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Questions

977. Hernia occurring through triangle of Petit: (AMU 94)a. Superior lumbar herniab. Inferior lumbar herniac. Obturator herniad. Femoral hernia

978. Howship-Romberg sign is most specific finding in: (Delhi 90)a. Superior lumbar herniab. Inferior lumbar herniac. Obturator herniad. Femoral hernia

979. Clinically, a saphena varix is likely to be confused with: (Kar 2002)a. Baker’s cystb. Femoral herniac. Spermatoceled. Varicocele

980. Spigelian hernia occurs through: (Kerala 2001)a. Medial border of rectus abdominisb. Lateral border of rectic. Epigastriumd. Lumbar triangle

981. Richter’s hernia is commonly associated with: (UPSC 2001)a. Direct inguinal herniab. Femoral herniac. Indirect inguinal herniad. Obturator hernia

982. True about hernia: (PGI 2000 Dec)a. Direct hernias are usually acquiredb. Femoral is most common hernia to strangulatec. Extraabdominal hernia are more commond. 50 % old people suffer from direct type of herniae. Treatment of choice for indirect inguinal hernia is surgery

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983. Relation of hernial sac to spermatic cord in direct inguinal herniais: (BIHAR 99)

a. Sac is anterior to cordb. Sac is posterior to cordc. Sac is medial to cordd. Sac is lateral to cord

984. Femoral artery begins at: (Maha 2000)a. Midinguinal Pointb. Femoral ringc. Mid point of inguinal ligamentd. Any of the above

985. Deep inguinal ring is present in: (Maha 2000)a. Internal oblique muscleb. Lacunar ligamentc. Fascia transversalisd. Transverses abdominis

986. Medial border of femoral canal is formed by: (DNB 2004)a. Inguinal ligamentb. Pectineal ligamentc. Lacunar ligamentd. Femoral Vein

987. All are true about femoral hernia except: (Manipal 2006)a. More common in femalesb. More risk of strangulationc. Surgery should be performed as soon as possibled. Conservative management — truss can be fitted

988. True about femoral hernia: (Delhi 2005)a. Commoner in malesb. Least likely to strangulatec. Litter’s hernia is its variantd. None

989. True about the inguinal canal: (PGI 2005)a. The internal ring lies midway between the symphysis pubis and

anterior superior iliac spineb. The internal ring lies medial to the inferior epigastric vesselsc. The external oblique aponeurosis forms the anterior boundaryd. The inguinal ligament forms the inferior boundarye. 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 openedat: (AIIMS 1996)

a. Fundusb. Neckc. Bodyd. Base

991. The diagnostic feature of congenital diaphragmatic hernia onprenatal ultrasonography is: (AIIMS 2001 MAY)

a. A cyst behind the left atriumb. Mediastinal shift with normal heart axisc. Peristalsis in the thoracic cavityd. 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 signsb. Stomach and transverse colon are commonest contents to herniatec. Diagnosed prenatally by ultrasoundd. Common on left posterior side

993. Which of the following is a contraindication for Bag and maskventilation: (PGI 2002; AIIMS 2000)

a. Septicemiab. Tracheoesophageal fistulac. Meconium aspirationd. Diaphragmatic hernia

994. Sliding constituent of a large direct hernia is: (PGI 97)a. Bladderb. Sigmoid colonc. Caecumd. Appendix

995. The most common content of ‘hernia en glissade’/sliding herniais: (AI 1988)

a. Sigmoid colonb. Caecumc. Appendixd. Urinary bladder

996. The most important and essential step in repair of indirect inguinalhernia is: (UP 2000)

a. Isolation and excision of sacb. Narrowing of the internal ringc. Division of the cordd. Strengthening of the posterior wall of the canal

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997. Hernia most often overlooked is: (TN 98)a. Femoral herniab. Inguinal herniac. Incisional herniad. Paraumbilical hernia

998. In children, umbilical hernia is best operated after age: (DNB2001)

a. 9-12 monthsb. 1-2 yearsc. 3-4 yearsd. 10-12 years

999. A 25-year-old male presents with reducible right inguinal swellingpresent since 2 years with history of irreducibility since 10 hrs.On examination, there is distension of abdomen, hyperperistalticbowel sounds, the swelling is tense and tender, red with absentcough impulse and patient has tachycardia. Most likely diagnosisin such patient is: (SGPGI 98)

