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The most common hernia in females is:

A. Femoral hernia.
B. Direct inguinal hernia.
C. Indirect inguinal hernia.
D. Obturator hernia.
E. Umbilical hernia.
Answer: C
DISCUSSION: Indirect inguinal hernias are the most common hernia in both females and males. Femoral hernias are more common in females than in males.

3. Staples may safely be placed during laparoscopic hernia repair in each of the following structures except:
A. Cooper's ligament.
B. Tissues superior to the lateral iliopubic tract.
C. The transversus abdominis aponeurotic arch.
D. Tissues inferior to the lateral iliopubic tract.
E. The iliopubic tract at its insertion onto Cooper's ligament.
Answer: D
DISCUSSION: Placement of staples inferior to (below) the lateral iliopubic tract may result in injury to the lateral femoral cutaneous nerve or the genitofemoral
nerve. Staples should also not be placed within the triangle of doom, owing to the risk of major vascular injury.
Which of the statement(s) is/are true concerning laparoscopic hernia repair?

1.General anesthesia is required
2.Either an abdominal or preperitoneal approach is possible
3.The use of prosthetic mesh is required in all variations
4.Long-term results suggest that the laparoscopic approach is equal or better than traditional repairs
Answer: a, b, c

The laparoscopic approach to the repair of groin hernias has been recently developed. Either a transabdominal approach, wherein the peritoneum in the inguinal
area is opened, and the repair is performed in the preperitoneum or an entirely preperitoneal approach can be used. In either technique, which are both
performed under general anesthesia, after reducing the visceral contents out of the hernia, the repair is performed by placing a sheet of prosthetic mesh over the
internal aspect of the inguinal floor and internal ring. Although early results and short-term benefits appear promising, long-term follow-up data is still not
available to compare these techniques with traditional repairs.

Which of the following statement(s) is/are true concerning repair of inguinal hernias?

1.The Bassini repair approximates the transversus abdominis aponeurosis and transversalis fascia and the shelving edge of the inguinal ligament.
2.The Bassini repair is an adequate repair for a femoral hernia
3.A relaxing incision is important for repairs of direct and large indirect inguinal hernias to prevent excessive tension in the closure
4.An advantage to the use of prosthetic material is the mesh incites formation of scar tissue to further increase tensile strength provided by the mesh alone
The Bassini repair is an inguinal hernia repair
used world-wide and has been the standard
against which other repairs are judged. The
repair involves approximation of the
transversus abdominis aponeurosis and
transversalis fascia and the lateral edge of the
rectus sheath to the shelving edge of the
inguinal ligament. A femoral hernia cannot be
repaired by the Bassini repair because the
orifice to the femoral canal lies deep to the
inguinal ligament. A Coopers ligament repair
does approximate the structures to the
transversalis fascia of the pectineal (Coopers)
ligament between the pubic tubercle and the
femoral vein and therefore is appropriate for
repair of a femoral hernia
. A relaxing incision for repairs of direct and large indirect inguinal hernias
prevents excessive tension in the closure. There are an increasing number of
proponents for the use of prosthetic material for the routine repair of inguinal
hernias. Prosthetic material, such as polypropylene mesh, have been used for
years for repair of large or recurrent inguinal and femoral hernias. The
prosthetic mesh provides a low-tension repair for such large defects which
otherwise could not be closed without excessive tension. In addition, the
mesh incites the formation of scar tissue to further increase tensile strength
beyond that provided by mesh alone. Results reported for inguinal hernia
repairs using mesh have been excellent, although there is a slight risk of
infection of the prosthetic material which must be considered.

The following statement(s) is/are true concerning incarceration of an inguinal hernia.

1.All incarcerated hernias are surgical emergencies and require prompt surgical intervention
2.Attempt at reduction of an incarcerated symptomatic hernia is generally considered safe
3.Vigorous attempts at reduction of an incarcerated hernia may result in reduction en masse with continued entrapment and possible progression to
obstruction or strangulation
4.Incarcerated hernias frequently cause both small and large bowel obstruction
Answer: b, cHernia incarceration denotes the condition wherein viscera are contained within a
hernia sac and cannot be disgorged from the sac. Patients with an incarcerated hernia may be
asymptomatic except for the presence of a bulge. Pain associated with an incarcerated hernia
should be interpreted as indicative of strangulation. Many hernias are of such size that they
cannot be reduced either spontaneously or manually. If the patient is asymptomatic, elective
surgery should be planned. In a patient with pain, attempt at reduction is relatively safe as long
as excessive force is not applied. An incarcerated hernia with discomfort or signs of bowel
obstruction is best treated with urgent hernia repair, although gentle attempts at reduction
may be without consequences. Reduction of a symptomatic hernia may result in reduction of
gangrenous bowel into the peritoneal cavity. Reduction of bowel with necrotic areas
eventuates in bowel perforation and peritonitis with an associated 10% to 30% mortality and
high levels of morbidity. Vigorous attempts at reduction may result in reduction en masse, in
which the viscera remain within the peritoneal sac after reduction with the entire sac and its
contained viscera forced through the abdominal wall defect into the preperitoneal layer.
Reduction en masse usually occurs when a small fibrous neck traps enclosed viscera and is
associated with a high risk of continued entrapment and progression to obstruction or
World-wide hernias are the leading cause of intestinal obstruction. The obstruction is almost
exclusively small intestinal with only rarely the colon as the site of obstruction.
30. The following statement about peritonitis are all true except:
A. Peritonitis is defined as inflammation of the peritoneum.
B. Most surgical peritonitis is secondary to bacterial contamination.
C. Primary peritonitis has no documented source of contamination and is more common in adults than in children and in men than in women.
D. Tuberculous peritonitis can present with or without ascites.
Answer: C
DISCUSSION: Peritonitis is inflammation of the peritoneum and can be septic or aseptic, bacterial or viral, primary or secondary, acute or chronic. Most surgical
peritonitis is secondary to bacterial contamination from the gastrointestinal tract. Primary peritonitis refers to inflammation of the peritoneal cavity without a
documented source of contamination. It is more common in children than in adults and in women than in men. The female predominance is felt to be explained
by entry of organism into the peritoneal cavity through the fallopian tubes. The clinical manifestations of tuberculous peritonitis are of two types. The moist form
consists of fever, ascites, abdominal pain, and weakness. The dry form presents in a similar manner but without ascites.

