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5. The use of mesh in the repair of an abdominal incisional
hernia has become common for both open and laparoscopic repairs. Which position of the mesh relative to the
components of the abdominal wall is associated with the
lowest hernia recurrence rate?
A. Overlay technique, where the mesh is fixed to the
anterior fascia above (superficial to) the repair
B. Underlay technique, where the mesh is placed in the
CHAPTER 35
6. A 40-year-old woman who underwent total abdominal
Abdominal Wall, Omentum, Mesentery, and Retroperitoneum
abdominal cavity under the repair
C. Interlay technique, where the mesh is placed across
fascial defects below the anterior fascia
D. Sublay technique, where the mesh is placed under the
anterior fascia
colectomy for familial adenomatous polyposis (FAP)
5 years previously presents with a gradually expanding painless 4 cm mass of the anterior abdominal wall.
A biopsy is returned as “desmoid tumor with no sign of
malignancy.” The correct management is:
A. Observation.
B. A course of doxorubicin, dacarbazine, or carboplatin.
C. Enucleation.
D. Wide local excision.
Answer: D
The sublay technique has been found to be associated with a
lower incidence of recurrent hernia and wound related complications. (See Schwartz 11th ed., p. 1555.)
Answer: D
Desmoid tumors of the abdominal wall are fibrous neoplasms
that occur sporadically or in the setting of FAP. The condition can result in mortality due to aggressive local growth, so
radical excision with confirmation of tumor-free margins of
resection is required.
Medical treatment with an antineoplastic agent such as
doxorubicin, dacarbazine, or carboplatin can produce remission but the prognosis of advanced desmoids is poor. (See
Schwartz 11th ed., p. 1557.)
7. The greater omentum, referred to as the “policeman of
the abdomen,” includes all of the following EXCEPT:
A. The gastroepiploic vessels.
B. The gastrosplenic ligament.
C. The gastrocolic ligament.
D. The gastrohepatic ligament.
8. Most tumors of the omentum are metastatic in nature.
Which of the following primary tumor sites are most
commonly associated with omental metastases?
A. Ovarian tumors
B. Endometrial tumors
C. Melanoma
D. Renal tumors
9. The mesentery of the small bowel is usually fixed in the
left upper quadrant at the ligament of Treitz and the
right lower quadrant at the ileo-cecal valve. Defects in
the rotation and fixation of the mesentery can result in a
narrow small bowel mesentery that allows all of the following complications to occur EXCEPT:
A. Irritable bowel syndrome.
B. Intestinal malrotation with volvulus.
C. Internal hernia formation.
D. Recurrent attacks of acute abdominal pain.
Answer: D
The greater omentum extends from the greater curve of the
stomach to the transverse colon and is supplied by the gastroepiploic vessels. It includes the gastrocolic and gastrosplenic
ligaments. The lesser omentum extends from the lesser
curve of the stomach to the underside of the liver forming
the gastrohepatic ligament and the opening of the foramen of
Winslow. (See Schwartz 11th ed., p. 1558.)
Answer: A
Primary tumors of the omentum are rare, but the omentum
is a common site of metastasis for ovarian carcinoma. Other
tumors are sometimes metastatic to the omentum including
renal cell carcinomas, endometrial cancer, gastrointestinal
tumors, and melanoma. (See Schwartz 11th ed., p. 1559.)
Answer: A
A narrow fixation point for the small bowel mesentery is usually the cause of intestinal malrotation. Although this condition usually presents in infancy and early childhood, it may
go undetected until adulthood when unexplained attacks of
abdominal pain occur. It can result in internal hernia formation and intermittent bowel obstruction but is not usually a
cause of the symptoms that lead to a diagnosis of irritable
bowel syndrome. (See Schwartz 11th ed., p. 1559.)
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10. The retroperitoneum contains all of the following organs
EXCEPT:
A. The aorta.
B. The pancreas.
C. The kidneys.
D. The ovaries.
11. Surgical infections of the retroperitoneum typically arise
from all of the following conditions EXCEPT:
A. Perforated retrocecal appendicitis.
B. Infected acute pancreatitis.
C. Crohn’s disease of the small bowel.
D. Diverticulitis.
12. Retroperitoneal infections are notable due to their:
A. Lack of abdominal signs and symptoms.
B. Failure to be detected on computed tomography (CT)
scan.
