MSC - F. Surgery Answers 2025

Imaging (CT/cystography) is critical for preoperative planning in sliding hernias.

6.Femoral hernia. Anatomy of the femoral canal, clinical picture, surgical treatment.

Femoral Hernia

1.Anatomy of the Femoral Canal

Femoral canal is the innermost of the three compartments of the femoral sheath.

Length: ~2 cm, funnel-shaped.

Contents:

o Areolar tissue

o Fat

o Lymphatic vessels

oCloquet’s lymph node

Boundaries:

oAnterior: Inguinal ligament

oPosterior: Pectineus and adductor longus (medially); psoas major and iliacus (laterally)

o Medial: Lacunar ligament

oLateral: Femoral vein

Openings:

oSuperior: Femoral ring (covered by femoral septum)

oInferior: Saphenous opening (covered by cribriform fascia)

2.Pathogenesis and Course

Hernia protrudes through the femoral ring, passes down the femoral canal, exits via the saphenous opening, and may extend upwards into the subcutaneous tissue of the thigh.

3.Epidemiology

5–8% of all abdominal hernias.

More common in females, especially multiparous women over 50 years.

Right-sided hernias are more common than left; bilateral in 20%.

4.Clinical Features

Local Symptoms:

Pain in the groin and lower abdomen, especially on walking or physical activity.

Swelling:

o Below and lateral to the pubic tubercle.

o Small, hemispherical, smooth.

o More prominent on standing/straining; disappears when lying down.

General Symptoms:

Symptoms of intestinal obstruction: vomiting, abdominal distension, constipation.

Strangulation is frequent:

o Sudden pain that spreads across the abdomen.

o Vomiting and signs of peritonitis.

oCan present as Richter’s hernia (partial bowel wall strangulation).

5.Differential Diagnosis

Inguinal hernia

Lipoma in the upper part of Scarpa’s triangle

Lymphadenopathy (e.g., from infection or malignancy)

Varix of the great saphenous vein

6.Treatment

Surgery is always indicated due to high risk of strangulation and poor efficacy of conservative management (e.g., trusses).

Surgical Approaches:

1. Lockwood's (Low approach):

o Incision below the inguinal ligament

oSuitable for elective, uncomplicated hernias

2.Lotheissen’s (Inguinal approach):

oAccess through the inguinal canal

oEasier repair of femoral ring

3.McEvedy’s (High approach):

oIncision above inguinal ligament

o Preferred for strangulated hernias for better exposure of bowel

Techniques:

Herniorrhaphy with closure of the femoral ring

Tissue repair methods:

o Baccini’s method (femoral access)

oRuggi–Parlavecchio (inguinal access):

Opening of inguinal canal

Suturing inguinal and pubic ligaments

Second layer of sutures includes internal oblique, transversus abdominis, and external oblique aponeurosis to Poupart’s ligament

7. Umbilical hernias and hernias of the linea alba. Anatomy, clinical picture and methods of surgical treatment.

Umbilical Hernia

Definition

Herniation through or near the umbilicus; the nature and treatment vary by age group and type.

1. Types of Umbilical Hernia

A.Exomphalos (Omphalocele)

Cause: Congenital failure of midgut to return to the abdominal cavity.

Hernial Sac: Covered by a membrane—amniotic layer (outer), Wharton’s jelly (middle), and peritoneum (inner).

Urgency: Surgical emergency in neonates to prevent sac rupture.

Treatment:

o NPO (Nothing by mouth)

o IV fluids, blood transfusion

o Broad-spectrum antibiotics

oEmergency surgical repair

B. Umbilical Hernia in Infants and Children

Pathophysiology: Protrusion through a weak umbilical scar, often postneonatal sepsis.

Symptoms:

oTypically painless

oSwelling increases on crying

Spontaneous Resolution: ~90% resolve by 12–18 months

Conservative Treatment:

oUse of coin pad or metal disc with adhesive plaster to maintain reduction

Surgical Indication: Persistent hernia after 18 months

Surgical Method: Lexer’s method (purse-string suture closure of umbilical ring)

C. Paraumbilical Hernia in Adults (Indirect Umbilical Hernia)

Site: Through the linea alba, above or below the umbilicus (not directly through the umbilical scar).