31. True or false?
A. Mesenteric cysts are most often due to congenital lymphatic spaces that gradually fill with lymph.
B. Mesenteric cysts usually present as abdominal masses accompanied by pain, nausea, or vomiting.
C. Mesenteric cysts are best treated by marsupialization.
D. Omental cysts are frequently asymptomatic unless they undergo torsion.
DISCUSSION: Mesenteric cysts are most often due to congenital lymphatic spaces that gradually enlarge as they fill with lymph. They generally present as
abdominal masses accompanied by pain, nausea, and vomiting. They usually can be diagnosed by physical examination and have characteristic lateral mobility.
They are best treated by surgical excision, and intestinal resection may be necessary for complete removal. Omental cysts are frequently asymptomatic but may
present with vague discomfort or as a mobile abdominal mass that can cause torsion of the omentum. Torsion generally presents with signs and symptoms
compatible with acute cholecystitis, appendicitis, or a twisted ovarian cyst. Treatment entails local resection.

37. The best type of x-ray to locate free abdominal air is:
A. A posteroanterior view of the chest.
B. A flat and upright view of the abdomen.
C. Computed tomograph (CT) of the abdomen.
D. A lateral decubitus x-ray, right side up.
Answer: D
Visceral pain is typically:

1.Well localized
3.Mediated via spinal nerves
4.Perceived to be in the midline
Answer: d

Peritoneum is a continuous visceral and parietal layer. The nerve supply to each layer is separate. The visceral layer, i.e., the layer surrounding all
intraabdominal organs, is supplied by autonomic nerves (sympathetic and parasympathetic) and the parietal peritoneum is supplied by somatic innervation
(spinal nerves). The pathways relaying the sensation of pain differ for each layer and differ in quality as well. Visceral pain is characteristically dull, crampy,
deep, aching and may involve sweating and nausea. Parietal pain is sharp, severe and persistent. Visceral organs have very little pain sensation, but stretching
of the mesentery and stimulation of the parietal peritoneum cause severe pain.
Normal embryologic development of the abdominal viscera proceeds with bilateral midline autonomic innervation that results in visceral pain usually being
perceived as arising from the midline. Epigastric pain is typical of foregut origin. Periumbilical pain signifies pain emanating from the midgut. Hypogastric or
lower abdominal midline pain indicates a hindgut origin.

True statements regarding appendiceal neoplasms include which of the following?

Carcinoid tumors of the appendix less than 1.5 cm are adequately treated by simple appendectomy
Appendiceal carcinoma is associated with secondary tumors of the GI tract in up to 60% of patients
Survival following right colectomy for a Dukes stage C appendiceal carcinoma is markedly better than that for a similarly staged colon cancer at 5 years
Mucinous cystadenocarcinoma of the appendix is adequately treated by simple appendectomy, even in patients with rupture and mucinous ascites
Up to 50% of patients with appendiceal carcinoma have metastatic disease, with the liver as the most common site of spread
Answer: a

Carcinoids represent two-thirds of all appendiceal neoplasms. Nearly half of all GI carcinoids arise in the appendix at a mean age of 41 years. Two-thirds of the
time the carcinoid is only incidentally detected, only 0.5% have evidence of distant metastatic spread at resection. In one experience, carcinoids between 1.5
and 2.0 cm have had minimal metastatic potential and those smaller than 1.5 cm never metastasized. In the 1% that are larger than 2 cm however, metastases
are frequent and 80% recur even after resection at this size.
Adenocarcinoma of the appendix is exceedingly rare. These tumors occur in elderly patients at the base of the appendix. Appendicitis often follows and the
diagnosis is not made preoperatively and is rarely considered during surgery since the appearance of the tumor may mimic perforated appendicitis. Up to half
the patients have metastatic disease at diagnosis and the peritoneum is the most common site of spread. Survival is proportional to tumor stage. Dukes Stage A
disease may be treated simply with appendectomy if all disease can be removed with reasonable margins. Dukes B and C lesions require formal right
hemicolectomy for disease control. Survival is, stage for stage, similar to colon cancer after 5 years. Appendiceal adenocarcinomas also appear to have an
association with secondary tumors, often of the GI tract, in up to 35% of patients.
Patients with mucinous cystadenocarcinoma of the appendix typically are symptomatic, and wide resection of the primary disease, together with debulking of
peritoneal implants, is indicated. Indolent progression of metastases commonly results in prolonged survival rates (50% at 5 years) during which patients may
require repeated laparatomies for complications of the disease.