilioinguinal nerve enters inguinal canal through interval between external and internal oblique Muscle and pass out through superficial inguinal ring. Inferior epigastric artery is not content of spermatic cord, it forms lateral boundary of Hasselbach triangle. 984. Ans.a (Midinguinal Point) (Ref. B.D.Chaurasia Anatomy, Vol 1, 2nd ed. 11) Femoral triangle 1. Is bounded superiorly by inguinal ligament, medially by Adductor longus and laterally by Sartorius.

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2. Structures from lateral to medial are nerve-artery-vein-empty space-lymphatics ( NAVEL) 3. Femoral sheath contains femoral artery, femoral vein and femoral canal (containing deep inguinal lymph nodes, gland of Cloquet and Rossenmuller (sex hormones). Femoral nerve lies outside femoral sheath. 4. A femoral pulse is palpable high within the femoral triangle just inferior to the inguinal ligament, at the mid inguinal point where femoral artery begins as a continuation of external iliac artery. 985. Ans. c (Fascia transversalis) (Ref. Bailey and Love Surgery-22nd ed.-885,B.D. Chaurasia Anatomy, Vol 1, 2nd ed. 151) Deep inguinal ring is an oval opening in fascia transversalis about half an inch above mid-inguinal point. It lies immediately lateral to inferior epigastric artery. It transmits spermatic cord in male and round ligament in female. Fascia transversalis is the inner surface of abdominal muscles lining. Fascia separates peritoneum from extraperitoneal tissue. Direct hernia occurs through it. 986. Ans. c (Lacunar ligament) Anatomy of the femoral canal · Anterior border is the inguinal ligament · Posterior border is the pectineal ligament · Medial border is the lacunar ligament · Lateral border is the femoral vein 987. Ans. d. (Conservative management — truss can be fitted) Femoral hernias · Account for 7% of all abdominal wall hernia · Female : male ratio is 4:1 · Commonest in middle aged and elderly women, More common in parous · Rare in children · Much less common than inguinal hernias but are as common as inguinal hernias in older women Management of femoral hernia · All uncomplicated femoral hernias should be repaired as an urgent elective procedure · Three classical approaches to the femoral canal have been described · Low (Lockwood). · Transinguinal (Lotheissen) · High (McEvedy)

582

Surgery · · · · ·

Irrespective of approach used the following will be achieved Dissection of the sac Reduction / inspection of the contents Ligation of the sac Approximation of the inguinal and pectineal ligaments

988. Ans. c (Litter’s hernia is its variant) Special types of hernia · Richter’s hernia · Partial enterocele (circumference of intestine involved) · Presents with strangulation and obstruction · Maydl’s hernia · W loop strangulation · Strangulated bowel within abdominal cavity · Littre’s hernia · Strangulated Meckel’s diverticulum · Can cause small bowel fistula 989. Ans. a, c and d The internal ring lies lateral to the inferior epigastric vessels The conjoint tendon forms the medial part of the posterior wall 990. Ans. a (Fundus) (Ref. Bailey and Love 1279) Sac is opened at fundus to avoid the risk of contaminating the peritoneal cavity with highly toxic fluid swarming with organisms. 991. Ans. c (Peristalsis in the thoracic cavity) (Ref. Sutton Radiology, 6th 221) The sonographic diagnosis of fetal congenital diaphragmatic hernia relies on the visualization of abdominal organs in the chest. Other pointers may be, absence of a normally positioned stomach, mediastinal displacement, small abdominal circumference and polyhydramnios. 992. Ans. a (Early respiratory distress leading to early diagnosis and treatment are good prognostic signs) (Ref. Sabiston, 16th Ed. 1480) Although the gross anatomy and, to some extent, the pathophysiology of CDH have been well described for more than 200 years, CDH as remained one of the most frustrating of the major birth defects to manage successfully. Despite early detection of severe diaphragmatic defects by prenatal ultrasonography and the more common recognition of CDH as a cause of significant respiratory distress at birth, current mortality has improved little from the series presented in 1940 by ladd and Gross.

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Congenital diaphragmatic hernia is of many types · Anterior (through foramen of Morgagni) · Posterior (through foramen of Bochdalek ) -MC · Through esophageal hiatus. · Eventration Bochdalek hernia: · During formation of the diaphragm, the pleura and coelomic cavities remain in continuity by means of the pleuroperitoneal canal (foramen of Bochdalek), The posterolateral communication is closed by the developing diaphragm. Failure of diaphragmatic development leaves a posterolateral defect. · This is more common on the left side. · Visceral contents herniate and fill the chest cavity. · Stomach and transverse colon are the commonest contents of CDH. · The abdominal cavity is small and undeveloped and remains scaphoid after birth. · The herniated viscera act as a space-occupying lesion and prevent normal lung development. · CDH can be accurately diagnosed prenatally as early as 15th of weeks gestation by USG. 993. Ans.: d (Diaphragmatic hernia) (Ref. OP Ghai Paediatrics 5th 168) Bag and mask ventilation is contraindicated in diaphragmatic hernia, because in diaphragmatic hernia the abdominal contents have herniated into the thoracic cavity and are compressing the lung. By using bag and mask ventilation air will also move into the GIT along with the lung. More air in the stomach and intestines will cause more compression of the already compressed lung. 994. Ans. a (Bladder), b (Sigmoid colon), c) (Caecum) Sliding hernia occurs exclusively in males, five out of six hernias are situated on left side. It presents as a large globular inguinal hernia. Large intestine (sigmoid colon) is commonly present. A portion of the bladder or diverticulum of the bladder may be present in addition to other contents in sliding hernia. Bilateral sliding hernias are rare. 995. Ans. a (Sigmoid colon) This type of hernia occurs exclusively in males, five out of six hernias are situated on left side. It presents as a large globular inguinal hernia. Large intestine (sigmoid colon) is commonly present. A portion of the bladder or diverticulum of the bladder may be present in addition to other contents in sliding hernia. Bilateral sliding hernias are rare.

