Hernias 573

Hernias

Questions
977. Hernia occurring through triangle of Petit: (AMU 94)
a. Superior lumbar hernia
b. Inferior lumbar hernia
c. Obturator hernia
d. Femoral hernia

978. Howship-Romberg sign is most specific finding in: (Delhi 90)

a. Superior lumbar hernia
b. Inferior lumbar hernia
c. Obturator hernia
d. Femoral hernia

979. Clinically, a saphena varix is likely to be confused with: (Kar 2002)

a. Baker’s cyst
b. Femoral hernia
c. Spermatocele
d. Varicocele

980. Spigelian hernia occurs through: (Kerala 2001)

a. Medial border of rectus abdominis
b. Lateral border of recti
c. Epigastrium
d. Lumbar triangle

981. Richter’s hernia is commonly associated with: (UPSC 2001)

a. Direct inguinal hernia
b. Femoral hernia
c. Indirect inguinal hernia
d. Obturator hernia

982. True about hernia: (PGI 2000 Dec)

a. Direct hernias are usually acquired
b. Femoral is most common hernia to strangulate
c. Extraabdominal hernia are more common
d. 50 % old people suffer from direct type of hernia
e. Treatment of choice for indirect inguinal hernia is surgery

573
574 Surgery
983. Relation of hernial sac to spermatic cord in direct inguinal hernia
is: (BIHAR 99)
a. Sac is anterior to cord
b. Sac is posterior to cord
c. Sac is medial to cord
d. Sac is lateral to cord

984. Femoral artery begins at: (Maha 2000)

a. Midinguinal Point
b. Femoral ring
c. Mid point of inguinal ligament
d. Any of the above

985. Deep inguinal ring is present in: (Maha 2000)

a. Internal oblique muscle
b. Lacunar ligament
c. Fascia transversalis
d. Transverses abdominis

986. Medial border of femoral canal is formed by: (DNB 2004)

a. Inguinal ligament
b. Pectineal ligament
c. Lacunar ligament
d. Femoral Vein

987. All are true about femoral hernia except: (Manipal 2006)
a. More common in females
b. More risk of strangulation
c. Surgery should be performed as soon as possible
d. Conservative management — truss can be fitted

988. True about femoral hernia: (Delhi 2005)

a. Commoner in males
b. Least likely to strangulate
c. Litter’s hernia is its variant
d. None

989. True about the inguinal canal: (PGI 2005)

a. The internal ring lies midway between the symphysis pubis and
anterior superior iliac spine
b. The internal ring lies medial to the inferior epigastric vessels
c. The external oblique aponeurosis forms the anterior boundary
d. The inguinal ligament forms the inferior boundary
e. The conjoint tendon forms the lateral part of the posterior wall
 Hernias 575
990. While operating for obstructed inguinal hernia the sac is opened
at: (AIIMS 1996)
a. Fundus
b. Neck
c. Body
d. Base

991. The diagnostic feature of congenital diaphragmatic hernia on

prenatal ultrasonography is: (AIIMS 2001 MAY)
a. A cyst behind the left atrium
b. Mediastinal shift with normal heart axis
c. Peristalsis in the thoracic cavity
d. 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 signs
b. Stomach and transverse colon are commonest contents to herniate
c. Diagnosed prenatally by ultrasound
d. Common on left posterior side

993. Which of the following is a contraindication for Bag and mask

ventilation: (PGI 2002; AIIMS 2000)
a. Septicemia
b. Tracheoesophageal fistula
c. Meconium aspiration
d. Diaphragmatic hernia

994. Sliding constituent of a large direct hernia is: (PGI 97)

a. Bladder
b. Sigmoid colon
c. Caecum
d. Appendix

995. The most common content of ‘hernia en glissade’/sliding hernia

is: (AI 1988)
a. Sigmoid colon
b. Caecum
c. Appendix
d. Urinary bladder

996. The most important and essential step in repair of indirect inguinal
hernia is: (UP 2000)
a. Isolation and excision of sac
b. Narrowing of the internal ring
c. Division of the cord
d. Strengthening of the posterior wall of the canal
576 Surgery
997. Hernia most often overlooked is: (TN 98)
a. Femoral hernia
b. Inguinal hernia
c. Incisional hernia
d. Paraumbilical hernia

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

2001)
a. 9-12 months
b. 1-2 years
c. 3-4 years
d. 10-12 years

999. A 25-year-old male presents with reducible right inguinal swelling

present since 2 years with history of irreducibility since 10 hrs.
On examination, there is distension of abdomen, hyperperistaltic
bowel sounds, the swelling is tense and tender, red with absent
cough impulse and patient has tachycardia. Most likely diagnosis
in such patient is: (SGPGI 98)
a. Strangulation
b. Obstruction
c. Irreducibility
d. Sliding Hernia

