MedCosmos Surgery
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Hernia and Acute Abdomen MCQ
1. 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.
2. Which of the following statements regarding unusual hernias is
incorrect?
A. An obturator hernia may produce nerve compression diagnosed by
a positive Howship-Romberg sign.
B. Grynfeltt's hernia appears through the superior lumbar triangle,
whereas Petit's hernia occurs through the inferior lumbar triangle.
C. Sciatic hernias usually present with a painful groin mass below the
inguinal ligament.
D. Littre's hernia is defined by a Meckel's diverticulum presenting as
the sole component of the hernia sac.
E. Richter's hernia involves the antimesenteric surface of the intestine
within the hernia sac and may present with partial intestinal
obstruction.
Answer: C
DISCUSSION: Sciatic hernias usually present with intestinal
obstruction or a mass in the gluteal or infragluteal region.
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.
4. The following Nyhus classification of hernias is correct except for:
A. Recurrent direct inguinal hernia—Type IVa.
B. Indirect inguinal hernia with a normal internal inguinal ring—Type I.
C. Femoral hernia—Type IIIc.
D. Direct inguinal hernia—Type IIIa.
E. Indirect inguinal hernia with destruction of the transversalis fascia
of Hesselbach's triangle—Type II.
Answer: E
DISCUSSION: An indirect inguinal hernia with destruction of the
transversalis fascia of Hesselbach's triangle is classified as a Type IIIb
hernia. Also classified as Type IIIb hernias are sliding, pantaloon, and
massive scrotal hernias. Type II hernia is an indirect inguinal hernia
with a dilated internal ring but without displacement of the inferior
deep epigastric vessels or destruction of the transversalis fascia of
Hesselbach's triangle.
5. Which of the following statements about the causes of inguinal
hernia is correct?
A. Excessive hydroxyproline has been demonstrated in the
aponeuroses of hernia patients.
B. Obliteration of the processus vaginalis is a contributing factor for
the development of an indirect inguinal hernia.
C. Physical activity and athletics have been shown to have a protective
effect toward the development of inguinal hernias.
D. Elevated levels of circulating serum elastalytic activity have been
demonstrated in patients with direct herniation who smoke.
E. The majority of inguinal hernias are acquired.
Answer: D
DISCUSSION: A correlation between cigarette smoking and an inguinal
hernia formation has been demonstrated. Elevated circulating serum
elastalytic activity and free active unbound neutrophil elastase has
,been detected in smokers.
6. The following statements about the repair of inguinal hernias are
true except:
A. The conjoined tendon is sutured to Cooper's ligament in the Bassini
hernia repair.
B. The McVay repair is a suitable option for the repair of femoral
hernias.
C. The Shouldice repair involves a multilayer, imbricated repair of the
floor of the inguinal canal.
D. The Lichtenstein repair is accomplished by prosthetic mesh repair
of the inguinal canal floor in a tension-free manner.
E. The laparoscopic transabdominal preperitoneal (TAPP) and totally
extraperitoneal approach (TEPA) repairs are based on the
preperitoneal repairs of Cheattle, Henry, Nyhus, and Stoppa.
Answer: A
DISCUSSION: The Bassini repair is accomplished by high ligation of the
hernia sac followed by suturing the conjoined tendon and the internal
oblique muscle to the inguinal ligament.
7. Which of the following statements concerning the abdominal wall
layers are correct?
A. Scarpa's fascia affords little strength in wound closure.
B. The internal abdominal oblique muscles have fibers that continue
into the scrotum as cremasteric muscles.
C. The transversalis fascia is the most important layer of the
abdominal wall in preventing hernias.
D. The lymphatics of the abdominal wall drain into the ipsilateral
axillary lymph nodes above the umbilicus and into the ipsilateral
superficial inguinal lymph nodes below the umbilicus.
Answer: ABCD
DISCUSSION: The integrity of the abdominal wall is maintained
principally by the transversalis fascia. Scarpia's fascia affords little
strength in wound closure, but its approximation contributes
considerably to the creation of an aesthetically acceptable scar. The
cremasteric muscles of the spermatic cord are a continuation of
muscle fibers from the internal abdominal oblique musculature. The
lymphatic supply of the abdominal wall follows a simple pattern.
These superficial lymphatics run parallel to the superficial veins, which
above the umbilicus drain into the ipsilateral axillary vein and below it
into the ipsilateral femoral vein.
