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Thread: Hernia-Viva Question

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    Default Hernia-Viva Question

    Oral Questions on a Case of Hernia



    Case 1. INGUINAL HERNIA
    Q. What is your diagnosis ?
    A. Rt. oblique inguinal hernia, uncomplicated,
    containing intestine (omentum), no other hernias,
    no predisposing factors.


    Q. Why this is a hernia ?
    A. Because 1) It is a swelling, 2) At the anatomical
    site of a hernia, 3) Gives an impulse on cough,
    and 4) It is (or was) reducible on lying down and
    by the patient fingers.


    Q. Why inguinal and not a femoral hernia ?
    A. Because 1) the hernia is above the inguinal
    ligament and not below it, and 2) the neck of the
    hernia is above and medial to the pubic tubercle
    and because the hernia descends into the scrotum.


    Q. Why oblique and not direct ?
    A. Because 1) it descends into the scrotum, 2) On
    doing the internal ring test, there was no swelling
    to appear on coughing, and 3) the patient is a
    young male.


    Q. Describe how did you do the internal ring
    test ?

    A. After reduction of the hernia, the patient is
    asked to stand while occluding the internal ring
    (by pressing the finger 1/2 an inch above the mid
    inguinal point), the patient is then asked to cough,
    observing the appearance of any inguinal swelling.


    Q. Why you did not do the external ring test ?
    A. Because it is painful.

    Q. Can a direct hernia descend into the
    scrotum ?

    A. A direct hernia can reach the scrotum very
    rarely.


    Q. Where is the defect in oblique inguinal
    hernia ?

    A. In the internal ring.


    Q. Where is the defect in direct inguinal
    hernia ?

    A. The posterior wall of the inguinal canal
    (Hasselbach's triangle).


    Q. What are the boundaries of Hasselbach's
    triangle ?

    A. Lateral border of the rectus abdominis muscle
    medially, the inferior epigastric artery laterally and
    the inguinal ligament inferiorly.

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    Q. What are the subdivisions of the
    Hasselbach's triangle ?

    A. Hasselbach's triangle is subdivided into medial
    and lateral parts by means of the medial umbilical
    ligament.


    Q. What are the common contents of a hernia
    in general ?

    A. Intestine, omentum and fluid.


    Q. Mention the clinical types of oblique
    inguinal hernias ?

    A. 1) Bubonocoele, 2) Funicular type and 3)
    Scrotal (complete) type
    1. Bubonocoele = Hernia is only in the groin.
    2. Funicular type = Hernia descends into the
    scrotum but the testis is felt separate from
    the hernial sac.
    3. Scrotal (complete) type = Hernia descends
    into the scrotum and the hernial sac
    surrounds the testis which is not felt through
    the contents of the hernia.


    Q. What is hydrocoele of the hernial sac ?
    and what is hernia of hydrocoele ?!

    A. Hydrocoele of the hernial sac : Part of the sac
    near its neck becomes encysted by a piece of
    omentum and accumulates fluid.
    A. Hernia of hydrocoele : In cases of vaginal
    hydrocoele, a defect occurs in the dartos fascia of
    the scrotum through which a part of the
    hydrocoele herniates.

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    Q. What are the causes of residual swelling
    after reducing the hernia ?

    A. 1) Sliding hernia , 2) incomplete reducibility
    due to adhesions between the contents and the
    sac , 3) hydrocoele of the hernial sac and 4)
    associated lipoma of the cord


    Q. How would you clinically differentiate
    between obstructed and strangulated
    hernias ?

    A.
    # This is difficult because both are very acute
    conditions with the hernia being painful,
    irreducible & tender.
    # Impulse on cough is preserved in
    obstructed but is lost in strangulated hernias.
    # The hernia is tense in strangulation but not
    in obstruction.
    # Symptoms and signs of intestinal
    obstruction are present in obstructed hernias
    and maybe present in strangulated hernis
    # The degree of shock and toxaemia are
    more severe in strangulated hernias.
    # However, both conditions are considered
    surgical emergencies and necessitate an
    urgent interference to relieve the cause of
    strangulation and to deal with the contents.
    N.B. An enterocoele can be obstructed and can be
    strangulated while an omentocoele can only be
    strangulated as it has no lumen to be obstructed.


