Chapter 32: Hernias & Other Lesions of the Abdominal Wall

Chapter 32. Hernias & Other Lesions of the Abdominal Wall

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The most important principle for successful repair of a groin hernia in an adult is

A. Approximation of the conjoined tendon and inguinal ligament

B. High ligation of the hernia sac

C. A vertical relaxing incision in the anterior rectus sheath

D. A tension free repair

E. Reduction in the size of the internal inguinal ring

D. A tension free repair. A tension free repair is the key factor in successful repair of all groin hernias. Although a tension-free repair can be accomplished by using a relaxing incision in the traditional tissue repairs, the use of mesh for either an open or laparoscopic repair obviates the need for a relaxing incision. Although decreasing the size of the internal ring will help prevent recurrence of an indirect inguinal hernia, it is not sufficient to prevent a recurrence through the transversalis fascia if a strong, tension-free repair is not accomplished.

All of the following are features of a femoral hernia repair except

A. Complete excision of the hernia sac

B. Use of a relaxing incision in the anterior rectus sheath when a tissue repair is done

C. Elimination of the defect in the transversalis fascia

D. Use of Cooper’s ligament or iliopubic tract

E. Use of the inguinal ligament in the repair

E. The use of the inguinal ligament in the repair. Keys to successful repair of a femoral hernia include the knowledge that the femoral canal lies beneath the inguinal ligament. For this reason, the repair must be performed to Cooper’s ligament or the iliopubic tract, which lie deep to the inguinal ligament. The repair must result in obliteration of the hernial defect, whose medial border is the stiff lacunar ligament, superior border is the inguinal ligament, and lateral border is the femoral vein; these structures do not lend themselves to primary repair with sutures. After the contents of the hernia sac are reduced and the sac excised, either mesh or tissue is used to cover the defect in a tension-free manner. If a tissue repair is used, a vertical relaxing incision in the anterior rectus sheath is necessary to prevent tension on the repair. If a laparoscopic or open mesh repair is elected, the defect in the transversalis fascia must be covered completely.

Randomized trials of groin hernia repair show

A. Equivalent recurrence rate of open and laparoscopic hernia repairs with mesh in the hands of experienced surgeons

B. Lower operative complication rate with a laparoscopic extraperitoneal repair

C. A greater rate of recurrence with open mesh repairs than laparoscopic repairs

D. Less chronic pain and numbness with open mesh repairs than laparoscopic repairs

E. Laparoscopic extraperitoneal repair had the lowest recurrence rate

A. Equivalent recurrence rate of open and laparoscopic hernia repairs with mesh in the hands of experienced surgeons. Although early trials of open and laparoscopic mesh hernia repairs showed higher recurrence with laparoscopic repairs, more recent randomized trials involving surgeons with greater laparoscopic experience show equivalent recurrence rates for mesh repair performed open or laparoscopically. Perioperative complications are higher with extraperitoneal laparoscopic procedures than other repairs, as are recurrence rates, compared to laparoscopic transabdominal or open techniques. Laparoscopic repairs are generally associated with less pain and numbness long-term than open repairs.

Of the following, the greatest risk for incisional hernia after an abdominal operation is found in patients who

A. Are more than 65 years old

B. Have coronary artery disease

C. Develop a wound infection

D. Have diabetes

E. Have COPD

C. Develop a wound infection. Several comorbidities have been demonstrated to increase the risk of incisional hernia formation after an abdominal operation: poor surgical technique, advanced age, obesity, pulmonary disease, smoking, diabetes, previous radiation, blood loss greater than 1000 mL, poor nutrition, steroid use, and immunocompromise. The greatest risk of incisional hernia, as high as 80%, is found in patients who develop a wound infection.

Of the following, the most durable method of repairing a large incarcerated incisional hernia containing strangulated bowel is

A. Open primary repair

B. Open inlay synthetic mesh

C. Open biologic mesh inlay

D. Laparoscopic synthetic mesh

E. Underlay of biologic mesh with primary tissue brought to midline

E. Underlay of biologic mesh with primary tissue brought to midline. For all but the very smallest (< 2 cm) hernias, primary repair carries an unacceptable recurrence rate. Similar poor results are seen with inlay mesh repair, whether synthetic or biologic mesh is used. Synthetic mesh has high infection risk when bowel must be resected and should not be used under these circumstances. The best results in a contaminated field are seen with an underlay of biologic mesh with the patient’s primary tissue brought together in the midline.

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Chapter 32: Hernias & Other Lesions of the Abdominal Wall

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Chapter 32. Hernias & Other Lesions of the Abdominal Wall

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