C. Benign course.
D. Association with tooth decay.
13. Which of the following statements about sclerosing mesenteritis is FALSE?
A. It is always associated with acute abdominal pain.
B. It can appear as a mass on computed tomography
(CT) scan.
C. It can improve or resolve without surgical therapy.
D. It can be mistaken for primary or metastatic tumor.
Answer: D
The retroperitoneum contains the ascending and descending colon, the duodenum and the pancreas, the inferior vena
cava, the aorta, the kidneys and the adrenal glands. It does not
contain the pelvic organs. (See Schwartz 11th ed., p. 1561.)
Answer: C
Retroperitoneal infections typically arise from infections of
retroperitoneal organs such as the duodenum, the pancreas,
the retroperitoneal region behind the cecum, or the descending colon. They do not typically complicate Crohn’s disease of
the small bowel or other intraperitoneal organs. (See Schwartz
11th ed., pp. 1561–1562.)
Answer: A
Retroperitoneal infections and abscesses are difficult to diagnose on history and physical but are usually apparent on CT
scan. They carry a high risk of mortality and may require
operative debridement if percutaneous drainage is infeasible
or insufficient. Oropharyngeal infections are not typically
associated with retroperitoneal abscess except in patients with
severe immunodeficiency. (See Schwatrz 11th ed., p. 1562.)
Answer: A
The etiology of sclerosing mesenteritis is unknown but its cardinal feature is increased tissue density within the mesentery.
This can be associated with a discreet nonneoplastic mass
or it can be more diffuse involving large swaths of thickened
mesentery without well-defined borders. Most cases present
with chronic abdominal pain but many cases are discovered
incidentally on CT scans performed for unrelated reasons.
The process is self-limited and may demonstrate regression on follow-up imaging studies. (See Schwartz 11th ed.,
pp. 1559–1560.)
CHAPTER 35
Abdominal Wall, Omentum, Mesentery, and Retroperitoneum
14. The primary treatment of retroperitoneal fibrosis is:
A. Corticosteroids.
B. Cyclosporine.
C. Radiation therapy.
D. Surgical resection.
Answer: A
Once malignancy, drug-induced disease, and infectious
etiologies are ruled out, corticosteroids are the mainstay of
medical therapy. Surgical intervention is reserved for ureterolysis or ureteral stenting, or endovascular interventions for
ileocaval obstruction. (See Schwartz 11th ed., p. 1563.)
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CHAPTER 36
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Soft Tissue Sarcomas
1. All of the following are TRUE about soft tissue sarcoma
EXCEPT:
A. Most common site is trunk and retroperitoneum.
B. There are more than 11,000 new diagnoses of soft tis-
sue sarcoma annually in the United States.
C. Most soft tissue sarcoma-specific deaths are due to
uncontrolled pulmonary metastases.
D. The overall 5-year survival rate for all stages of soft
tissue sarcoma approximates 50%–60%.
2. Which of the following is not associated with the development of sarcoma?
A. Radiation exposure
B. Herbicide exposure
C. Chronic lymphedema
D. History of trauma
Answer: A
Most primary soft tissue sarcomas originate in an extremity
(50%–60%); the next most common sites the trunk (19%),
retroperitoneum (15%), and head and neck (9%). The overall
5-year survival rate for patients with all stages of soft tissue
sarcoma is 50% to 60%. Of the patients who die of sarcoma,
most succumb to lung metastasis; 80% of these occur within 2
to 3 years after initial diagnosis. In the United States in 2012,
approximately 11,280 new cases of soft tissue sarcoma were
diagnosed, and 3900 deaths were attributable to this disease.
The incidence rates are declining for most cancer sites, but
they are increasing among both men and women for melanoma of the skin, cancers of the liver, sarcoma, and thyroid.
(See Schwartz 11th ed., p. 1567.)
