Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1232_Библиотеки_им_академика_М_И_Перельмана.pdf
Testicular Mass
FariFall
77
Concept
The most common causes of painless scrotal swelling are
hydrocele, inguinal hernia, varicocele, spermatocele, epididymal cyst, and testicular cancer. The most common symptom
of testicular cancer is a painless enlargement of the testis.
Testicular masses can be distinguished from these other
intrascrotal masses based on physical exams or imaging
studies. Most palpable testicular tumors in adults are malignant, while most are benign in prepubertal children. Though
relatively rare, testicular cancer is the most common solid
tumor in males aged 20–34years, and the incidence has been
steadily rising globally over the past several decades.
Fortunately, testicular cancer is one of the most curable solid
neoplasms, with 5-year survival rates of approximately 95%.
In the pediatric population, it is important to distinguish
prepubertal from pubertal testis tumors. Benign tumors are
more frequent in prepubertal boys. Teratoma is the most
common histologic benign tumor in pediatric tumors. Germ
cell tumors make up the majority of malignant testicular
tumors. Tumor markers (AFP, hCG, and LDH) are most useful in diagnosis and staging. Ultrasound is the best imaging
modality to diagnose testicular tumors. Testicular-sparing
surgery is preferred in benign tumors. Lymphoma is the most
common secondary testicular cancer and is more common in
men older than 50years than primary testicular cancer. When
malignancy is suspected, scrotal violation through transscrotal biopsy or orchiectomy should be avoided due to the
risk of local tumor seeding with recurrence and pelvic or
inguinal lymph node metastasis.
Germ cell tumors make up the majority of malignant testicular tumors (95%) and are categorized into two main histologic subtypes-seminoma and non-seminoma.
Non-seminomas are less common but more aggressive. Nonseminomatous germ cell tumors include yolk sac tumors,
F. Fall (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Fari.Fall@jefferson.edu
teratomas, mixed germ cell tumors, choriocarcinoma, and
embryonal tumors. Many testicular cancers are mixed germ
cells, containing both seminoma and non-seminoma cells,
and are treated as non-seminomas because they grow and
spread like non-seminomas. Lastly, cancers that metastasize
to the testicle are known as secondary cancers. Lymphoma is
the most common secondary testicular cancer and is more
common in men older than 50years than primary testicular
cancer.
Testicular cancer is staged using the American Joint
Committee on Cancer (AJCC) TNM system and is based on
the extent of cancer in the testis, status of regional lymph
nodes, presence of metastases in distant lymph nodes or
other viscera, and serum levels of tumor markers.
Way Questions May BeAsked?
A 26-year-old male with no past medical history presents to
your clinic with a 3-month history of painless right scrotal
mass. Physical exam reveals a 3cm solid, nontender right
testicular mass. How do you manage this patient?
Given the patient’s age and clinical presentation, testicular cancer is highly likely. Almost all postpubertal testicular
tumors are malignant and tend to be mixed germ cell or nonseminomatous germ cell tumors. These tumors are diagnosed
and treated by radical orchiectomy via an inguinal approach.
Alternate Scenario
An 8-year-old prepubertal boy is referred to your clinic by
the pediatrician for a 2 cm solid, nontender left testicular
mass that was noted during a wellness visit. How do you
manage this patient?
Testicular tumors are very rare in children, accounting for
1–2% of all childhood solid tumors. Prepubertal testicular
masses are more likely to be benign with the diagnosis,
including benign teratomas, dermoid cysts, epidermoid
cysts, and Leydig cell hyperplasia. Most malignant tumors in
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_77
249
250
F. Fall
prepubertal boys are yolk sac tumors (non-seminomatous).
Given the fact that most prepubertal tumors are benign in this
group, it opens the possibility of a testis-sparing approach in
the initial management.
How toAnswer?