a. Strangulationb. Obstructionc. Irreducibilityd. Sliding Hernia

1000. Best possible treatment of a congenital indirect uncomplicatedinguinal hernia in a 10-year-old boy is: (TN 99)

a. Herniotomyb. Herniorrhaphyc. Hernioplastyd. Truss

1001. A 75-year-old male patient has asymptomatic right-sided directinguinal hernia since 10 years. Patient has bronchial asthmawith IHD, arrhythmias and poor left ventricular function bestpossible plan of management will be: (Bihar 2000)

a. Observation onlyb. Herniorrhaphyc. Hernioplastyd. Truss

1002. Prevention of injury to ilioinguinal nerve is an important stepduring inguinal hernia operation while: (UPSC 1997)

a. Incising the subcutaneous tissueb. Incising the external oblique aponeurosisc. Incising the cremasteric fasciad. Isolating the sac

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1003. Which of the following is content of Littre’s hernia? (DNB 2004)a. Urinary bladderb. Meckle’s diverticulumc. Circumference of intestinal walld. Appendix

1004. Richter’s hernia involves: (MP 2003)a. Meckle’s diverticulumb. Hernia with hydrocelec. Abdominal organ especially on posterior walld. Circumference of intestine

1005. A patient operated for direct inguinal hernia developed anesthesiaat the root of the penis and adjacent part of the scrotum. Thenerve likely to be injured is: (AIIMS 2001 nov)

a. Genital branch of genitofemoral nerveb. Femoral branch of genitofemoral nervec. Iliohypogastric nerved. Ilioinguinal nerve

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Answers

977. Ans. b (Inferior lumbar hernia)(Ref. CSDT 11th ed. 794)LUMBAR HERNIAThe superior and inferior spaces or triangles are sites of flankherniation. The superior lumbar triangle (triangle of Grynfeltt) isbordered by the 12th rib superiorly, the internal oblique muscleanteriorly, and the erector spinal muscle posteriorly. The inferiorlumbar triangle (triangle of Petit) is bordered by the external obliquemuscle anteriorly, the latissimus dorsi muscle posteriorly, and theiliac crest inferiorly. These hernias are rare, often presenting as abulge in the flank. Hernia contents can include bowel, retroperitonealfat, kidney, or other visceral organs. Incarceration and strangulationdo occur (in about 10% cases). Barium studies are helpful whenbowel is contained in the hernia; however, computed tomographyis most useful in determining location and contents of lumbarhernias.Repair is by mobilization of the nearby fascia and obliteration of thehernial defect by precise fascia-to-fascia closure. The recurrencerate is very low.

978. Ans. c (Obturator hernia)(Ref. CSDT 11th ed. 795)OBTURATOR HERNIAObturator hernias are uncommon and difficult to diagnose. Theperitoneal sac and its contents herniate through the obturator canalin the superolateral aspect of the obturator foramen alongside theobturator vessels and nerves, and come to lie between the obturatorexternus and pectineus muscles or between the layers of theobturator membrane. This is primarily a hernia of elderly femalescommonly containing bowel, but it may also contain appendix,omentum, bladder, uterus, or adnexal tissue. Incarceration is almostcertain. The hernia sac may be palpable on rectal or vaginalexamination.Howship-Romberg sign is specific of obturator hernia, in whichthe 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 obstructionwith a fixed loop containing gas or contrast in the obturator region.

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Computed tomography will depict the hernia sac protruding throughthe obturator foramen and extending between the pectineus andobturator muscles.This hernia should not be repaired from the thigh approach. Theabdominal approach gives the best exposure, however , retropubicapproach (Cheatle-Henry operation) may also be used.

979. Ans. b (Femoral hernia)FEMORAL HERNIAFemoral hernias are difficult to diagnose clinically because of theirdeep location in the femoral canal. They always remain below theinguinal ligament and lateral to the pelvic tubercle and are moreprone to incarceration and strangulation than inguinal hernias. Thistype of hernia occurs more commonly in females and usuallycontains properitoneal fat, omentum, and/or small bowel.Clinically, saphena varix is its closest differential diagnosis.

980. Ans. b (Lateral border of recti)SPIGELIAN HERNIASpigelian hernias are caused by a congenital weakness in theposterior layer of transversalis fascia, which allows viscera toprolapse between the lateral abdominal wall muscles and throughthe linea semilunaris. Thus, it occurs usually at infraumbilicallocation. Typically, the omentum and short segments of large orsmall bowel protrude through the hernia defect. Diagnosis of theserare hernias is notoriously difficult. Computed tomography is theimaging modality of choice because it allows visualization of thehernia defect in the rectus sheath and identification of the herniacontents.

