MSC - F. Surgery Answers 2025

3.Combined Factors

Collagen disorders (Ehlers-Danlos, Marfan syndrome) → weak connective tissue.

Smoking → impaired healing (↓ collagen synthesis).

Prevention Strategies

1.General Measures

Weight management (avoid obesity/cachexia).

Proper lifting techniques (bend knees, avoid Valsalva).

Treat chronic cough (e.g., bronchodilators for COPD).

Manage constipation (high-fiber diet, laxatives if needed).

2.Surgical & Postoperative Prevention

Mesh reinforcement in high-risk surgeries (reduces incisional hernia risk).

Avoid midline incisions when possible (higher hernia risk than transverse).

Post-op abdominal bracing (supports healing muscles).

3.Specific Populations

Infants: Monitor umbilical hernias (most close by age 5).

Pregnant women: Pelvic floor exercises, avoid excessive straining.

Openings:

o Deep (internal) ring: Entrance (lateral to inferior epigastric vessels).

oSuperficial (external) ring: Exit (medial to inferior epigastric vessels).

Clinical Presentation

Symptoms

Pain/Dragging sensation in the groin (worsens with standing/coughing).

Visible lump (reducible or irreducible).

Systemic symptoms if obstructed/strangulated:

o Colicky pain, vomiting (fecaloid if bowel obstruction), constipation.

Signs

1. Inspection:

oSwelling above the inguinal ligament (extends toward scrotum in indirect hernia).

2.Palpation:

oCough impulse (expansile impulse on coughing).

oInvagination test: Finger in external ring → ask patient to cough:

Indirect: Impulse felt at fingertip (through canal).

Direct: Impulse felt at pulp of finger (bulges posteriorly).

3.Differentiation:

oZieman’s technique: 3-finger palpation (deep ring, superficial ring, femoral canal).

o Imaging (US/CT): If diagnosis uncertain (e.g., obese patients).

Stages of Indirect Inguinal Hernia

1. Initial (Incipient):

oNo visible lump; + cough jerk (finger in external ring detects impulse).

2.Incomplete (Canal):

oHernia fills the canal (lump in groin on straining).

3.Complete:

oHernia exits superficial ring (visible swelling).

4.Scrotal:

oHernia descends into the scrotum (large/chronic cases).

Complications

Incarceration: Irreducible hernia (risk of obstruction).

Strangulation: Compromised blood supply (surgical emergency!). o Signs: Severe pain, erythema, fever, tachycardia.

Diagnosis

Clinical exam (90% accuracy).

Ultrasound: For equivocal cases or to rule out hydrocele/lymphadenopathy.

CT/MRI: For complex/recurrent hernias or suspected obstruction.

Key Takeaways

Indirect hernias are more common, often congenital, and follow the spermatic cord.

Direct hernias bulge through Hesselbach’s triangle (medial to epigastric vessels).

Strangulation risk is higher in indirect hernias due to a narrower neck.

Surgical repair (hernioplasty with mesh) is the definitive treatment.

4.Surgical methods of inguinal hernia treatment.

Surgical Treatment of Inguinal Hernia

General Principles

Goal: Repair the hernia defect while reinforcing the inguinal canal to prevent recurrence.

Key Steps:

1.Access to the inguinal canal.

2.Isolation and excision of the hernial sac.

3. Reconstruction (plasty) of the inguinal canal.

Surgical Techniques

1. Open Hernia Repair

(A)Herniotomy

Procedure:

oOnly excision of the hernial sac (no canal repair).

Indications:

oInfants/children (congenital indirect hernia with preformed sac).

oYoung adults with strong abdominal muscles.

(B)Herniorrhaphy (Bassini’s Technique)

Procedure:

oHerniotomy + posterior wall repair by suturing:

Conjoined tendon (internal oblique + transversus abdominis) to the inguinal ligament.

oSpermatic cord is repositioned over the repaired wall.

Indications:

oIndirect hernias in adults (good muscle tone).

oNon-complex primary hernias.

(C)Hernioplasty (Mesh Repair – Lichtenstein Technique)

Procedure:

oHerniotomy + mesh placement over the posterior wall.

oMesh types: Polypropylene (most common), polyester, or biologic.