• History: obtain a thorough history
– timing of onset and duration of the testicular mass
– pain or swelling
– recent scrotal trauma
– constitutional symptoms (fevers, night sweats, weight
loss)
– personal or family history of testicular cancer
– history of scrotal surgeries including hydrocele or her-
nia repairs
– orchiopexy for cryptorchidism
– history of hypospadias or cryptorchidism
– elicit other symptoms that may suggest metastasis
such as back pain (retroperitoneal mets), cough (pul-
monary mets), or lower extremity edema (vena cava
obstruction)
• Physical Exam: Carefully examine both testicles.
– A mass that cannot be separated from the testis is
assumed to be a testicular tumor until proven
otherwise.
– Also pay attention to any palpable abdominal or retro-
peritoneal masses, inguinal or supraclavicular lymphadenopathy, and look for gynecomastia.
• Diagnostic tests
Ultrasound is the preferred initial diagnostic study for
any palpable testicular mass.
– Sensitivity approaches 100%.
– Ultrasound can usually differentiate whether a mass is
solid or cystic.
– Cystic masses are more likely to be benign and better
suited for testis-sparing approaches.
– Tumors typically present as heterogeneous, hypoechoic
lesions with evidence of blood ow on Doppler
imaging.
– If the US ndings are suspicious of malignancy, then a
radical inguinal orchiectomy is generally performed to
make a diagnosis.
MRI is used in rare instances where ultrasound nd-
ings are inconclusive or non-diagnostic.
Serum levels of alpha-fetoprotein (AFP), beta human
chorionic gonadotropin (hCG), and LDH levels should be
obtained prior to resection as they can provide important
pre-op diagnostic and prognostic information.
Certain histologic subtypes can be predicted based on
the results of the serum tumor markers.
– AFP is never elevated in seminomas.
– Beta hCG is sometimes elevated in seminomas, but
levels tend to be lower than those seen in
non-seminomas.
– LDH may be elevated in either type of tumor.
Other basic labs such as complete blood count, basic
chemistry prole, and liver function test are also obtained.
Once the diagnosis of testicular cancer is made, clinical staging is accomplished by CT scan of the abdomen/
pelvis and CT or X-ray of the chest.
• Staging
In pediatric patients, the Children’s Oncology Group
(COG) staging system is preferred.
Four stages based on:
– completeness and technique of the resection
– lymph node status
– tumor markers status
– presence or absence of distant metastases.
Stage I tumors are limited to the testis, completely
resected with inguinal orchiectomy and with the return of
tumor markers to normal postresection.
Stage I tumors in prepubertal boys can be treated with
radical orchiectomy alone.
Stage II tumors have residual disease and/or markers
that fail to return to normal.
Stage III tumors have positive lymph nodes.
Stage IV disease indicates metastasis.
Stages II–IV require chemotherapy.
In adults, the joint staging system of the American
Joint Committee on Cancer (AJCC) TNM system (eighth
edition) and the Union for International Cancer Control
(UICC) is the internationally accepted standard for staging testicular tumors.
Based on:
– the extent of cancer in the testis
– status of regional lymph nodes
– presence of metastases in distant lymph nodes or other
viscera
– serum levels of tumor markers.
There are three stages in this system.
– Stage IA consists of primary tumors conned to the
testis without lymphovascular invasion.
– Stage IB tumors demonstrate lymphovascular invasion
or disease extending outside of the testis.
– Stage II tumors have retroperitoneal lymph node
involvement only.
– Stage III tumors have distant metastasis.
77 Testicular Mass
251
In advanced disease, the staging is supplemented with
a validated prognostic model that was developed by the
International Germ Cell Cancer Collaborative Group that
straties patients into good, intermediate, and poor-risk
groups for both progression-free and overall survival
based on histology of the tumor (seminoma vs nonseminoma), primary site of the tumor, metastatic sites of
involvement, and levels of serum tumor markers. The
nuances of further management are beyond the scope of
this review, but the NCCN Guidelines for Testicular
Cancer is an excellent resource.
Surgical Treatment
• Radical orchiectomy
– If the examinee does not have direct experience with
radical orchiectomy, it is appropriate to mention this
and ask that a Urologic Oncologist (or at least a
Urologist) is available for assistance.