1000. Best possible treatment of a congenital indirect uncomplicated

inguinal hernia in a 10-year-old boy is: (TN 99)
a. Herniotomy
b. Herniorrhaphy
c. Hernioplasty
d. Truss

1001. A 75-year-old male patient has asymptomatic right-sided direct

inguinal hernia since 10 years. Patient has bronchial asthma
with IHD, arrhythmias and poor left ventricular function best
possible plan of management will be: (Bihar 2000)
a. Observation only
b. Herniorrhaphy
c. Hernioplasty
d. Truss

1002. Prevention of injury to ilioinguinal nerve is an important step

during inguinal hernia operation while: (UPSC 1997)
a. Incising the subcutaneous tissue
b. Incising the external oblique aponeurosis
c. Incising the cremasteric fascia
d. Isolating the sac
 Hernias 577
1003. Which of the following is content of Littre’s hernia? (DNB 2004)
a. Urinary bladder
b. Meckle’s diverticulum
c. Circumference of intestinal wall
d. Appendix

1004. Richter’s hernia involves: (MP 2003)

a. Meckle’s diverticulum
b. Hernia with hydrocele
c. Abdominal organ especially on posterior wall
d. Circumference of intestine

1005. A patient operated for direct inguinal hernia developed anesthesia

at the root of the penis and adjacent part of the scrotum. The
nerve likely to be injured is: (AIIMS 2001 nov)
a. Genital branch of genitofemoral nerve
b. Femoral branch of genitofemoral nerve
c. Iliohypogastric nerve
d. Ilioinguinal nerve
578 Surgery

Hernias

Answers
977. Ans. b (Inferior lumbar hernia)
(Ref. CSDT 11th ed. 794)
LUMBAR HERNIA
The superior and inferior spaces or triangles are sites of flank
herniation. The superior lumbar triangle (triangle of Grynfeltt) is
bordered by the 12th rib superiorly, the internal oblique muscle
anteriorly, and the erector spinal muscle posteriorly. The inferior
lumbar triangle (triangle of Petit) is bordered by the external oblique
muscle anteriorly, the latissimus dorsi muscle posteriorly, and the
iliac crest inferiorly. These hernias are rare, often presenting as a
bulge in the flank. Hernia contents can include bowel, retroperitoneal
fat, kidney, or other visceral organs. Incarceration and strangulation
do occur (in about 10% cases). Barium studies are helpful when
bowel is contained in the hernia; however, computed tomography
is most useful in determining location and contents of lumbar
hernias.
Repair is by mobilization of the nearby fascia and obliteration of the
hernial defect by precise fascia-to-fascia closure. The recurrence
rate is very low.

978. Ans. c (Obturator hernia)

(Ref. CSDT 11th ed. 795)
OBTURATOR HERNIA
Obturator hernias are uncommon and difficult to diagnose. The
peritoneal sac and its contents herniate through the obturator canal
in the superolateral aspect of the obturator foramen alongside the
obturator vessels and nerves, and come to lie between the obturator
externus and pectineus muscles or between the layers of the
obturator membrane. This is primarily a hernia of elderly females
commonly containing bowel, but it may also contain appendix,
omentum, bladder, uterus, or adnexal tissue. Incarceration is almost
certain. The hernia sac may be palpable on rectal or vaginal
examination.
Howship-Romberg sign is specific of obturator hernia, in which
the 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 obstruction
with a fixed loop containing gas or contrast in the obturator region.
578
 Hernias 579
Computed tomography will depict the hernia sac protruding through
the obturator foramen and extending between the pectineus and
obturator muscles.
This hernia should not be repaired from the thigh approach. The
abdominal approach gives the best exposure, however , retropubic
approach (Cheatle-Henry operation) may also be used.

979. Ans. b (Femoral hernia)

FEMORAL HERNIA
Femoral hernias are difficult to diagnose clinically because of their
deep location in the femoral canal. They always remain below the
inguinal ligament and lateral to the pelvic tubercle and are more
prone to incarceration and strangulation than inguinal hernias. This
type of hernia occurs more commonly in females and usually
contains properitoneal fat, omentum, and/or small bowel.
Clinically, saphena varix is its closest differential diagnosis.

980. Ans. b (Lateral border of recti)

SPIGELIAN HERNIA
Spigelian hernias are caused by a congenital weakness in the
posterior layer of transversalis fascia, which allows viscera to
prolapse between the lateral abdominal wall muscles and through
the linea semilunaris. Thus, it occurs usually at infraumbilical
location. Typically, the omentum and short segments of large or
small bowel protrude through the hernia defect. Diagnosis of these
rare hernias is notoriously difficult. Computed tomography is the
imaging modality of choice because it allows visualization of the
hernia defect in the rectus sheath and identification of the hernia
contents.