Answer: D
External radiation therapy is a rare but well-established risk
factor for soft tissue sarcoma that may be associated with
radiation-induced mutations of the p53 gene. Exposure to
herbicides such as phenoxyacetic acid and to wood preservatives containing chlorophenols has been linked to an
increased risk of soft tissue sarcoma. In 1948, Stewart and
Treves first described the association between chronic lymphedema after axillary dissection and subsequent lymphangiosarcoma. Although patients with sarcoma often report a
history of trauma, no causal relationship has been established.
More often, a minor injury calls attention to a pre-existing
tumor. (See Schwartz 11th ed., p. 1568.)
3. All of the following are known molecular pathogenic
events in sarcoma EXCEPT:
A. Chromosomal translocations.
B. Oncogene amplification.
C. Complex genomic rearrangements.
D. Proteomic suppression.
In general, sarcomas resulting from identifiable molecular
events tend to occur in younger patients with histology suggesting a clear line of differentiation. The identifiable molecular events include point mutations, translocations causing
overexpression of an autocrine grow factor, and oncogenic
fusion transcription factor producing a cellular environment
prone to malignant transformation. In contrast, sarcomas
without identifiable genetic changes or expression profile signatures tend to occur in older patients and exhibit pleomorphic cytology and p53 dysfunction. (See Schwartz 11th ed.,
pp. 1569–1570.)
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4. Factors that are part of the American Joint Committee
on Cancer (AJCC) sarcoma staging system include all of
the following EXCEPT:
A. Tumor location.
B. Tumor size.
C. Number of mitoses per high powered field.
D. Ki-67 positivity.
CHAPTER 36
5. Current therapy for American Joint Committee on Cancer
(AJCC) Stage III soft tissue sarcoma of the extremity
includes all of the following EXCEPT:
Soft Tissue Sarcomas
A. Chemotherapy.
B. Immunotherapy.
C. Radiation therapy.
D. Surgical excision.
Answer: D
The AJCC staging system for soft tissue sarcomas is based on
histologic grade, tumor size and depth, and the presence of
metastases. Histologic grade is the most important prognostic factor for patients with soft tissue sarcoma. For accurate
determination of grade, an adequate tissue sample must be
appropriately fixed, stained, and reviewed by an experienced
sarcoma pathologist. The features that define grade are cellularity, differentiation (good, moderate, or poor/anaplastic),
pleomorphism, necrosis, and number of mitoses per highpower field. (See Schwartz 11th ed., p. 1573.)
Answer: B
Primary tumors with no evidence of distant metastasis are
managed with surgery alone or, when wide pathologic margins cannot be achieved because of anatomic constraints and/
or the grade is high, surgery plus radiation therapy. Radiation therapy is part of the standard treatment for high-grade
extremity and trunk wall soft tissue sarcomas either in the
pre- or postoperative setting. Because the evidence regarding
adjuvant systemic therapy for stage III soft tissue sarcoma is
inconclusive, considerable variation still exists in treatment
recommendations even though patients with large, stage II or
stage III soft tissue sarcomas are at high risk for recurrence
and metastasis. Chemotherapy may be considered to downstage large tumors to enable limb-sparing procedures, particularly for tumors known to be chemosensitive. (See Schwartz
11th ed., pp. 1574–1580.)
6. Concerning sarcoma of the breast, which of the following
is TRUE?
A. Modified radical mastectomy is a standard treatment
for tumors > 5 cm.
B. Sentinel node biopsy is a standard treatment.
C. Leiomyosarcoma is the most common histology of
breast sarcoma.
D. Lumpectomy is a standard treatment for T1 breast
sarcoma.
Answer: D
Angiosarcoma of the breast accounts for about 50% of all
sarcomas of the breast and has increasingly been associated
with radiation therapy for treatment of primary breast cancer. Complete excision with negative margins is the primary
therapy. Simple mastectomy confers no additional benefit if
complete excision can be accomplished by segmental mastectomy. Because of low rates of regional lymphatic spread,
axillary dissection is not routinely indicated. (See Schwartz
11th ed., p. 1584.)