981. Ans. b (Femoral hernia)(Ref. Bailey and Love-23rd ed.-1145)Hernias involving only a part of the bowel wall are termed “Richter’shernias.” Generally, a segment of large bowel is involved. Sinceonly a portion of the intestinal wall is incorporated into the hernia,the lumen remains patent, and there is no obstruction. Incarcerationis uncommon. It may be associated with femoral hernia.

982. Ans. a, b, c, eINGUINAL HERNIAInguinal hernia, the most common abdominal hernia, can be director indirect. Indirect inguinal hernia occurs with the greatestfrequency, is usually congenital, but may be acquired in olderindividuals. The processus vaginalis normally closes before birth.In one third of infants and one sixth of adults, the process vaginalisremains patent, persisting as a peritoneal sac into which viscera

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may enter. Hernia contents typically include small bowel loops andmobile colon segments such as sigmoid, appendix, cecum andtransverse colon. Retroperitoneal organs such as the urinarybladder, distal ureters, or ascending or descending colon may beincorporated into the hernia. Preoperative recognition of retroperiton-eal contents in the hernia is essential to avoid injury during surgicalrepair. The peritoneal sac and viscera protrude lateral and inferiorto the inferior epigastric vessels through the inguinal canal andemerge at the external inguinal ring. In males, the hernia can extendalong the spermatic cord into the scrotum, whereas in females, thehernia follows the course of the round of ligament into the labiamajoris. Bowel obstruction, incarceration, and strangulation arecommon sequelae of indirect inguinal hernia. Diverticulitis, appe-ndicitis, and primary or metastatic tumors may occur within the he-rnia.Direct inguinal hernias protrude directly through the lowerabdominal wall through a defect in the transversalis fascia, medialto the inferior epigastric vessels. More common in men, they rarelyincarcerate.

983. Ans. d (Sac is posterior to cord)(Ref: B and L, Surgery, 23rd ed., 1145; B.D.Chaurasia’s HumanAnatomy- Vol. II 3rd ed. 61, 179)An indirect inguinal hernial sac travels down the canal onanterolateral aspect of spermatic cord, while direct hernial sac isposterior to cord.

CONTENTS OF SPERMATIC CORD1. The Ductus deferens2. Testicular and Cremasteric Arteries and Artery of Ductus Deferens3. Pampiniform plexus of veins4. Genital branch of Genitofemoral nerve and Plexus of sympathetic

nerves5. Lymphatic vessel from testes6. Remnants of Processes Vaginalis.Ilioinguinal nerve enters inguinal canal through interval betweenexternal and internal oblique Muscle and pass out throughsuperficial inguinal ring.Inferior epigastric artery is not content of spermatic cord, it formslateral boundary of Hasselbach triangle.

984. Ans.a (Midinguinal Point)(Ref. B.D.Chaurasia Anatomy, Vol 1, 2nd ed. 11)Femoral triangle1. 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-emptyspace-lymphatics ( NAVEL)

3.Femoral sheath contains femoral artery, femoral vein and femoralcanal (containing deep inguinal lymph nodes, gland of Cloquetand Rossenmuller (sex hormones). Femoral nerve lies outsidefemoral sheath.

4.A femoral pulse is palpable high within the femoral triangle justinferior to the inguinal ligament, at the mid inguinal point wherefemoral 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 Anato-my, Vol 1, 2nd ed. 151)Deep inguinal ring is an oval opening in fascia transversalis abouthalf 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 muscleslining.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 womenManagement 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)

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· 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 dThe internal ring lies lateral to the inferior epigastric vesselsThe 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 theperitoneal 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 herniarelies on the visualization of abdominal organs in the chest.Other pointers may be, absence of a normally positioned stomach,mediastinal displacement, small abdominal circumference andpolyhydramnios.

992. Ans. a (Early respiratory distress leading to early diagnosis andtreatment are good prognostic signs)(Ref. Sabiston, 16th Ed. 1480)Although the gross anatomy and, to some extent, the pathophysi-ology of CDH have been well described for more than 200 years,CDH as remained one of the most frustrating of the major birthdefects to manage successfully. Despite early detection of severediaphragmatic defects by prenatal ultrasonography and the morecommon recognition of CDH as a cause of significant respiratorydistress at birth, current mortality has improved little from the seriespresented 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.· EventrationBochdalek hernia:· During formation of the diaphragm, the pleura and coelomic

cavities remain in continuity by means of the pleuroperitonealcanal (foramen of Bochdalek), The posterolateral communicationis closed by the developing diaphragm. Failure of diaphragmaticdevelopment 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 diaphragmatichernia, because in diaphragmatic hernia the abdominal contentshave herniated into the thoracic cavity and are compressing thelung. By using bag and mask ventilation air will also move into theGIT along with the lung. More air in the stomach and intestines willcause 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 herniasare situated on left side. It presents as a large globular inguinalhernia. Large intestine (sigmoid colon) is commonly present. Aportion of the bladder or diverticulum of the bladder may be presentin addition to other contents in sliding hernia. Bilateral slidinghernias are rare.