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Surgery

996. Ans. b (Narrowing of the internal ring) When internal ring is weak and stretched, the repair should include Lytle method of repairing and narrowing the ring. 997. Ans. a (Femoral hernia) Symptoms of femoral hernia are less pronounced than inguinal hernia, since it is small. It may remain unnoticed for years till it strangulates. 998. Ans. b (1-2 years) UMBILICAL HERNIA In children and infants, patent umbilical rings are common, and the resulting herniation is asymptomatic. Occasionally incarceration may occur requiring surgical intervention. Adults presenting with umbilical hernias usually have diastasis of the rectus muscles resulting from multiple pregnancies, obesity, or chronic increased abdominal pressure. Greater omentum and bowel are the typical hernia contents that protrude through the linea alba at the umbilicus and can incarcerate, causing symptoms of intestinal obstruction and umbilical tenderness. Mayo’s operation is done to repair it. Masterly inactivity is the treatment of choice for umbilical hernia in children as hernia usually close spontaneously by 2 years in 95% cases. Obstruction or strangulation below 3 years age is extremely uncommon. In case masterly inactivity fails operation should be carried out after age of 2 years. 999. Ans. a (Strangulation) Strangulated obstructed irreducible hernia will give irreducible swelling with absent cough impulse. With strangulation the swelling will become tense, tender with or without local rise of temperature and systemic signs of sepsis. Obstructed hernias may be tense and non-tender. More often than not, the obstruction culminates into strangulation. 1000. Ans. a (Herniotomy) In congenital hernia, problem is patent processes vaginalis but the posterior wall is normal, hence Herniotomy is sufficient for treatment. But in old patients the posterior wall is weak and therefore they will require, herniorraphy or hernioplasty depending on the nature of tissue as seen during the operative procedure. 1001. Ans. a (Observation only) Direct hernias have wide neck and hence are unlikely to undergo strangulation and indication of surgery in such case will be persistent pain and for cosmesis. But in this patient risk of surgery is going to be very high and natural history of disease being benign, observation is preferred modality of treatment.

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1002. Ans. b (Incising the external oblique aponeurosis) (Ref. Bailey and Love 1277) External oblique aponeurosis is in close relation to ilioinguinal nerve and hence during operation for inguinal hernia prevention of injury to ilioinguinal nerve to avoid later development of incisional hernia is very important. 1003. Ans: b (Meckle’s diverticulum) (Ref. Bailey and Love 24th Ed.- 1273) Littre’s hernia is external anterior abdominal weal hernia with Meckle’s diverticulum as its content. 1004. Ans. d (Circumference of intestine) (Ref. Bailey and Love-23rd ed.-1145, 24th 1273) —————————————————————————————— Hernia

Content

—————————————————————————————— Omentocele/epiplocele Enterocele Richter’s Littre’s Sliding Pantaloon Inferior lumbar Obturator hernia

Omentum Small bowel commonly, may be large bowel or appendix A portion of circumference of intestine Meckel’s diverticulum Contents of posterior abdominal wall, commonly bladder Direct + Indirect hernia Herniation through triangle of Petit Herniation through obturator canal

—————————————————————————————— 1005. Ans. d (Ilioinguinal nerve) (Ref. Gray’s Anatomy, 2nd ed. 127) All the three nerves i.e. genitofemoral, ilioinguinal and iliohypogastric are branches of the lumbar plexus and all may be injured in operation for hernia. Ilioinguinal nerve Enters the inguinal canal by piercing the internal oblique muscle (not through the deep ring) It then emerges from the superficial inguinal ring to supply skin of o proximomedial skin of the thigh. o skin over the penile root. o upper part of the scrotum Iliohypogastric nerve Divides into two branches -lateral cutaneous and anterior cutaneous. Lateral cutaneous supplies -posterolateral gluteal skin Anterior cutaneous supplies -supra pubic skin

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Surgery Genitofemoral nerve divides into two branches Genital and Femoral Genital branch of Genitofemoral nerve -enters the inguinal canal at its deep ring and supplies o the Cremaster muscle o the scrotal skin Femoral branch of genitofemoral nerve Passes behind the inguinal ligament, enters the femoral sheath lateral to femoral artery, pierces the anterior layer of the femoral sheath and fascia lata and supplies the skin anterior to the upper part of femoral triangle.