hernia and acute abdomen mcq.docx

8/16/2019 Hernia and Acute Abdomen MCQ.docx

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4. $ta*les ma) safel) be *laced during la*arosco*ic hernia re*air in each ofthe follo#ing structures e5ce*t:A. Coo*er/s ligament.B. Tissues su*erior to the lateral ilio*ubic tract.C. The trans+ersus abdominis a*oneurotic arch.D. Tissues inferior to the lateral ilio*ubic tract.!. The ilio*ubic tract at its insertion onto Coo*er/s ligament.Ans#er: D

DI$C"$$I %: lacement of sta*les inferior to 6belo#7 the lateral ilio*ubic

tract ma) result in in8ur) to the lateral femoral cutaneous ner+e or thegenitofemoral ner+e. $ta*les should also not be *laced #ithin the triangle ofdoom0 o#ing to the ris3 of ma8or +ascular in8ur).

9. The follo#ing %)hus classification of hernias is correct e5ce*t for:A. -ecurrent direct inguinal hernia T)*e I;a.B. Indirect inguinal hernia #ith a normal internal inguinal ring T)*e I.

C. Femoral hernia T)*e IIIc.D. Direct inguinal hernia T)*e IIIa.!. Indirect inguinal hernia #ith destruction of the trans+ersalis fascia ofHesselbach/s triangle T)*e II.Ans#er: !

DI$C"$$I %: An indirect inguinal hernia #ith destruction of thetrans+ersalis fascia of Hesselbach/s triangle is classified as a T)*e IIIb hernia.Also classified as T)*e IIIb hernias are sliding0 *antaloon0 and massi+escrotal hernias. T)*e II hernia is an indirect inguinal hernia #ith a dilatedinternal ring but #ithout dis*lacement of the inferior dee* e*igastric +esselsor destruction of the trans+ersalis fascia of Hesselbach/s triangle.


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Ans#er: A

DI$C"$$I %: The Bassini re*air is accom*lished b) high ligation of thehernia sac follo#ed b) suturing the con8oined tendon and the internal obli=uemuscle to the inguinal ligament.

?. 'hich of the follo#ing statements concerning the abdominal #all la)ersare correct(A. $car*a/s fascia affords little strength in #ound closure.B. The internal abdominal obli=ue muscles ha+e fibers that continue into thescrotum as cremasteric muscles.

C. The trans+ersalis fascia is the most im*ortant la)er of the abdominal #allin *re+enting hernias.D. The l)m*hatics of the abdominal #all drain into the i*silateral a5illar)l)m*h nodes abo+e the umbilicus and into the i*silateral su*erficial inguinall)m*h nodes belo# the umbilicus.Ans#er: ABCD

DI$C"$$I %: The integrit) of the abdominal #all is maintained *rinci*all)

b) the trans+ersalis fascia. $car*ia/s fascia affords little strength in #oundclosure0 but its a**ro5imation contributes considerabl) to the creation of anaestheticall) acce*table scar. The cremasteric muscles of the s*ermatic cordare a continuation of muscle fibers from the internal abdominal obli=uemusculature. The l)m*hatic su**l) of the abdominal #all follo#s a sim*le

*attern. These su*erficial l)m*hatics run *arallel to the su*erficial +eins0#hich abo+e the umbilicus drain into the i*silateral a5illar) +ein and belo# itinto the i*silateral femoral +ein.

@. 'hich of the follo#ing congenital abnormalities are correctl) defined(A. m*halocele re*resents a defect in the abdominal #all lateral to theumbilical cord.


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hernia com*lications is significantl) greater than for electi+e re*air of theidentical herniad. A truss maintains a hernia in the reduced state0 therefore0 minimi ing theris3 of incarceration and strangulationAns#er: b0 c

The indications for hernia re*air must be indi+iduali ed for each *atient andthe *articular situation. In general0 the *resence of a hernia ma) beconsidered an ade=uate indication for hernia re*air. Certainl) the *resence ofcom*lications due to hernia necessitates the correction of those com*licationsand usuall) the re*air of the hernia. As #ith an) treatment0 the benefits of

o*erati+e re*air must be #eighed against the natural histor) of the disease0the e5tent to #hich the treatment can correct the *roblem0 the *ossibilit) oftreatment,related in8ur)0 and the interference of concomitant disease #ith thetreatment results. 'ith a fe# e5ce*tions0 the natural histor) of an abdominal#all hernia is that the si e of the defect and the sac enlarges o+er time0 andthis enlargement increases the difficult) of ade=uate re*air and the chances of recurrence of the hernia. The ris3 of ma8or com*lications is greater in anindi+idual *atient0 the longer the e5*osure to a hernia and the larger the sac