995. Ans. a (Sigmoid colon)This type of hernia occurs exclusively in males, five out of six herniasare situated on left side. It presents as a large globular inguinalhernia. Large intestine (sigmoid colon) is commonly present.A portion of the bladder or diverticulum of the bladder may be presentin addition to other contents in sliding hernia. Bilateral sliding hern-ias are rare.

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996. Ans. b (Narrowing of the internal ring)When internal ring is weak and stretched, the repair should includeLytle method of repairing and narrowing the ring.

997. Ans. a (Femoral hernia)Symptoms of femoral hernia are less pronounced than inguinalhernia, since it is small. It may remain unnoticed for years till itstrangulates.

998. Ans. b (1-2 years)UMBILICAL HERNIAIn children and infants, patent umbilical rings are common, and theresulting herniation is asymptomatic. Occasionally incarcerationmay occur requiring surgical intervention. Adults presenting withumbilical hernias usually have diastasis of the rectus musclesresulting from multiple pregnancies, obesity, or chronic increasedabdominal pressure. Greater omentum and bowel are the typicalhernia contents that protrude through the linea alba at the umbilicusand can incarcerate, causing symptoms of intestinal obstructionand umbilical tenderness. Mayo’s operation is done to repair it.Masterly inactivity is the treatment of choice for umbilical hernia inchildren as hernia usually close spontaneously by 2 years in 95%cases. Obstruction or strangulation below 3 years age is extremelyuncommon. In case masterly inactivity fails operation should becarried out after age of 2 years.

999. Ans. a (Strangulation)Strangulated obstructed irreducible hernia will give irreducibleswelling with absent cough impulse. With strangulation the swellingwill become tense, tender with or without local rise of temperatureand systemic signs of sepsis. Obstructed hernias may be tenseand non-tender. More often than not, the obstruction culminatesinto strangulation.

1000. Ans. a (Herniotomy)In congenital hernia, problem is patent processes vaginalis but theposterior wall is normal, hence Herniotomy is sufficient fortreatment. But in old patients the posterior wall is weak and thereforethey will require, herniorraphy or hernioplasty depending on thenature of tissue as seen during the operative procedure.

1001. Ans. a (Observation only)Direct hernias have wide neck and hence are unlikely to undergostrangulation and indication of surgery in such case will bepersistent pain and for cosmesis. But in this patient risk of surgeryis 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 nerveand hence during operation for inguinal hernia prevention of injuryto ilioinguinal nerve to avoid later development of incisional herniais very important.

1003. Ans: b (Meckle’s diverticulum)(Ref. Bailey and Love 24th Ed.- 1273)Littre’s hernia is external anterior abdominal weal hernia withMeckle’s diverticulum as its content.

1004. Ans. d (Circumference of intestine)(Ref. Bailey and Love-23rd ed.-1145, 24th 1273)——————————————————————————————Hernia Content——————————————————————————————Omentocele/epiplocele OmentumEnterocele Small bowel commonly, may be large bowel or appendixRichter’s A portion of circumference of intestineLittre’s Meckel’s diverticulumSliding Contents of posterior abdominal wall,

commonly bladderPantaloon Direct + Indirect herniaInferior lumbar Herniation through triangle of PetitObturator hernia 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 iliohypogastricare branches of the lumbar plexus and all may be injured in operati-on for hernia.

Ilioinguinal nerveEnters 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 ofo proximomedial skin of the thigh.o skin over the penile root.o upper part of the scrotumIliohypogastric nerveDivides into two branches -lateral cutaneous and anterior cutan-eous.Lateral cutaneous supplies -posterolateral gluteal skinAnterior cutaneous supplies -supra pubic skin

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Genitofemoral nerve divides into two branches Genital and FemoralGenital branch of Genitofemoral nerve -enters the inguinal canal atits deep ring and supplieso the Cremaster muscleo the scrotal skin

Femoral branch of genitofemoral nervePasses behind the inguinal ligament, enters the femoral sheathlateral to femoral artery, pierces the anterior layer of the femoralsheath and fascia lata and supplies the skin anterior to the upperpart of femoral triangle.