    Q. What are the conditions that you may find
    strangulation without obstruction ?

    A. If the content of the hernia is one of the
    following :
    1. Omentum
    2. Part of the circumference of the intestinal
    lumen (Richter's hernia)
    3. Michael's diverticulum (Littre's hernia)
    4. Fallopian tube & ovary
    5. Intestine, but there is an associated mesenteric
    vascular occlusion

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    Q. What is the treatment of this case of
    oblique inguinal hernia ?

    A.
    O.I.H. in children and adolescents -----------
    > Inguinal herniotomy
    O.I.H. in adults -------------------------->
    Inguinal herniorrhaphy
    O.I.H. in elderly and recurrent cases --------
    > Inguinal hernioplasty


    Q. What is the principle of operation for
    inguinal hernia in children & adolescents ?

    A. Inguinal herniotomy, that is excision of the
    hernial sac. They do not need repair as they have
    very good muscles


    Q. What is the principle of operation for O.I.H.
    in adults?

    A. Excision of the sac + repair of the defect

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    Q. What are the principles of such repair ?
    A. Repair of the defect is done either by the local
    tissues (herniorrhaphy) or by adding a graft of
    tissue (hernioplasty).
    The principles in both herniorrhaphy and
    hernioplasty, in general, are the following ;
    1. Narrowing the internal ring,
    2. Repair of the fascia transversalis, and;
    3. Reinforcement of the posterior wall of the
    inguinal canal.


    Q. What is the most popular type of repair ?
    A. Bassini repair.


    Q. What is its principle ?
    A. Suturing the conjoined muscle to the inguinal
    ligament.


    Q. What are the causes of recurrence of a
    hernia ?

    A.
    1. Untreated preoperative condition : Chronic
    straining (asthmatic bronchitis, prostatic
    enlargement ....etc.), debility, obesity
    2. Intraoperative causes: Improper
    haemostasis, tense repair, lax repair, repair
    with absorbable suture material
    3. Postoperative causes : Haematoma,
    infection, early return to hard work

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    Default PARAUMBILICAL HERNIA- Viva Questions

    Case 2. PARAUMBILICAL HERNIA


    Q. What is your diagnosis ?
    A. Paraumilical hernia, uncomplicated.


    Q. What are the types of umbilical hernias
    you know ?

    A.
    1. True umbilical hernias :
    i) Congenital umbilical hernia (exomphalos major
    and minor)
    ii) Infantile umbilical hernia (from weak umbilical
    cicatrix)
    iii) Adult umbilical hernia (from increased
    intrabdominal pressure)
    2. Paraumilical hernias : due to defect in linea alba
    close to umbilicus:
    1) Supraumbilical
    2) Infraumbilical


    Q. Is it common for patients with PUH to
    complain of dyspepsia ?

    A. Yes.
    Q. Why ?
    A. Due to traction on the greater omentum which
    is commonly the content of such a hernia.

    Q. What is the commonest complication of
    paraumbilical hernia ?

    A. Irreducibility, due to marked adhesions
    between the contents.

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    Q. What is the danger of such irreducibility ?
    A. It predisposes to obstruction and strangulation.


    Q. What is the treatment of this case ?
    A. Herniorrhaphy.


    Q. What type of repair do you do ?
    A. It varies according to the size of the defect as
    follows :
    Very small defect ---------> Anatomical
    repair
    Small to Moderate defect ---------> Mayo's
    repair
    Moderate to Large defect --------->
    Hernioplasty (prolene mesh graft)


    Q. How do you clinically differentiate
    between a paraumbilical and an epigastric
    hernia ?

    A. In paraumbilical hernia, the defect is close to
    the umbilicus so that the umbilicus forms a
    crescent at the edge of the sac, while in epigastric
    hernia, there is a bridge of normal abdominal
    muscles between the defect and the umbilicus.
    Besides, epigastric hernia could be multiple


    Q. What are the causes of incisional hernia
    A. There are;
    1. Untreated preoperative condition : Chronic
    straining (asthmatic bronchitis, prostatic
    enlargement ....etc.), debility, obesity
    2. Intraoperative causes: Improper
    haemostasis, tense repair, lax repair, repair
    with absorbable suture material
    3. Postoperative causes : Haematoma,
    infection, early return to hard work

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