relati+e to the hernia defect. In addition0 ma8or com*lications necessitate anemergent o*eration #ith attended high mortalit) and morbidit) relati+e tothat e5*erienced #ith an electi+e re*air. The use of a truss0 an e5ternalsu**ort de+ice using a s)stem of stra*s to e5ert regional *ressure o+er thehernia defect0 should generall) be a+oided. Trusses do not consistentl)maintain a hernia in the reduced state0 and the) ma) *ut an unreduced herniain greater 8eo*ard) of strangulation. The *ressure e5erted induces edema b)decreasing l)m*hatic and +enous flo# out of the herniated bo#el. Trussesma) also lead to in8ur) to the s3in o+erl)ing the hernia.

1 . 'hich of the follo#ing statement6s7 is are true concerning the diagnosisand management of e*igastric hernias(


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a. A large *eritoneal sac containing abdominal +iscera is common b. At the time of surgical re*air0 a careful search for other defects should be *erformedc. -ecurrent e*igastric hernias after sim*le closure is uncommond. atients #ith s)m*toms of a *ainful midline abdominal mass fre=uentl)#ill contain incarcerated small bo#elAns#er: b

!*igastric hernias are usuall) small but the) +ar) considerabl) in si e. Mostof these defects occur in the midline. The small defects contain onl)

*re*eritoneal fat #ith no sac. 'ith increasing si e0 fat in the falciformligament and e+entuall) a *eritoneal sac and abdominal +iscera ma) becontained #ithin the hernia. The *re*eritoneal fat in the small defect isusuall) incarcerated. Multi*le defects ma) be *resent in u* to & E of

*atients. $urgical treatment is recommended in all adult *atients #iths)m*toms or #ith a hernia defect greater than 1.< to & cm. in diameter.Methods of re*air de*end u*on the si e of the defect. For small defects0sim*le closure #ith obli=uel) *laced sutures after reduction or remo+al of the

*re*eritoneal fat from the defect has been recommended. Ho#e+er recurrente*igastric hernias in u* to 1 E of the cases ha+e been re*orted #ith thismethod0 most li3el) as a result of additional undetected or unre*aired#ea3nesses in the e*igastric midline.

11. The follo#ing statement6s7 is are true concerning neuro+ascular structuresin the inguinal region.

a. The inferior e*igastric arter) and +ein run u*#ard in the *re*eritoneal fat *osterior to the trans+ersalis fascia close to the lateral margin of the internalinguinal ring

b. The ilioh)*ogastric and ilioinguinal are motor and sensor) ner+es in the


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inguinal region #hich lie beneath the e5ternal obli=ue a*oneurosisc. The ilioinguinal ner+e runs anterior to the s*ermatic cord in the inguinalcanal and at the su*erficial inguinal ring0 branches into the sensor) su**l) tothe *ubic region and the u**er scrotum or labium ma8orisd. The genital branch of the genitofemoral ner+e is a sensor) ner+e onl) tothe u**er thigh and genital areaAns#er: b0 c

Arising anteriorl) from the e5ternal iliac arter)0 the inferior e*igastric arter)#ith its accom*an)ing +ein runs obli=uel) mediall) and u*#ard in the

*re*eritoneal fat0 *osterior to the trans+ersalis fascia and close to the inferior

margin of the internal inguinal ring. Inguinal hernias arising su*erior to theinferior e*igastric +essels are indirect inguinal hernias0 #hereas those arisinginferior to the +essels are direct inguinal hernias. The ilioh)*ogastric andilioinguinal ner+es are motor and sensor) ner+es to the muscles and s3in ofthe inguinal region. The ner+es *enetrate the trans+ersus abdominis muscle atthe *oint abo+e the middle of the iliac crest0 lie belo# the internal obli=uemuscle u* to the *oint 8ust medial and su*erior to the anterior su*erior iliacs*ine0 and then *enetrate the internal obli=ue muscle and lie belo# the

e5ternal obli=ue a*oneurosis. The ilioinguinal ner+e runs anterior to thes*ermatic cord in the inguinal canal and at the su*erficial inguinal ligament0

branches into sensor) su**l) to the *ubic region and the u**er scrotum orlabium ma8oris. The genital branch of the genitofemoral ner+e *erforates thetrans+ersalis fascia usuall) 8ust inferior to the internal ring. It courses alongthe *osterior surface of the s*ermatic cord and su**lies motor fibers to thecremaster muscle. At the su*erficial inguinal ring0 it di+ides to *ro+idesensor) inner+ation to the scrotum and medial as*ect of the u**er thigh.