Common in: Women > 40 years, multiparous, obese (female:male = 5:1)

Contents: Greater omentum, small intestine, or transverse colon

Symptoms:

oDiscomfort, pain on exertion

oMay cause colicky pain, subacute obstruction, or strangulation

Physical Exam:

oLump above/below umbilicus, dull/resonant on percussion depending on contents

o Reducible with cough impulse (if not adherent)

oIrreducible if adherent at fundus of sac

2.Clinical Features

Local:

oSwelling at or around the umbilicus

oExpands with coughing/straining

Systemic (in complicated hernias):

oVomiting

o Abdominal pain

oConstipation, signs of obstruction

3.Diagnostic Considerations

Differentiation: From epigastric hernia, diastasis recti, incisional hernia

Imaging (optional): Ultrasound or CT for complex or obese patients

4.Treatment

Children:

Observation until 18 months

Lexer’s repair if persistent

Adults:

Surgery is the treatment of choice:

o High risk of irreducibility and strangulation

o Weight loss may be advised before surgery in obese patients

Common Surgical Techniques:

Mayo’s repair:

o Overlapping horizontal sutures to close the defect

oOften used for paraumbilical hernias

Sapezhko’s and Mayer’s methods:

oAutoplastic repairs (use of patient’s tissues)

Mesh Repair (modern approach):

oReinforces weakened abdominal wall

oPreferred for large or recurrent hernias

Small hernias: May include excision of loose skin and umbilicus

5.Sliding Hernia (Special Note)

Often occurs with inguinal hernias, not umbilical.

Involves retroperitoneal organs (e.g., cecum, sigmoid, bladder) forming part of the hernia sac.

Important intraoperative finding due to surgical risk—posterior sac wall is not pure peritoneum.

Key Points

Umbilical hernias vary by age, location, and contents.

Surgery is always indicated in adults.

Infants often improve without surgery.

Paraumbilical hernias in adults require timely repair due to risk of adhesion and strangulation.

8. Postoperative and recurrent hernias. Causes and surgical treatment.

Postoperative & Recurrent Hernias (Incisional Hernias)

Definition

Incisional hernia: Herniation through a previous surgical or traumatic scar in the abdominal wall.

Also includes recurrent hernias after prior hernia repair.

Etiology (Causes)

1.Patient-Related Factors

Obesity – Increased intra-abdominal pressure.

Chronic cough – Persistent strain on the abdominal wall.

Abdominal distension – Early postoperative bloating stretches the scar.

Malnutrition – Deficiencies in protein, vitamin C, or anemia compromise healing.

2.Intraoperative Errors

Nerve injury:

o Kocher’s incision → 8th–10th intercostal nerves

oMcBurney’s incision → iliohypogastric/ilioinguinal nerves

Poor wound closure – Inadequate attention to deep layers.

Tissue trauma or poor hemostasis – Promotes infection.

Tube drains through the wound.

Certain incisions (e.g., midline infraumbilical) are more prone to herniation.

3.Postoperative Complications

Wound infection – Most common cause.

Post-op cough, distension, peritonitis

Premature suture removal

Steroid therapy – Impairs healing

Clinical Features

History

Prior abdominal surgery or trauma

Often wound infection history

Common in elderly, obese women

Symptoms

Swelling at or near the previous scar

Pain, especially on exertion

Intermittent obstruction: colicky pain, vomiting, constipation, distension

2.Conservative Treatment

Indications: Only in Type I, reducible hernias or unfit surgical candidates.

Method:

o Hernia belt or corset with pad to maintain reduction

oLong-term use may induce fibrosis and closure of defect

3.Surgical Treatment

Always indicated for:

oType II hernias

o Irreducible or symptomatic Type I

oFailed conservative management

Surgical principles:

oIdentify and free adhesions

o Close the muscle and fascial defect

oUse of mesh repair is standard in modern practice to reduce recurrence

oComponent separation technique or laparoscopic repair may be needed in complex/recurrent cases

Key Takeaways

Infection, poor technique, and patient factors (obesity, cough) are leading causes.

Early recognition and proper surgical technique during the first operation are crucial in prevention.

Type I hernias may be observed or treated conservatively.

Type II hernias need surgical repair due to risk of adhesion and strangulation.