8. Which of the following congenital abnormalities are correctly
, defined?
A. Omphalocele represents a defect in the abdominal wall lateral to
the umbilical cord.
B. The herniated viscera associated with omphaloceles are usually
covered with a membranous sac.
C. An umbilical polyp is a small excrescence of omphalomesenteric
duct mucosa that is retained in the umbilicus.
D. Meckel's diverticulum results when the intestinal end of the
omphalomesenteric duct persists and represents a true diverticulum.
Answer: BCD
DISCUSSION: Omphalocele may be seen in newborns and represents
a defect in the closure of the umbilical ring. The herniated viscera are
usually covered with a sac. Gastroschisis, a defect of the abdominal
wall lateral to the umbilical cord, is caused by failure of closure of the
body wall. The intestines protrude through the defect, and no sac is
present to cover the herniated intestine. In the fetus, the
omphalomesenteric duct may present as abnormalities related to the
abdominal wall when the duct fails to obliterate. Meckel's diverticulum
is the result of the failure of obliteration of the intestinal end of the
omphalomesenteric duct. This is a true diverticulum with all layers of
the intestinal wall represented. An umbilical polyp is a small
excrescence of omphalomesenteric duct mucosa retained in the
umbilicus. Such polyps resemble umbilical granulomas except that
they do not disappear after silver nitrate cauterization. Appropriate
treatment is excision of the mucosal remnant.
9. The following statement(s) is/are true concerning the indications for
treatment of an inguinal hernia.
a. Most adult hernias will remain stable in size, therefore delay
seldom affects the technical aspects of a surgical repair
b. There is a direct correlation between the length of time that a
hernia is present and the risk of major complications
c. The morbidity and mortality associated with emergent operation
due to hernia complications is significantly greater than for elective
repair of the identical hernia
d. A truss maintains a hernia in the reduced state, therefore,
minimizing the risk of incarceration and strangulation
Answer: b, c
The indications for hernia repair must be individualized for each
patient and the particular situation. In general, the presence of a
hernia may be considered an adequate indication for hernia repair.
Certainly the presence of complications due to hernia necessitates the
correction of those complications and usually the repair of the hernia.
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Hernia and Acute Abdomen MCQ
1. 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.
2. Which of the following statements regarding unusual hernias is
incorrect?
A. An obturator hernia may produce nerve compression diagnosed by
a positive Howship-Romberg sign.
B. Grynfeltt's hernia appears through the superior lumbar triangle,
whereas Petit's hernia occurs through the inferior lumbar triangle.
C. Sciatic hernias usually present with a painful groin mass below the
inguinal ligament.
D. Littre's hernia is defined by a Meckel's diverticulum presenting as
the sole component of the hernia sac.
E. Richter's hernia involves the antimesenteric surface of the intestine
within the hernia sac and may present with partial intestinal
obstruction.
Answer: C
DISCUSSION: Sciatic hernias usually present with intestinal
obstruction or a mass in the gluteal or infragluteal region.
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.
4. The following Nyhus classification of hernias is correct except for:
A. Recurrent direct inguinal hernia—Type IVa.
B. Indirect inguinal hernia with a normal internal inguinal ring—Type I.
C. Femoral hernia—Type IIIc.
D. Direct inguinal hernia—Type IIIa.
E. Indirect inguinal hernia with destruction of the transversalis fascia
of Hesselbach's triangle—Type II.
Answer: E
DISCUSSION: An indirect inguinal hernia with destruction of the
transversalis fascia of Hesselbach's triangle is classified as a Type IIIb
hernia. Also classified as Type IIIb hernias are sliding, pantaloon, and
massive scrotal hernias. Type II hernia is an indirect inguinal hernia
with a dilated internal ring but without displacement of the inferior
deep epigastric vessels or destruction of the transversalis fascia of
Hesselbach's triangle.
5. Which of the following statements about the causes of inguinal
hernia is correct?
A. Excessive hydroxyproline has been demonstrated in the
aponeuroses of hernia patients.
B. Obliteration of the processus vaginalis is a contributing factor for
the development of an indirect inguinal hernia.
C. Physical activity and athletics have been shown to have a protective
effect toward the development of inguinal hernias.
D. Elevated levels of circulating serum elastalytic activity have been
demonstrated in patients with direct herniation who smoke.