1&. In ad+ising a *atient *reo*erati+el) of *otential com*lications ofo*erati+e treatment of an inguinal hernia0 #hich of the follo#ing statement6s7is are true(


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a. $e+ere s)m*toms due to sensor) ner+e entra*ment or in8ur) can occur b. The most common +ascular structure in8ured during the course of a groinhernia re*air is the femoral arter)c. -ecurrent hernia after *rimar) groin re*air should occur in less than 1 Eof casesd. 'ound infection increases the ris3 of recurrent herniaAns#er: a0 c0 d

Man) com*lications can occur #ith o*erations to re*air an inguinal hernia.$ensor) ner+e in8ur) ma) lead to disabling s)m*toms from neuromas or

ner+e entra*ment during inguinal hernia re*air. Although +ascular in8uries areuncommon in inguinal re*air0 the *ro5imit) of the femoral +ein to thestructures used in the hernia re*air ma3es in8ur) of this +essel the mostfre=uent +ascular in8ur) obser+ed. Hernia recurrence after *rimar) groinhernia re*airs should be infre=uent and +aries in se+eral large series from lessthan one *ercent to almost nine *ercent. The *re+alence of recurrent herniama) be higher after re*air of recurrent groin hernia. Factors res*onsible forhernia recurrence include closure under e5cessi+e tension0 failure to identif)

and use an ade=uatel) strong musculoa*oneurotic tissue0 and #oundinfection.

14. Ch)lous ascites is the accumulation of ch)le #ithin the *eritoneal ca+it).'hich of the follo#ing statement6s7 is are true concerning ch)lous ascites(

a. The cisterna ch)li lies at the anterior surface of the first and second lumbar+ertebrae and recei+es l)m*hatic fluid from the mesenteric l)m*hatics

b. Ch)lous ascites is most commonl) associated #ith abdominal l)m*homac. aracentesis and anal)sis of ch)lous fluid t)*icall) re+eals ele+atedtrigl)cerides0 *rotein0 and leu3oc)te le+els #ith c)tologic anal)sis reflectingthe underl)ing *resence of malignanc)


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l)m*h flo#. Although there ha+e been re*orts of success using such dietar)mani*ulation0 man) failures ha+e been re*orted. Therefore0 in most *atients#ith ch)lous ascites0 treatment is li3el) to be successful onl) #hen directedto#ard the underl)ing cause. For *atients #ith l)m*homa0 thera*) effecti+eagainst l)m*homa is li3el) to eliminate ch)lous ascites.The *rognosis for *atients #ith ch)lous ascites is much better in infants andchildren than in adults0 *rinci*all) because of the differences in causes of thecondition. A mortalit) of &1E is re*orted in infants and children #hereas amortalit) of @@E has been noted in adults. atients #ith ch)lous ascites #ithassociated neo*lasms t)*icall) ha+e the gra+est *rognosis.

19. 'hich of the statement6s7 is are true concerning la*arosco*ic herniare*air(

a. eneral anesthesia is re=uired b. !ither an abdominal or *re*eritoneal a**roach is *ossiblec. The use of *rosthetic mesh is re=uired in all +ariationsd. 2ong,term results suggest that the la*arosco*ic a**roach is e=ual or better

than traditional re*airsAns#er: a0 b0 c

The la*arosco*ic a**roach to the re*air of groin hernias has been recentl)de+elo*ed. !ither a transabdominal a**roach0 #herein the *eritoneum in theinguinal area is o*ened0 and the re*air is *erformed in the *re*eritoneum oran entirel) *re*eritoneal a**roach can be used. In either techni=ue0 #hich are

both *erformed under general anesthesia0 after reducing the +isceral contentsout of the hernia0 the re*air is *erformed b) *lacing a sheet of *rostheticmesh o+er the internal as*ect of the inguinal floor and internal ring. Althoughearl) results and short,term benefits a**ear *romising0 long,term follo#,u*data is still not a+ailable to com*are these techni=ues #ith traditional re*airs.


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organs such as bladder to achie+e these margins. -econstruction of theabdominal #all #ith *ol)*ro*)lene mesh is necessar) in most cases. In

*atients in #hom ade=uate margins of resection are achie+ed0 there is no benefit from ad8u+ant radiothera*). $econd and third resections afterrecurrence ha+e been associated #ith no higher rate of recurrence than

*rimar) resection. -adiothera*) alone has achie+ed local control in desmoidtumor in as man) as 1 E of tumors treated *rimaril) and ? ) are considered necessar) forconsistent control. The large radiation dose ris3s ma8or damage to ad8acent

bo#el and therefore *rimar) radiation treatment of abdominal #all desmoidtumors has a limited role.