– Patient is placed supine. The lower abdomen and
groins are prepped and draped in a sterile fashion.
– A 5–10 cm oblique incision is made in the inguinal
region parallel to the inguinal canal beginning just lateral to the pubic tubercle.
– After dividing the fascia, the external oblique aponeu-
rosis is incised in the direction of its bers to the level
of the internal ring.
– The ilioinguinal nerve is identied and preserved.
– The cord is isolated and clamped at the level of the
internal ring.
– The testicle is then delivered from the scrotum into the
surgical eld.
– The distal gubernaculum is divided, and the proximal
cord is then suture ligated as close to the internal ring
as possible.
– The cord vessels are ligated.
– The wound is irrigated and then closed in layers after
satisfactory hemostasis is achieved.
Clean Kills
• Scrotal violation through biopsy of testicular mass or
trans-scrotal orchiectomy.
• Failure to examine contralateral testis.
• Failure to check tumor markers prior to surgery.
Bonus Points
• Sperm banking should be discussed with patients of
reproductive age before undergoing any therapeutic intervention that may compromise fertility.
• The incidental identication of non-palpable small testicular masses is increasingly frequent, likely due to the
widespread use of testicular ultrasound for other indications. No specic guidelines exist for the management of
incidentally image-detected testicular subcentimeter testicular lesions in adults or children. The general recommendation is to follow lesions smaller than 5mm in the
United States. For lesions >5mm or with suspicious US
ndings, testis-sparing surgery through an inguinal
approach with intraoperative frozen sections analysis is
recommended.
Words ofWisdom
Groin and testicle masses that initially present or are referred
to by the examinee as inguinal hernias but turn out to be
something else (e.g., testicular tumor or inguinal soft tissue
sarcoma) are a tactic used on the oral boards. Careful listening by the examinee is important, as the surgeon will discover that the examiner will give away that one is not dealing
with a straightforward inguinal hernia.
Bibliography
Goldberg H, Klaassen Z, Chandrasekar T, Fleshner N, Hamilton RJ,
Jewett MAS.Germ cell testicular tumors—contemporary diagnosis,
staging and management of localized and advanced disease. Urology.
2018;125:8–19. https://doi.org/10.1016/j.urology.2018.12.025.
NCCN clinical practice guidelines in oncology: testicular cancer.
National Comprehensive Cancer Network, Inc. 2023 [cited 2023
Aug 21].
Sangüesa C, Veiga D, Llavador M, Serrano A. Testicular tumours in
children: an approach to diagnosis and management with pathologic
correlation. Insights Imaging. 2020;11:74. https://doi.org/10.1186/
s13244- 020- 00867- 6.
Schade GR. 39-23: Testicular cancers (germ cell tumors). In: Current
medical diagnosis & treatment 2022. McGraw Hill; 2023.
Steele GS, Richie JP, Michaelson MD. Clinical manifestations, diag-
nosis, and staging of testicular germ cell tumors. UpToDate; 2023
[cited 2023 Aug 11].
Stevenson SM, Lowrance WT. Epidemiology and diagnosis of testis
cancer. Urol Clin N Am. 2015;42:269–75. https://doi.org/10.1016/j.
ucl.2015.04.001.
Part XI
Hernia
Groin Hernias
NatalieWall andSayuriJinadasa
78
Inguinal Hernia
Concept
Inguinal hernias are a common presentation in general surgery and as such provide excellent testing scenarios, examining both surgical and anatomical knowledge. Inguinal
hernias are classied depending on their relationship to the
inferior epigastric vessels—direct hernias are medial, and
indirect are lateral. While a physical exam is crucial for the
diagnosis of inguinal hernias, denitive differentiation
between the two is determined intraoperatively.
Way Question May BeAsked?
A 65year-old male presents to your ofce with a 3-month
history of right groin swelling.