981. Ans. b (Femoral hernia)

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

982. Ans. a, b, c, e
INGUINAL HERNIA
Inguinal hernia, the most common abdominal hernia, can be direct
or indirect. Indirect inguinal hernia occurs with the greatest
frequency, is usually congenital, but may be acquired in older
individuals. The processus vaginalis normally closes before birth.
In one third of infants and one sixth of adults, the process vaginalis
remains patent, persisting as a peritoneal sac into which viscera
580 Surgery
may enter. Hernia contents typically include small bowel loops and
mobile colon segments such as sigmoid, appendix, cecum and
transverse colon. Retroperitoneal organs such as the urinary
bladder, distal ureters, or ascending or descending colon may be
incorporated into the hernia. Preoperative recognition of retroperiton-
eal contents in the hernia is essential to avoid injury during surgical
repair. The peritoneal sac and viscera protrude lateral and inferior
to the inferior epigastric vessels through the inguinal canal and
emerge at the external inguinal ring. In males, the hernia can extend
along the spermatic cord into the scrotum, whereas in females, the
hernia follows the course of the round of ligament into the labia
majoris. Bowel obstruction, incarceration, and strangulation are
common 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 lower
abdominal wall through a defect in the transversalis fascia, medial
to the inferior epigastric vessels. More common in men, they rarely
incarcerate.

983. Ans. d (Sac is posterior to cord)

(Ref: B and L, Surgery, 23rd ed., 1145; B.D.Chaurasia’s Human
Anatomy- Vol. II 3rd ed. 61, 179)
An indirect inguinal hernial sac travels down the canal on
anterolateral aspect of spermatic cord, while direct hernial sac is
posterior to cord.

CONTENTS OF SPERMATIC CORD

1. The Ductus deferens
2. Testicular and Cremasteric Arteries and Artery of Ductus Deferens
3. Pampiniform plexus of veins
4. Genital branch of Genitofemoral nerve and Plexus of sympathetic
nerves
5. Lymphatic vessel from testes
6. Remnants of Processes Vaginalis.
Ilioinguinal nerve enters inguinal canal through interval between
external and internal oblique Muscle and pass out through
superficial inguinal ring.
Inferior epigastric artery is not content of spermatic cord, it forms
lateral boundary of Hasselbach triangle.

984. Ans.a (Midinguinal Point)

(Ref. B.D.Chaurasia Anatomy, Vol 1, 2nd ed. 11)
Femoral triangle
1. Is bounded superiorly by inguinal ligament, medially by Adductor
longus and laterally by Sartorius.
 Hernias 581
2. Structures from lateral to medial are nerve-artery-vein-empty
space-lymphatics ( NAVEL)
3. Femoral sheath contains femoral artery, femoral vein and femoral
canal (containing deep inguinal lymph nodes, gland of Cloquet
and Rossenmuller (sex hormones). Femoral nerve lies outside
femoral sheath.
4. A femoral pulse is palpable high within the femoral triangle just
inferior to the inguinal ligament, at the mid inguinal point where
femoral 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 about
half 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 muscles
lining.
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 women
Management 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)
582 Surgery
· 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 d

The internal ring lies lateral to the inferior epigastric vessels
The 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 the
peritoneal 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 hernia
relies on the visualization of abdominal organs in the chest.
Other pointers may be, absence of a normally positioned stomach,
mediastinal displacement, small abdominal circumference and
polyhydramnios.

992. Ans. a (Early respiratory distress leading to early diagnosis and

treatment 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 birth
defects to manage successfully. Despite early detection of severe
diaphragmatic defects by prenatal ultrasonography and the more
common recognition of CDH as a cause of significant respiratory
distress at birth, current mortality has improved little from the series
presented in 1940 by ladd and Gross.
 Hernias 583
Congenital diaphragmatic hernia is of many types
· Anterior (through foramen of Morgagni)
· Posterior (through foramen of Bochdalek ) -MC
· Through esophageal hiatus.
· Eventration
Bochdalek hernia:
· During formation of the diaphragm, the pleura and coelomic
cavities remain in continuity by means of the pleuroperitoneal
canal (foramen of Bochdalek), The posterolateral communication
is closed by the developing diaphragm. Failure of diaphragmatic
development 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 diaphragmatic
hernia, because in diaphragmatic hernia the abdominal contents
have herniated into the thoracic cavity and are compressing the
lung. By using bag and mask ventilation air will also move into the
GIT along with the lung. More air in the stomach and intestines will
cause 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 hernias
are situated on left side. It presents as a large globular inguinal
hernia. Large intestine (sigmoid colon) is commonly present. A
portion of the bladder or diverticulum of the bladder may be present
in addition to other contents in sliding hernia. Bilateral sliding
hernias are rare.