1>. 'hich of the follo#ing statement6s7 is are true concerning re*air ofinguinal hernias(

a. The Bassini re*air a**ro5imates the trans+ersus abdominis a*oneurosisand trans+ersalis fascia and the shel+ing edge of the inguinal ligament.

b. The Bassini re*air is an ade=uate re*air for a femoral hernia

c. A rela5ing incision is im*ortant for re*airs of direct and large indirectinguinal hernias to *re+ent e5cessi+e tension in the closured. An ad+antage to the use of *rosthetic material is the mesh incites formationof scar tissue to further increase tensile strength *ro+ided b) the mesh aloneAns#er: a0 c0 d

The Bassini re*air is an inguinal hernia re*air used #orld,#ide and has beenthe standard against #hich other re*airs are 8udged. The re*air in+ol+esa**ro5imation of the trans+ersus abdominis a*oneurosis and trans+ersalisfascia and the lateral edge of the rectus sheath to the shel+ing edge of theinguinal ligament. A femoral hernia cannot be re*aired b) the Bassini re*air

because the orifice to the femoral canal lies dee* to the inguinal ligament. ACoo*er s ligament re*air does a**ro5imate the structures to the trans+ersalis


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fascia of the *ectineal 6Coo*er s7 ligament bet#een the *ubic tubercle andthe femoral +ein and therefore is a**ro*riate for re*air of a femoral hernia. Arela5ing incision for re*airs of direct and large indirect inguinal hernias

*re+ents e5cessi+e tension in the closure. There are an increasing number of *ro*onents for the use of *rosthetic material for the routine re*air of inguinalhernias. rosthetic material0 such as *ol)*ro*)lene mesh0 ha+e been used for)ears for re*air of large or recurrent inguinal and femoral hernias. The

*rosthetic mesh *ro+ides a lo#,tension re*air for such large defects #hichother#ise could not be closed #ithout e5cessi+e tension. In addition0 themesh incites the formation of scar tissue to further increase tensile strength

be)ond that *ro+ided b) mesh alone. -esults re*orted for inguinal hernia

re*airs using mesh ha+e been e5cellent0 although there is a slight ris3 ofinfection of the *rosthetic material #hich must be considered.

1?. The follo#ing statement6s7 is are true concerning the e*idemiolog) ofinguinal hernias.

a. Inguinal hernias occur #ith a male,to,female ratio of about ?:1

b. Femoral and umbilical hernias are more common in #omen0 #ith afemale,to,male ratio of 9:1c. The fre=uenc) of inguinal hernias increases #ith aged. Almost all umbilical hernias occur in the *ediatric age grou*Ans#er: a0 c

Inguinal hernias are the most fre=uentl) occurring hernia b) a factor of fi+eo+er other indi+idual t)*es. "mbilical hernias constitute about 19E ofhernias0 femoral hernias about


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*ea3ing in the *ediatric *o*ulation and then in the 9 to > )ear grou*0 in#hich the hernias are *rinci*all) *araumbilical.

1@. A ??,)ear,old multi*arous female *resents #ith a bo#el obstruction. $hehas no *re+ious abdominal o*erations and no abdominal #all hernias can bedetected. In addition to her abdominal s)m*toms0 she re*orts *ain in her rightmedial thigh. The follo#ing statement6s7 is are true concerning her diagnosisand management.

a. !5*ectant management #ith nasogastric suction and I; fluid re*lacement

is indicated b. A right groin a**roach is indicated for e5*loration and re*air of the *resumed herniac. The use of a *ol)*ro*)lene mesh #ill li3el) be necessar) for re*air d. A correct diagnosis can usuall) be made b) +isuali ing an e5ternal mass inthe u**er0 medial thighAns#er: c

An obturator hernia is a hernia that occurs through the obturator canal0accom*anied b) the obturator +essels and the obturator ner+e. Although rare0most obturator hernias occur in older multi*arous #omen and are

*redominantl) right,sided. $)m*toms are fre=uentl) intermittent but tend to be acute and become increasingl) se+ere #ith incarceration of the hernia.Intestinal s)m*toms *redominate0 but d)sesthesia or *ain in the medial thigh#ith occasional radiation to the hi* is often *resent. D)sesthesia results fromcom*ression of either di+ision of the obturator ner+e. Although the hernia isne+er e5ternall) +isible0 in a small *ercentage of *atients a mass can be

*al*ated in the u**er0 medial thigh. A correct diagnosis of obturator hernia ismade in onl) about one,third of *atients *resenting #ith intestinalobstruction. lain radiogra*hs are seldom hel*ful0 ho#e+er a CT scan #illusuall) confirm the diagnosis. Treatment is o*erati+e. There is no *lace for