Advantages:

oTension-free repair → lower recurrence rates (<1%).

Indications:

o Direct hernias (weak posterior wall).

o Recurrent hernias.

oPatients with risk factors (chronic cough, obesity, heavy lifting).

2.Laparoscopic Hernia Repair (TAPP/TEP)

Transabdominal Preperitoneal (TAPP):

oMesh placed intraperitoneally after reducing the hernia.

Totally Extraperitoneal (TEP):

oMesh placed in preperitoneal space without entering the abdomen.

Advantages:

oFaster recovery, less post-op pain.

oIdeal for bilateral/recurrent hernias.

Disadvantages:

oSteeper learning curve, higher cost.

Postoperative Care

Activity:

oAvoid heavy lifting (>10 kg) for 4–6 weeks.

Pain Management: NSAIDs/local anesthesia.

Follow-up: Monitor for recurrence/infection.

Key Takeaways

Mesh repair (hernioplasty) is the gold standard for most adults (low recurrence).

Laparoscopic repair preferred for bilateral/recurrent hernias.

Bassini’s repair is historical but still used in resource-limited settings.

Herniotomy alone suffices for pediatric cases.

5. Congenital and sliding inguinal hernia. Concepts, clinical picture, features of surgical treatment.

1. Congenital Inguinal Hernia

Definition:

Results from failure of the processus vaginalis to obliterate after testicular descent in males or round ligament passage in females.

In males: The patent processus forms a preformed hernial sac extending from the deep inguinal ring to the scrotum (covering the testis).

In females: The persistent processus is called the canal of Nuck, accompanying the round ligament into the labia majora.

Clinical Picture:

Swelling in the inguinal/scrotal region (males) or labia majora (females), worsens with crying/Valsalva.

Reducible when lying down; may cause discomfort.

Complications: Incarceration (irreducibility, risk of strangulation).

Surgical Treatment:

Herniotomy:

oLigation and excision of the hernial sac (no canal repair needed in children).

oHigh ligation at the deep inguinal ring to prevent recurrence.

Approach: Open (inguinal incision) or laparoscopic (in infants).

2.Sliding Inguinal Hernia

Definition:

A hernia where part of the hernial sac is formed by a retroperitoneal organ (e.g., cecum, ascending colon, bladder) with incomplete peritoneal coverage.

Types:

o Periperitoneal: Organ forms part of the sac wall (e.g., cecum).

o Extraperitoneal: Organ protrudes without a sac (e.g., bladder).

Clinical Picture:

Atypical symptoms:

oBladder involvement: Dysuria, urinary retention, "two-stage" urination (empties bladder, then feels urge again after reduction).

oColon involvement: Constipation, bloating.

Palpation: Thickened, doughy consistency; may be partially irreducible.

Diagnosis:

oImaging: Cystography, CT, or barium enema to identify sliding components.

o Intraoperative suspicion: Thickened sac wall or abnormal mobility.

Surgical Treatment:

Key Principle: Avoid injury to the sliding organ (e.g., bowel/bladder).

Technique:

1.Identify the sliding component: Open the sac away from the organ (e.g., anteriorly for bladder, medially for cecum).

2.Reduce the organ: Carefully dissect the sac from the sliding structure.

3.High ligation: Place a purse-string suture 1 cm above the peritoneal reflection (Fig. 15).

4.Mesh reinforcement: For adults, use a preperitoneal mesh (e.g., Lichtenstein or TAPP).

Special Cases:

oBladder hernia: Catheterize to decompress; resect excess peritoneal sac to prevent recurrence.

oCecum/colon: Ensure no bowel injury; consider appendectomy if cecum is involved.

Complications to Avoid

Bladder injury: Suspect if hematuria or urinary leakage post-op.

Bowel obstruction: From inadvertent narrowing during sac ligation.

Recurrence: Due to inadequate sac resection or missed sliding component.

Prognosis:

Congenital: Excellent with herniotomy (recurrence <1%).

Sliding: Requires meticulous technique; recurrence higher if mesh not used.

Takeaway:

Congenital hernias are developmental; treat with sac excision.

Sliding hernias demand organ-sparing dissection and reinforced repair.