A 72year-old male presents to the emergency department
with groin pain, nausea, and vomiting. Radiographic imaging demonstrates bowel-containing left inguinal hernia with
decompressed distal intestine.
The most common presentation of an inguinal hernia is a
groin mass. A thorough history and physical examination
can quickly help differentiate a hernia from other pathology.
Patients with easily reducible, asymptomatic hernias may
initially be offered nonoperative management, however, you
should expect such scenarios to progress toward symptoms
requiring intervention. Questions derived from a brief history should be focused on chronicity, reducibility, and concern for associated complications such as obstruction,
strangulation, and sepsis.
N. Wall
Department of Surgery, Virginia Commonwealth University,
Richmond, VA, USA
e-mail: natalie.wall@vcuhealth.org
S. Jinadasa (
Division of Acute Care Surgical Services, Department of Surgery,
Virginia Commonwealth University, Richmond, VA, USA
e-mail: sayuri.jinadasa@vcuhealth.org
*)
How toAnswer?
History
• Duration
• Location
• Presence of pain
• Obstructive symptoms (nausea, vomiting, obstipation,
constipation)
• Comorbidities (if asymptomatic with high-risk comorbidities, may opt for nonsurgical management), make
sure to specically ask about diabetes and obesity
• Prior hernia repair, abdominal operations (will affect your
approach)
• Tobacco use
Physical Exam
• Vital signs (evaluate for septic shock if concern for incarceration/strangulation/perforation)
• Weight/BMI
• Location of mass in relation to inguinal ligament
• Reducibility of hernia
• Contralateral groin examination
• Scrotal examination
• Palpation of supercial inguinal ring
• Overlying skin changes suggesting strangulation or
perforation
• Prior surgical scar(s)
Diagnostic Studies
• Inguinal hernia is primarily a clinical diagnosis. If difcult to identify, ultrasound, CT scan, or MRI can be utilized. If large size and/or concern for bowel-containing
hernia, may obtain CT imaging of the abdomen and pelvis
with IV contrast to aid in surgical planning.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_78
255
256
N. Wall and S. Jinadasa
Surgical Treatment
Indications
• Patients with an easily reducible, symptomatic inguinal
hernia may be repaired on an elective basis. Those with
incarceration or strangulation should be repaired urgently
to avoid bowel ischemia, resultant perforation, and/or
sepsis.
• Asymptomatic patients may be offered elective repair,
however, it is safe for these patients to choose expectant
management if desired.
Technique
• Laparoscopic/Robotic versus open technique acceptable.
Laparoscopic/Robotic approach should be offered to
patients with prior open repair, bilateral hernias, or female
patients due to the higher incidence of femoral hernias.
You should utilize the technique that you are most comfortable with.
• Key components of repair: identify and preserve ilioinguinal nerve, iliohypogastric nerve, and genital branch of
genitofemoral nerve, identify hernia sac, completely
reduce contents intraperitoneally, reapproximate integrity
of the deep inguinal ring (mesh versus tissue repair if contraindication to mesh placement).
• Different types of repairs:
– Lichtenstein: tension-free mesh repair. This has
become the gold standard approach for open repair.
Mesh is anchored to pubic tubercle, shelving edge
(inferiorly), and conjoint tendon (superiorly). External
oblique closed overtop mesh.
– Bassini: tissue repair. Conjoint tendon/internal oblique
primarily sewn to the shelving edge of the inguinal
ligament. If tension, may require relaxing incision of
the anterior rectus sheath.
– McVay: tissue repair. Conjoint tendon sutured to
Cooper’s ligament. Will require relaxing incision of
anterior rectus sheath to minimize tension. Only tissue
repair that will correctly address a femoral hernia.
– Shouldice: tissue repair. Performed in four layers, with
two sutures run forward and back. Transversalis fascia
is incised along the trajectory of the tubercle to the
internal ring. The inferior portion of the transversalis is
sewn to the lateral edge of the rectus sheath in a running fashion (medial to lateral). The same suture is the
run lateral to medial, suturing the superior portion of
the transversalis to the shelving edge of the inguinal
ligament. The second suture starts lateral and proceeds
medially, attaching the inferior external oblique to the
conjoint tendon. The same suture then runs medial to
lateral, suturing these same structures before being
tied at the internal ring.