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e5*ectant thera*)0 es*eciall) in a *atient #ith *ain an *arasthesias along theinner as*ect of the thigh or #ith clinical or radiogra*hic e+idence of bo#elobstruction. Man) surgical a**roaches ha+e been *romoted0 but thetransabdominal a**roach should be used because it has se+eral ad+antages. It

best confirms the diagnosis and e5*oses the obturator canal0 orifice0 +essels0and ner+e0 also *ermitting bo#el resection #hen re=uired. The sac is dealt#ith in a standard fashion. The hernia defect should be re*aired0 but re*airusuall) re=uires a *ol)*ro*)lene mesh *atch because the margin of the defectcannot be a**ro5imated *rimaril).

1 . The follo#ing statement6s7 is are true concerning umbilical hernias inadults.

a. Most umbilical hernias in adults are the result of a congenital defect carriedinto adulthood

b. A *araumbilical hernia t)*icall) occurs in multi*arous femalesc. The *resence of ascites is a contraindication to electi+e umbilical herniare*air.

d. Incarceration is uncommon #ith umbilical herniasAns#er: b

An umbilical hernia in a child is usuall) considered to be congenital. nl)about 1 E of umbilical hernias in adults are thought to be the result of acongenital defect carried into adulthood. Most adult umbilical hernias areac=uired and are called *araumbilical hernias. The *araumbilical herniat)*icall) occurs in a multi*arous female. ther *atients #ith increasedintraabdominal *ressure0 *articularl) #ith concomitant chronic abdominaldistension as from ascites0 are also at increased ris3 for the de+elo*ment of

*araumbilical hernias. "mbilical and *araumbilical hernias +ar) from smallto e5tremel) large. Incarceration is fre=uent in the large hernias0 #hicht)*icall) ha+e a small nec3.


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Indications for umbilical hernia re*air in adults include s)m*toms0incarceration0 large hernia relati+e to the nec30 and tro*hic changes in theo+erl)ing s3in. Among adults #ith associated ascites0 re*air is ad+ocated toa+oid *otentiall) serious com*lications. The *resence of discoloration orulceration of o+erl)ing s3in or a ra*id increase in si e of the hernia heraldim*ending ru*ture. $*ontaneous ru*ture of the hernia in these *atients can becatastro*hic and is fre=uentl) associated #ith mortalit) rates a**roaching4 E. B) com*arison0 electi+e umbilical hernia re*air can be *erformedsafel) in *atients #ith ascites #ith acce*table morbidit) and mortalit).

& . -etro*eritoneal fibrosis is a fibrosing condition of retro*eritoneum0 #hichis of significance as it generall) encom*asses the ureters and e+entuall)causes h)drone*hrosis and 3idne) damage. 'hich of the follo#ingstatement6s7 is are true concerning this condition(

a. The ma8orit) of cases are idio*athic in nature b. A histor) of use of meth)sergide for treatment of migraine headaches#ould be significant

c. There is no 3no#n association of malignanc) #ith retro*eritoneal fibrosisd. The disease occurs more commonl) in #omen than in menAns#er: a0 b

-etro*eritoneal fibrosis is a rare condition in #hich fibrosis de+elo*s in theretro*eritoneal s*ace. The ureters fre=uentl) #ill become encom*assed b) the

*rocess e+entuall) causing h)drone*hrosis and 3idne) damage.-etro*eritoneal fibrosis occurs most commonl) in the fifth and si5th decades#ith a &:1 male,female *redominance. The *atho*h)siolog) ofretro*eritoneal fibrosis remains to be delineated. In full) t#o,thirds of cases0retro*eritoneal fibrosis is idio*athic0 ho#e+er0 an autoimmune *rocess has

been suggested as a *otential cause. About 1&E of cases of retro*eritonealfibrosis ha+e been associated #ith the use of meth)sergide0 a serotonin


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trans+ersus abdominis muscle is the innermost of the lateral abdominal #allmusculature. The trans+ersalis fascia lies on the dee* side of the trans+ersusmuscle and e5tends to form an essentiall) com*lete fascial en+elo*e of theabdominal ca+it). The semicircular line is defined b) the lo#er edge of the

*osterior sheath about 4 to > cm belo# the le+el of the umbilicus0 and itscon+e5it) is directed su*eriorl). Abo+e the semicircular line0 the internalobli=ue a*oneurosis s*lits into *osterior and anterior laminae. The *osteriorlamina 8oins #ith the trans+ersus abdominis a*oneurosis to form the *osterior rectus sheath. The anterior lamina fuses #ith the e5ternal obli=ue a*oneurosisto form the anterior rectus sheath. Belo# the semicircular line0 the internalobli=ue end trans+ersus abdominis a*oneurosis fuse to form an internal

lamina of the anterior sheath0 #ith the e5ternal obli=ue a*oneurosis formingthe e5ternal lamina of the anterior sheath. The medial *aired rectus abdominismuscles originate on the ribs su*eriorl) and on the *ubis inferiorl). Belo# thesemicircular line0 the rectus muscles are nearl) fused in the midline andindistinct0 and their *osterior surfaces co+ered onl) #ith the trans+ersalisfascia.