CHAPTER 37
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Inguinal Hernias
1. The incidence of inguinal hernias in men has a bimodal
distribution, which peaks before the:
A. second year of life and after age 50.
B. first year of life and after age 40.
C. eighth year of life and after age 40.
D. fifth year of life and after age 50.
Answer: B
Approximately 75% of abdominal wall hernias occur in the
groin. The lifetime risk of inguinal hernia is 27% in men and
3% in women. Of inguinal hernia repairs, 90% are performed
in men and 10% in women. The incidence of inguinal hernias in men has a bimodal distribution, with peaks before the
first year of age and after age 40. Abramson demonstrated the
age dependence of inguinal hernias in 1978. Those age 25 to
34 years had a lifetime prevalence rate of 15%, whereas those
age ≥ 75 years had a rate of 47% (Table 37-1). Approximately
70% of femoral hernia repairs are performed in women;
however, inguinal hernias are five times more common than
femoral hernias. The most common subtype of groin hernia in men and women is the indirect inguinal hernia. (See
Schwartz 11th ed., p. 1599.)
TABLE 37-1 Inguinal hernia prevalence by age
Age (Y) 25–34 35–44 45–54 55–64 65–74 75+
Current prevalence (%) 12 15 20 26 29 34
Lifetime prevalence (%) 15 19 28 34 40 47
Current = repaired hernias excluded; lifetime = repaired hernias included.
2. According to the Nyhus classification system, which categorizes hernia defects by location, size, and type, type
IIIC represents:
A. Indirect hernia internal abdominal ring normal;
typical in infants, children, small adults.
B. Direct hernia; size is not taken into account.
C. Recurrent hernia; modifiers A–D are sometimes
added, which correspond to indirect, direct, femoral,
and mixed.
D. Femoral hernia.
Answer: D
TABLE 37-2 Nyhus classification system
Type I Indirect hernia; internal abdominal ring normal; typically
in infants, children, small adults
Type II Indirect hernia; internal ring enlarged without
impingement on the floor of the inguinal canal;
does not extend to the scrotum
Type IIIA Direct hernia; size is not taken into account
Type IIIB Indirect hernia that has enlarged enough to encroach
upon the posterior inguinal wall; indirect sliding or
scrotal hernias are usually placed in this category
because they are commonly associated with extension
to the direct space; also includes pantaloon hernias
Type IIIC Femoral hernia
Type IV Recurrent hernia; modifiers A–D are sometimes added,
which correspond to indirect, direct, femoral, and mixed,
respectively. (See Schwartz 11th ed., Table 37-2, p. 1602.)
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3. All of the following are TRUE regarding an incidence
of acquired inguinal hernias EXCEPT:
A. Increases with strenuous activity.
B. Increases with family history.
C. Increases with chronic obstructive pulmonary dis-
ease (COPD).
D. Increases with obesity.
CHAPTER 37
Inguinal Hernias
4. The high incidence of inguinal hernias in preterm babies
is most often due to:
A. Failure of the peritoneum to close.
B. Familial history.
C. Female gender.
D. Developmental dysplasia of the hip.
Answer: D
Several studies have documented strenuous physical activity
as a risk factor for acquired inguinal hernia. A casecontrolled study of over 1400 male patients with inguinal hernia revealed that a positive family history was associated with
an eightfold lifetime incidence of inguinal hernia. Chronic
obstructive pulmonary disease also significantly increases the
risk of direct inguinal hernias, thought to be due to repeated
instances of intra-abdominal pressure during coughing. Several studies have suggested a protective effect of obesity. In
a large, population-based prospective study of American
individuals (First National Health and Nutrition Examination Survey), the risk of inguinal hernia development in
obese men was only 50% that of normal-weight men, while
the risk in overweight men was 80% that of nonobese men.
A possible explanation is the increased difficulty in detecting
inguinal hernias in obese individuals. (See Schwartz 11th ed.,
Table 37-2, p. 1604.)