– Totally Extraperitoneal Repair (TEP): laparoscopic/
robotic approach. Preperitoneal space created, blunt
dissection performed medially exposing the pubic
tubercle/retropubic space then carried laterally to
ASIS. Hernia sac reduced and separated from cord
structures. Avoid dissection within the triangle of
doom and triangle of pain.
– Transabdominal Preperitoneal Repair (TAPP): laparo-
scopic/robotic approach. Peritoneum incised, dissection carried out laterally to ASIS, medially to the
tubercle. Hernia sac reduced and dissected away from
cord structures. Peritoneum bluntly swept down below
the inferior border of mesh to prevent recurrence.
Mesh placed, secured, and peritoneum closed.
Common Curveballs
• If a nerve injury occurs intraoperatively, perform a neurectomy of the nerve.
• If the peritoneum is violated during a TEP repair, make
sure to repair the peritoneal injury and decompress CO2
from the abdominal cavity.
• Identication of femoral hernia intraoperatively, make
sure to discuss femoral hernia repair.
• If the patient has a postoperative mesh infection, the mesh
should be excised.
• If a patient reports postoperative scrotal swelling and
pain, you must rule out testicular ischemia or necrosis
with a duplex ultrasound.
• If a strangulated inguinal hernia cannot be reduced via the
groin incision, proceed with laparotomy to assist in the
reduction.
• If a patient has an Amyand’s hernia (acute appendicitis
within an inguinal hernia) perform a tissue repair.
Clean Kills
• Reducing a strangulated hernia: do not try to reduce it at
the bedside; rather, evaluate and repair the hernia in the
operating room to assure ischemic or necrotic bowel is
not missed.
• Placing mesh in a contaminated operative eld: in these
scenarios, perform a tissue repair.
• Failing to examine contralateral groin.
• Failing to inquire about prior inguinal hernia repair.
• Failing to evaluate the groins for hernias in a patient who
presents with a small bowel obstruction.
78 Groin Hernias
257
Words ofWisdom
It is imperative to know the steps to a mesh repair, tissue
repair, and femoral hernia repair. Consider memorizing the
steps of the McVay repair as it is both a tissue repair and a
way to repair femoral hernias.
If you provide one way of repairing a hernia and an examiner asks you why you would not choose a different equally
appropriate method, consider stating, “that is also an appropriate way to approach this hernia, but in my hands, I am
most comfortable with X approach.”
Femoral Hernia
Concept
Femoral hernias, while less common than inguinal hernias,
are important to clinically differentiate, as the urgency of
their management may differ. Given their high risk of strangulation, recognition of these hernias warrants expedient
repair. Femoral hernias are predominantly found in women;
however, inguinal hernias remain the most common groin
hernia among both sexes. These occur within the empty
space of the femoral canal, bordered medially by the lacunar
ligament, laterally by the femoral vein, and anterosuperior
by the inguinal ligament. Common presentation is a groin
bulge below the inguinal ligament.
Way Question May BeAsked?
• Paresthesia
Physical Exam
• Vital signs (evaluate for septic shock if concern for incarceration/strangulation)
• Weight/BMI
• Location of mass in relation to inguinal ligament (femoral=typically below)
• Reducibility of hernia
• Contralateral groin examination
• Palpation for concomitant inguinal hernia (commonly
present with both)
• Overlying skin changes suggesting strangulation (discoloration, pain, rm mass)
• Associated numbness or tingling
• Prior surgical scar(s)
Diagnostic Studies
• Laboratory values including lactate if concerned for
obstruction/strangulation
• CT abdomen/pelvis
• +/− Ultrasound
Surgical Treatment
Indications
• Given their high risk of strangulation, the presence of a
femoral hernia indicates surgical repair. Ideally, repair is
performed at the time of diagnosis, as the risk of complication increases with time.