&&. A 9@,)ear,old #oman maintained on 'arfarin for a histor) of cardiac+al+ular re*lacement and a histor) of recent u**er res*irator) infection

*resents #ith se+ere abdominal *ain e5acerbated b) mo+ement. Her *h)sicale5amination sho#s tenderness in the right *aramedian area #ith +oluntar)guarding but no *eritoneal signs. The follo#ing statement6s7 is are trueconcerning the diagnosis and management of this *atient.

a. "rgent la*arotom) should be *erformed because of concern for arterialmesenteric embolus

b. The correct diagnosis could li3el) be made b) CT scan and o*erationa+oidedc. The status of her anticoagulation should be chec3ed and if her *rothrombintime is e5cessi+el) *rolonged0 correction is necessar)


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d. If untreated0 hemod)namic instabilit) is commonAns#er: b0 c

-ectus sheath hematoma results from arterial or +enous bleeding into therectus sheath0 most commonl) from arterial bleeding. -ectus sheathhematomas *redominate in #omen b) a ratio of about 4:1. The mean age ofincidence is in the late fifth decade. Although s*ontaneous formation of arectus hematoma is rare0 it can occur #ith +asculitis0 arterial +enousmalformations0 a se+ere coagulo*ath)0 or #ith the administration ofanticoagulants. The usual cause is trauma. !+ents as tri+ial as snee ing0coughing0 or t#isting to the side ha+e initiated a rectus hematoma.

Abdominal *ain is almost al#a)s described at *resentation. ain is oftendescribed as se+ere and usuall) is e5acerbated b) mo+ements that re=uiremuscular contraction of the abdominal #all. n e5amination0 there istenderness o+er the rectus sheath0 +oluntar) guarding0 and often a diffusemass sensation in the area of tenderness. Contraction of the rectus musclee5acerbates the *ain and tenderness. eritoneal signs are absent. !cch)mosisma) occur but usuall) a**ears se+eral da)s after the onset of *ain. In cases#here the hematoma dissects or originates inferiorl) and e5*ands into the

*re+essicle and *re*eritoneal s*ace0 the hematocrit ma) fall significantl)Gho#e+er0 hemod)namic instabilit) is distinctl) unusual. 'hen theintraabdominal source of *ain is un3no#n0 ultrasound and *articularl)com*uted tomogra*h) can delineate the hematoma and locali e it to theabdominal #all in almost all cases.Treatment must ta3e into consideration the cause0 if 3no#n0 and #hether thehematoma is stable or *rogressi+e. Coagulo*ath) should be corrected #hen

*ossible. For *atients in #hom the hematoma is stable0 *ain medication anda+oidance of muscular stress on the abdominal #all are sufficient. For

*atients #ith *rogressi+e hematoma0 the treatment of choice is e+acuation ofthe hematoma from #ithin the rectus sheath and hemostasis0 sometimesre=uiring ligation of the e*igastric +essels abo+e and belo# the hematoma.


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tubes. 2ong,term resolution of ureteral obstruction most fre=uentl) has beenaccom*lished b) o*erati+e freeing of the ureters from the fibrosis anddis*lacing them laterall) or #ithin the *eritoneal ca+it). Although renalfunction is im*ro+ed in more than E of cases so treated0 in as man) asone,third of *atients0 ureteral obstruction recurs on the i*silateral orcontralateral side. rognosis for *atients #ith nonmalignant retro*eritonealfibrosis is good. $ur+i+als of @> 1 E for se+eral )ears ha+e been re*orted.