Answer: A
Inguinal hernias may be congenital or acquired. Most adult
inguinal hernias are considered acquired defects in the
abdominal wall although collagen studies have demonstrated
a heritable predisposition. A number of studies have attempted
to delineate the precise causes of inguinal hernia formation;
however, the best-characterized risk factor is weakness in the
abdominal wall musculature (Table 37-3). Congenital hernias, which make up the majority of pediatric hernias, can
be considered an impedance of normal development, rather
than an acquired weakness. During the normal course of
development, the testes descend from the intra-abdominal
space into the scrotum in the third trimester. Their descent
is preceded by the gubernaculum and a diverticulum of peritoneum, which protrudes through the inguinal canal and
becomes the processus vaginalis. Between 36 and 40 weeks
of gestation, the processus vaginalis closes and eliminates the
peritoneal opening at the internal inguinal ring. Failure of the
peritoneum to close results in a patent processus vaginalis
(PPV), hence the high incidence of indirect inguinal hernias
TABLE 37-3 Presumed causes of groin herniation
Coughing
Chronic obstructive pulmonary disease
Obesity
Straining
Constipation
Prostatism
Pregnancy
Birthweight <1500 g
Family history of a hernia
Valsalva’s maneuver
Ascites
Upright position
Congenital connective tissue disorders
Defective collagen synthesis
Previous right lower quadrant incision
Arterial aneurysms
Cigarette smoking
Heavy lifting
Physical exertion
in preterm babies. Children with congenital indirect inguinal
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hernias will present with a PPV; however, a patent processus
does not necessarily indicate an inguinal hernia (Fig. 37-1). In
a study of nearly 600 adults undergoing general laparoscopy,
bilateral inspection revealed that 12% had PPV. None of these
patients had clinically significant symptoms of a groin hernia.
In a group of 300 patients undergoing unilateral laparoscopic
inguinal hernia repair, 12% were found to have a contralateral
PPV, which was associated with a fourfold 5-year incidence of
inguinal hernia.(See Schwartz 11th ed., p. 11604.)
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CHAPTER 37
Inguinal Hernias
FIG. 37-1. Varying degrees of closure of the processus
vaginalis (PV). A. Closed PV. B. Minimally patent PV.
C. Moderately patent PV. D. Scrotal hernia.
5. The two types of collagen found to exist in a decreased
ratio of the skin of inguinal hernia patients are:
A. Types I and II.
B. Types II and III.
C. Types I and III.
D. Types III and VI.
Answer: C
Epidemiologic studies have identified risk factors that may
predispose to a hernia. Microscopic examination of skin of
inguinal hernia patients demonstrated significantly decreased
ratios of type I to type III collagen. Type III collagen does not
contribute to wound tensile strength as significantly as type I
collagen. Additional analyses revealed disaggregated collagen
tracts with decreased collagen fiber density in hernia patients’
skin. Collagen disorders such as Ehlers-Danlos syndrome are
also associated with an increased incidence of hernia formation (Table 37-4). Recent studies have found an association
between concentrations of extracellular matrix elements and
hernia formation. Although a significant amount of work
remains to elucidate the biologic nature of hernias, current
evidence suggests they have a multifactorial etiology with
both environmental and hereditary influences. (See Schwartz
11th ed., p. 1605.)
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CHAPTER 37
Inguinal Hernias
TABLE 37-4 Connective tissue disorders associated
with groin herniation
Osteogenesis imperfecta
Cutis laxa (congenital elastolysis)
Ehlers-Danlos syndrome
Hurler-Hunter syndrome
Marfan syndrome
Congenital hip dislocation in children
Polycystic kidney disease
α1-Antitrypsin deficiency
Williams syndrome
Androgen insensitivity syndrome
Robinow syndrome
Serpentine fibula syndrome
Alport syndrome
Tel Hashomer camptodactyly syndrome
Leriche syndrome
Testicular feminization syndrome
Rokitansky-Mayer-Küster syndrome
Goldenhar syndrome
Morris syndrome
Gerhardt syndrome
Menkes syndrome
Kawasaki disease
Pfannenstiel syndrome
Beckwith-Wiedemann syndrome
Rubinstein-Taybi syndrome
Alopecia-photophobia syndrome
6. Use of antibiotics in open repair of inguinal hernias:
A. Is supported by multiple randomized studies.
B. Has a larger impact when mesh is not used.
C. There is no universal guideline for open elective her-
nia repair.