A 72year-old female presents to the emergency department
with 1 day of obstipation, groin pain, and overlying skin
discoloration.
How toAnswer?
History
• Duration
• Location
• Reducibility
• Presence of pain
• Obstructive symptoms (nausea, vomiting, obstipation,
constipation)
• Comorbidities (if asymptomatic with high-risk comorbidities, may opt for nonsurgical management), make
sure to specically ask about diabetes and obesity
• Prior hernia repair, abdominal operations (will affect your
approach)
• Tobacco use
Technique
• Primary tissue repair: McVay technique (described above)
• May require a relaxing incision, as these repairs are often
under tension.
– Minimally invasive repair with mesh: TAPP or TEP
repair (described above).
• Open the hernia sac and evaluate the intestine within if
there is concern for incarceration, strangulation, and/or
bowel compromise.
Common Curveballs
• Identication of simultaneous inguinal hernia.
• What to do if there is tension on tissue during primary
repair—make sure to know where to place relaxing incisions based on the repair performed.
• Planned mesh repair, but there are intraoperative ndings
of bowel perforation with contamination—switch to a tissue repair.
258
N. Wall and S. Jinadasa
Clean Kills
• Observing a femoral hernia without offering surgical
intervention.
• Manual reduction of strangulated hernia.
• Choosing an incorrect repair technique that does not
obliterate the femoral space.
Words ofWisdom
If given a scenario involving a groin hernia, the option of an
operative approach will be up to the discretion of the testtaker. Knowing the ins and outs of a repair that may simultaneously account for both inguinal and/or femoral hernias
may set you up for success in the event of a surprise intraoperative nding.
Obturator Hernia
Obturator hernias are a low yield topic. Similar concepts as
above apply.
Approximately 50% of patients with obturator hernias
have a positive Howship–Romberg sign—pain on ipsilateral
thigh adduction and internal rotation due to obturator nerve
compression.
• Obturator hernias can be repaired through the following
techniques: TEP or TAP, making sure to have good mesh
coverage of the obturator foramen.
• Laparotomy with primary versus mesh closure of the
obturator foramen.
Bibliography
Lichtenstein IL, Shulman AG, Amid PK, etal. The tension-free hernio-
plasty. Am J Surg. 1989;157:188–93.
McCormack K, Scott NW, Go PM, etal. Laparoscopic techniques ver-
sus open techniques for inguinal hernia repair. Cochrane Database
Syst Rev. 2003;2003:CD001785.
Neumayer L, Giobbie-Hurder A, Jonasson O, etal. Open mesh ver-
sus laparoscopic mesh repair of inguinal hernia. N Engl J Med.
2004;350:1819–27.
Townsend JCM, Beauchamp RD, Evers BM, Mattox KL. Sabiston
textbook of surgery. 20th ed. Elsevier- Health Sciences Division;
2016.
Wake BL, McCormack K, Fraser C, et al. Transabdominal pre-
peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic
techniques for inguinal hernia repair. Cochrane Database Syst Rev.
2005;2005:CD004703.
Zhao G, Gao P, Ma B, etal. Open mesh techniques for inguinal hernia
repair: a meta-analysis of randomized controlled trials. Ann Surg.
2009;250:35–42.
Incarcerated Inguinal Hernia
TheresaKrawiec, JosephA.Sciacca, andPeterSantoro
79
Concept
An incarcerated inguinal hernia will likely present as a painful groin mass that is not reducible. It is important to look for
signs and symptoms of strangulation, such as overlying skin
changes, severe pain, and systemic/hemodynamic abnormalities. Prompt operative intervention is generally necessary
and requires examination of hernia contents for viability,
including any incarcerated or strangulated bowel. You should
be able to describe different options for hernia repair, including primary tissue and mesh repair depending on bowel viability, and be able to defend your management decision
based on the clinical scenario.