&9. The follo#ing statement6s7 is are true concerning incarceration of aninguinal hernia.

a. All incarcerated hernias are surgical emergencies and re=uire *rom*tsurgical inter+ention

b. Attem*t at reduction of an incarcerated s)m*tomatic hernia is generall)considered safec. ;igorous attem*ts at reduction of an incarcerated hernia ma) result inreduction en masse #ith continued entra*ment and *ossible *rogression toobstruction or strangulation

d. Incarcerated hernias fre=uentl) cause both small and large bo#elobstructionAns#er: b0 c

Hernia incarceration denotes the condition #herein +iscera are contained#ithin a hernia sac and cannot be disgorged from the sac. atients #ith anincarcerated hernia ma) be as)m*tomatic e5ce*t for the *resence of a bulge.ain associated #ith an incarcerated hernia should be inter*reted asindicati+e of strangulation. Man) hernias are of such si e that the) cannot bereduced either s*ontaneousl) or manuall). If the *atient is as)m*tomatic0electi+e surger) should be *lanned. In a *atient #ith *ain0 attem*t atreduction is relati+el) safe as long as e5cessi+e force is not a**lied. Anincarcerated hernia #ith discomfort or signs of bo#el obstruction is best


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treated #ith urgent hernia re*air0 although gentle attem*ts at reduction ma) be #ithout conse=uences. -eduction of a s)m*tomatic hernia ma) result inreduction of gangrenous bo#el into the *eritoneal ca+it). -eduction of bo#el#ith necrotic areas e+entuates in bo#el *erforation and *eritonitis #ith anassociated 1 E to 4 E mortalit) and high le+els of morbidit). ;igorousattem*ts at reduction ma) result in reduction en masse0 in #hich the +isceraremain #ithin the *eritoneal sac after reduction #ith the entire sac and itscontained +iscera forced through the abdominal #all defect into the

*re*eritoneal la)er. -eduction en masse usuall) occurs #hen a small fibrousnec3 tra*s enclosed +iscera and is associated #ith a high ris3 of continuedentra*ment and *rogression to obstruction or strangulation.

'orld,#ide hernias are the leading cause of intestinal obstruction. Theobstruction is almost e5clusi+el) small intestinal #ith onl) rarel) the colon asthe site of obstruction.

&


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*atholog). A chronic cough from chronic obstructi+e *ulmonar) diseaseshould be in+estigated and attem*ts made to control s)m*toms. $ignificantobstructi+e uro*ath) ma) #arrant urologic consultation and treatment *rior tohernia re*air. $uch treatment is im*ortant both to *re+ent *osto*erati+eurinar) retention0 as #ell as *ersistent straining on the ne#l),com*letedre*air. Change in bo#el habits #ith consti*ation or the *resence of bloodassociated #ith bo#el mo+ements ma) suggest a rectal or left,sided coloncancer. atients fre=uentl) relate a s*ecific e*isode of muscular strainingduring #hich a sudden discomfort occurs follo#ed b) hernia s)m*toms ofdiscomfort or a bulge. There is little e+idence to suggest that such a s*ecificacute e+ent can *reci*itate a hernia. A histor) of hea+) lifting is im*ortant0

ho#e+er0 in both *lanning of *osto*erati+e disabilit) as #ell as considerationfor long,term recurrence rates.

&>. The follo#ing statement6s7 is are true concerning abdominal incisionalhernias.

a. 2arge incisional hernias are associated #ith a high recurrence rate #hen

closed *rimaril) b. A large *otential s*ace remains anterior to the abdominal #all closure inmost *atients indicating a need for *osto*erati+e #ound drainagec. The use of *rosthetic mesh can often be a+oided b) em*lo)ing rela5ingincisions in the anterior fascia *arallel to the midlined. Incisional hernias are fre=uentl) associated #ith a tissue deficit either dueto chronic retraction and scarring or the result of tissue necrosis from eitherinfection or tension at the initial closureAns#er: a0 b0 c0 d

-e*air of an incisional hernia can be difficult #ith se+eral factors ma3ingthese hernias *articularl) challenging. First0 incisional hernias are oftenrelated to a *osto*erati+e #ound infection0 in #hich case associated fascitis


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or muscle necrosis ma) result in loss of tissue. $econd0 a *re+ious abdominal#all closure under tension or #ith a techni=ue that resulted in tension on

*articular sutures ma) lead to a multifenestrated region of themusculoa*oneurotic abdominal #all near or slightl) bac3 from its margin.Third0 chronic retraction of the abdominal #all muscles result in a largerdefect. Fourth0 a large *otential s*ace remains anterior to the abdominal #allclosure in the subcutaneous areaG *osto*erati+e fluid accumulation in thiss*ace contributes to the #ound infection rate of


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*osteriorl) and then su*eriorl) to form a shel+ing edge. Mediall)0 theinguinal ligament turns under e+en further to form the lacunar ligament0 as

*art of its insertion on the *ubis. The su*erficial inguinal ring is a triangularo*ening in the e5ternal a*oneurosis0 #ith its a*e5 su*eriorl) in *ositionslightl) abo+e and lateral to the *ubic tubercle0 through #hich the cord e5itsthe inguinal canal. The con8oined tendon is commonl) alluded to indescri*tions of inguinal hernia re*airs. The con8oined tendon is the fusion ofthe a*oneurosis of the internal obli=ue and trans+ersus abdominis muscles.