D. Is a part of Surgical Care Improvement Project (SCIP)
surgical prophylaxis guidelines.
7. A hernia sac that extends into the scrotum may require:
A. extensive dissection and reduction.
B. division within the inguinal canal.
C. amputation of the sac.
D. the sac to be inverted into the preperitoneum.
Answer: C
The debate as to whether or not to administer preoperative
prophylactic antibiotics in elective inguinal hernia repair still
remains controversial as elective hernia repair is considered
a clean procedure and as such are exempt from SCIP surgical prophylaxis guidelines. A Cochrane review of 17 randomized controlled trials in 2012 revealed an overall decrease
in infection rates (3.1% vs 4.5%, odds ratio [OR] 0.64, 95%
confidence interval [CI] 0.50–0.82) when prophylactic antibiotics are administered in patients. In subgroup analyses, the
difference was smaller in patients without mesh placement
(3.5% vs 4.9%, OR 0.71, 95% CI 0.51–1.00) than in those with
mesh placement (2.4% vs 4.2%, OR 0.56, 95% CI 0.38–0.81).
However, with inguinal hernia repair, overall wound infection rates were higher than those expected for clean operations, as a result, they were unable to definitively recommend
for or against antimicrobial prophylaxis. Although there is no
universal guideline regarding the administration of prophylactic antibiotics for open elective hernia repair, the routine
indexing of cases for quality improvement databases have
resulted in the routine administration of prophylactic perioperative antibiotics in inguinal hernia repairs. (See Schwartz
11th ed., p. 1609.)
Answer: B
In cases where the viability of sac contents is in question, the
sac should be incised, and hernia contents should be evaluated for signs of ischemia. The defect should be enlarged to
augment blood flow to the sac contents. Viable contents may
be reduced into the peritoneal cavity, while nonviable contents should be resected, and synthetic prostheses should
be avoided in the repair. In elective cases, the sac may be
8. The technique indicated for femoral hernias in cases
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where prosthetic material is contraindicated is:
A. The Bassini repair.
B. The Shouldice repair.
C. The McVay repair.
D. Lichtenstein tension-free repair.
amputated at the internal inguinal ring or inverted into the
preperitoneum. Both methods are effective; however, patients
undergoing sac excision had significantly increased postoperative pain in a prospective trial. Dissection of a densely adherent sac may result in injury to cord structures and should be
avoided; however, sac ligation at the internal inguinal ring is
necessary in these cases. A hernia sac that extends into the
scrotum may require division within the inguinal canal, as
extensive dissection and reduction risks injury to the pampiniform plexus, resulting in testicular atrophy and orchitis.
At this point, the inguinal canal is reconstructed, either
with native tissue or with prostheses. The following sections
describe the most commonly performed types of tissue-based
and prosthetic-based reconstructions. (See Schwartz 11th ed.,
p. 1610.)
Answer: C
The McVay repair addresses both inguinal and femoral ring
defects. This technique is indicated for femoral hernias and in
cases where the use of prosthetic material is contraindicated
(Fig. 37-2). Once the spermatic cord has been isolated, an
incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt
dissection of underlying tissue. Cooper’s ligament is bluntly
dissected to expose its surface. A 2- to 4-cm relaxing incision
is made in the anterior rectus sheath vertically from the pubic
tubercle. This incision is essential to reduce tension on the
repair; however, it may result in increased postoperative pain
and higher risk of ventral abdominal herniation. Using either
interrupted or continuous suture, the superior transversalis
flap is then fastened to Cooper ligament, and the repair is continued laterally along Cooper ligament to occlude the femoral
ring. Lateral to the femoral ring, a transition stitch is placed,
affixing the transversalis fascia to the inguinal ligament. The
transversalis is then sutured to the inguinal ligament laterally
to the internal ring. (See Schwartz 11th ed., p. 1610.)
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CHAPTER 37
Inguinal Hernias
FIG. 37-2. McVay Cooper ligament repair.
Cooper’s ligament
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