Way Question May BeAsked?
A 58-year-old male presents to the Emergency Department
(ED) with a 3-day history of right groin pain associated with
a non-reducible bulge. What are your next steps?
This is a common description of an incarcerated inguinal
hernia. The patient may also present with symptoms of bowel
obstruction, such as nausea, vomiting, and obstipation.
How toAnswer?
History
• Symptoms of bowel obstruction (i.e., nausea, vomiting,
obstipation)
• Duration of symptoms
T. Krawiec · J. A. Sciacca
General Surgery Residency, Christiana Care Hospital,
Newark, DE, USA
P. Santoro (
General Surgery, Department of Surgery, Christiana Care Hospital,
Wilmington, DE, USA
e-mail: psantoro@christianacare.org
*)
• History of prior inguinal hernia repair, including type of
repair
• Other surgical history
Physical Examination
• Check vital signs
• Evaluate for overlying skin changes
• Tenderness, size, and reducibility of hernia
• Peritoneal signs on abdominal exam
Diagnostic Studies
• Full laboratory panel including CBC, BMP and lactate.
• CT scan of the abdomen/pelvis with IV contrast
(Fig.79.1a–c).
Treatment
• Surgical management of an incarcerated inguinal hernia
may be either open or minimally invasive (laparoscopic/
robotic) based on patient-specic factors and the surgeon’s training and experience.
• Regardless of the operative approach, hernia contents,
including the bowel, should be examined to assess for
viability and need for resection.
• If performing an open repair and contents self-reduce, an
exploratory laparotomy or diagnostic laparoscopy should
be performed to examine the bowel and all prior hernia
contents to assess viability.
• If the bowel is found to be nonviable or the eld is contaminated, the mesh should NOT be placed during repair,
or a biological mesh may be utilized. So, if you proceed
with a laparoscopic repair initially and there is nonviable
bowel or contamination, the safest option is converting to
an open primary tissue repair such as a Bassini, Shouldice
or McVay repair. You should be able to describe in detail
the steps of those procedures.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_79
259
260
a
T. Krawiec et al.
b
c
Fig. 79.1 Computed Tomography (CT) of the pelvis with intravenous contrast demonstrating the cranial (a, b) to caudal (c) progression of an
acute incarcerated indirect right inguinoscrotal hernia containing small bowel with early signs of ischemia
Common Curveballs
• Hernia contents are not able to be reduced intraoperatively, or signicant intra-abdominal adhesions are present (perform laparotomy).
• There is signicant tension after primary tissue repair
(perform relaxing incision).
• A femoral hernia is found on exploration (McVay repair
should be completed).
• Recurrent inguinal hernia after prior open or laparoscopic
repair.
Summary
An incarcerated inguinal hernia is an extremely common
clinical scenario encountered by all general surgeons who
take calls. It is essential that the examinee is familiar with
management, including understanding the options for
hernia repair and be able to describe appropriate management including steps of operative repair. There should
be a low threshold to explore these patients if incarceration/strangulation is suspected to evaluate for bowel
viability.
• The patient develops a postoperative seroma or
hematoma.
Bibliography
Clean Kills
• Not evaluating hernia contents/bowel intraoperatively.
• Placement of synthetic mesh in a contaminated eld.
• Reduction of hernia at bedside without evaluating bowel
if hernia has been incarcerated for a prolonged period of
time.
• Not being able to describe inguinal structures involved in
repair (e.g., conjoint tendon, shelving edge of inguinal
ligament).
Cameron JL, Cameron AM.Current surgical therapy. Elsevier; 2023.
Dimick J, Kao L, Sonnenday C, Upchurch G. Section 1: abdominal
wall. In: Clinical scenarios in surgery: decision making and opera-
tive technique. Wolters Kluwer; 2019. p.3–46.
Hawn MT.Operative techniques in surgery. Wolters Kluwer; 2023.
Novitsky Y. Chapter 46. In: Hernia surgery: current principles.
Springer; 2016. p.473–9.