995. Ans. a (Sigmoid colon)

This type of hernia occurs exclusively in males, five out of six hernias
are situated on left side. It presents as a large globular inguinal
hernia. Large intestine (sigmoid colon) is commonly present.
A portion of the bladder or diverticulum of the bladder may be present
in addition to other contents in sliding hernia. Bilateral sliding hern-
ias are rare.
584 Surgery
996. Ans. b (Narrowing of the internal ring)
When internal ring is weak and stretched, the repair should include
Lytle method of repairing and narrowing the ring.

997. Ans. a (Femoral hernia)

Symptoms of femoral hernia are less pronounced than inguinal
hernia, since it is small. It may remain unnoticed for years till it
strangulates.

998. Ans. b (1-2 years)

UMBILICAL HERNIA
In children and infants, patent umbilical rings are common, and the
resulting herniation is asymptomatic. Occasionally incarceration
may occur requiring surgical intervention. Adults presenting with
umbilical hernias usually have diastasis of the rectus muscles
resulting from multiple pregnancies, obesity, or chronic increased
abdominal pressure. Greater omentum and bowel are the typical
hernia contents that protrude through the linea alba at the umbilicus
and can incarcerate, causing symptoms of intestinal obstruction
and umbilical tenderness. Mayo’s operation is done to repair it.
Masterly inactivity is the treatment of choice for umbilical hernia in
children as hernia usually close spontaneously by 2 years in 95%
cases. Obstruction or strangulation below 3 years age is extremely
uncommon. In case masterly inactivity fails operation should be
carried out after age of 2 years.

999. Ans. a (Strangulation)

Strangulated obstructed irreducible hernia will give irreducible
swelling with absent cough impulse. With strangulation the swelling
will become tense, tender with or without local rise of temperature
and systemic signs of sepsis. Obstructed hernias may be tense
and non-tender. More often than not, the obstruction culminates
into strangulation.

1000. Ans. a (Herniotomy)

In congenital hernia, problem is patent processes vaginalis but the
posterior wall is normal, hence Herniotomy is sufficient for
treatment. But in old patients the posterior wall is weak and therefore
they will require, herniorraphy or hernioplasty depending on the
nature of tissue as seen during the operative procedure.

1001. Ans. a (Observation only)

Direct hernias have wide neck and hence are unlikely to undergo
strangulation and indication of surgery in such case will be
persistent pain and for cosmesis. But in this patient risk of surgery
is going to be very high and natural history of disease being benign,
observation is preferred modality of treatment.
 Hernias 585
1002. Ans. b (Incising the external oblique aponeurosis)
(Ref. Bailey and Love 1277)
External oblique aponeurosis is in close relation to ilioinguinal nerve
and hence during operation for inguinal hernia prevention of injury
to ilioinguinal nerve to avoid later development of incisional hernia
is very important.

1003. Ans: b (Meckle’s diverticulum)

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

1004. Ans. d (Circumference of intestine)

(Ref. Bailey and Love-23rd ed.-1145, 24th 1273)
——————————————————————————————
Hernia Content
——————————————————————————————
Omentocele/epiplocele Omentum
Enterocele Small bowel commonly, may be large bowel or
appendix
Richter’s A portion of circumference of intestine
Littre’s Meckel’s diverticulum
Sliding Contents of posterior abdominal wall,
commonly bladder
Pantaloon Direct + Indirect hernia
Inferior lumbar Herniation through triangle of Petit
Obturator 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 iliohypogastric
are branches of the lumbar plexus and all may be injured in operati-
on for hernia.

Ilioinguinal nerve
Enters 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 of
o proximomedial skin of the thigh.
o skin over the penile root.
o upper part of the scrotum
Iliohypogastric nerve
Divides into two branches -lateral cutaneous and anterior cutan-
eous.
Lateral cutaneous supplies -posterolateral gluteal skin
Anterior cutaneous supplies -supra pubic skin
586 Surgery
Genitofemoral nerve divides into two branches Genital and Femoral
Genital branch of Genitofemoral nerve -enters the inguinal canal at
its deep ring and supplies
o the Cremaster muscle
o the scrotal skin

Femoral branch of genitofemoral nerve

Passes behind the inguinal ligament, enters the femoral sheath
lateral to femoral artery, pierces the anterior layer of the femoral
sheath and fascia lata and supplies the skin anterior to the upper
part of femoral triangle.