E. The majority of inguinal hernias are acquired.
Answer: D
DISCUSSION: A correlation between cigarette smoking and an inguinal
hernia formation has been demonstrated. Elevated circulating serum
elastalytic activity and free active unbound neutrophil elastase has
,been detected in smokers.
6. The following statements about the repair of inguinal hernias are
true except:
A. The conjoined tendon is sutured to Cooper's ligament in the Bassini
hernia repair.
B. The McVay repair is a suitable option for the repair of femoral
hernias.
C. The Shouldice repair involves a multilayer, imbricated repair of the
floor of the inguinal canal.
D. The Lichtenstein repair is accomplished by prosthetic mesh repair
of the inguinal canal floor in a tension-free manner.
E. The laparoscopic transabdominal preperitoneal (TAPP) and totally
extraperitoneal approach (TEPA) repairs are based on the
preperitoneal repairs of Cheattle, Henry, Nyhus, and Stoppa.
Answer: A
DISCUSSION: The Bassini repair is accomplished by high ligation of the
hernia sac followed by suturing the conjoined tendon and the internal
oblique muscle to the inguinal ligament.
7. Which of the following statements concerning the abdominal wall
layers are correct?
A. Scarpa's fascia affords little strength in wound closure.
B. The internal abdominal oblique muscles have fibers that continue
into the scrotum as cremasteric muscles.
C. The transversalis fascia is the most important layer of the
abdominal wall in preventing hernias.
D. The lymphatics of the abdominal wall drain into the ipsilateral
axillary lymph nodes above the umbilicus and into the ipsilateral
superficial inguinal lymph nodes below the umbilicus.
Answer: ABCD
DISCUSSION: The integrity of the abdominal wall is maintained
principally by the transversalis fascia. Scarpia's fascia affords little
strength in wound closure, but its approximation contributes
considerably to the creation of an aesthetically acceptable scar. The
cremasteric muscles of the spermatic cord are a continuation of
muscle fibers from the internal abdominal oblique musculature. The
lymphatic supply of the abdominal wall follows a simple pattern.
These superficial lymphatics run parallel to the superficial veins, which
above the umbilicus drain into the ipsilateral axillary vein and below it
into the ipsilateral femoral vein.
8. Which of the following congenital abnormalities are correctly
, defined?
A. Omphalocele represents a defect in the abdominal wall lateral to
the umbilical cord.
B. The herniated viscera associated with omphaloceles are usually
covered with a membranous sac.
C. An umbilical polyp is a small excrescence of omphalomesenteric
duct mucosa that is retained in the umbilicus.
D. Meckel's diverticulum results when the intestinal end of the
omphalomesenteric duct persists and represents a true diverticulum.
Answer: BCD
DISCUSSION: Omphalocele may be seen in newborns and represents
a defect in the closure of the umbilical ring. The herniated viscera are
usually covered with a sac. Gastroschisis, a defect of the abdominal
wall lateral to the umbilical cord, is caused by failure of closure of the
body wall. The intestines protrude through the defect, and no sac is
present to cover the herniated intestine. In the fetus, the
omphalomesenteric duct may present as abnormalities related to the
abdominal wall when the duct fails to obliterate. Meckel's diverticulum
is the result of the failure of obliteration of the intestinal end of the
omphalomesenteric duct. This is a true diverticulum with all layers of
the intestinal wall represented. An umbilical polyp is a small
excrescence of omphalomesenteric duct mucosa retained in the
umbilicus. Such polyps resemble umbilical granulomas except that
they do not disappear after silver nitrate cauterization. Appropriate
treatment is excision of the mucosal remnant.
9. The following statement(s) is/are true concerning the indications for
treatment of an inguinal hernia.
a. Most adult hernias will remain stable in size, therefore delay
seldom affects the technical aspects of a surgical repair
b. There is a direct correlation between the length of time that a
hernia is present and the risk of major complications
c. The morbidity and mortality associated with emergent operation
due to hernia complications is significantly greater than for elective
repair of the identical hernia
d. A truss maintains a hernia in the reduced state, therefore,
minimizing the risk of incarceration and strangulation
Answer: b, c
The indications for hernia repair must be individualized for each
patient and the particular situation. In general, the presence of a
hernia may be considered an adequate indication for hernia repair.
Certainly the presence of complications due to hernia necessitates the
correction of those complications and usually the repair of the hernia.