&@. A number of s*ecial circumstances e5ist in the re*air of inguinal hernias.

The follo#ing statement6s7 is are correct.

a. $imultaneous re*air of bilateral direct inguinal hernias can be *erformed#ith no significant increased ris3 of recurrence

b. The *re*eritoneal a**roach ma) be a**ro*riate for re*air of a multi*lerecurrent herniac. A femoral hernia re*air can best be accom*lished using a Bassini or$houldice re*air

d. Management of an incarcerated inguinal hernia #ith obstruction is besta**roached +ia la*arotom) incisionAns#er: b

The a**roach to bilateral groin hernias is based on the e5tent of the herniadefect. For hernias for #hich inguinal floor reconstruction is re=uired 6alldirect and moderate to large indirect inguinal hernias0 all femoral hernias70simultaneous re*air of bilateral hernia results in recurrence of one or both ofthe hernias t#ice as fre=uentl) as if the hernias #ere re*aired se=uentiall).-e*air of recurrent inguinal or much less commonl) femoral hernias can bere*aired +ia an anterior a**roach *articularl) at the time of first recurrence inmost cases. If a deficit of a*oneurotic tissue e5ists0 methods such as

*ol)*ro*)lene mesh as an o+erla) or *referabl) as an underla)0 and tailored


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absor*tion in the *eritoneal ca+it). Ascites occurs #hen either the secretionrate increases or the absor*tion rate decreases dis*ro*ortionatel).Accumulation of l)m*h in the *eritoneal ca+it) usuall) results from traumaor tumor in+ol+ing l)m*hatic structures. ro*osed treatment regimens rangefrom salt restriction and diuretics to surgical ligation and *eritoneo+enousshunting. "ninfected bile is a mild irritant to the *eritoneal ca+it) and causesincreased *roduction of *eritoneal fluid0 resulting in bile ascities orchole*eritoneum. Most cases of chole*eritoneum follo# biliar) tract surger)0

but cases of s*ontaneous bile duct *erforation ha+e been re*orted in infantsand some adults. The most common cause of hemo*eritoneum is trauma tothe li+er or s*leen. 2ess common causes include ru*tured ecto*ic *regnanc)0

ru*tured aortic aneur)sms0 and other intra,abdominal in8uries.

4 . The follo#ing statement about *eritonitis are all true e5ce*t:A. eritonitis is defined as inflammation of the *eritoneum.B. Most surgical *eritonitis is secondar) to bacterial contamination.C. rimar) *eritonitis has no documented source of contamination and ismore common in adults than in children and in men than in #omen.

D. Tuberculous *eritonitis can *resent #ith or #ithout ascites.Ans#er: C

DI$C"$$I %: eritonitis is inflammation of the *eritoneum and can bese*tic or ase*tic0 bacterial or +iral0 *rimar) or secondar)0 acute or chronic.Most surgical *eritonitis is secondar) to bacterial contamination from thegastrointestinal tract. rimar) *eritonitis refers to inflammation of the

*eritoneal ca+it) #ithout a documented source of contamination. It is morecommon in children than in adults and in #omen than in men. The female

*redominance is felt to be e5*lained b) entr) of organism into the *eritonealca+it) through the fallo*ian tubes. The clinical manifestations of tuberculous

*eritonitis are of t#o t)*es. The moist form consists of fe+er0 ascites0abdominal *ain0 and #ea3ness. The dr) form *resents in a similar manner but


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44. Acute a**endicitis is most commonl) associated #ith #hich of thefollo#ing signs(A. Tem*erature abo+e 1 9 F.B. Fre=uent loose stools.C. Anore5ia0 abdominal *ain0 and right lo#er =uadrant tenderness.D. 'hite blood cell count greater than & 0 *er cu. mm.Ans#er: C

49. 'hich of the follo#ing most often initiates the de+elo*ment of acutea**endicitis(A. A +iral infection.

B. Acute gastroenteritis.C. bstruction of the a**endiceal lumen.D. A *rimar) clostridial infection.Ans#er: C

DI$C"$$I %: The ma8orit) of *atients #ith acute a**endicitis ha+e anobstructed lumen that is due to either h)*er*lasia of the l)m*h follicles in the#all of the a**endi5 or a fecalith. The obstruction creates a site #here the

bacteria in the lumen multi*l) ra*idl)0 *roducing e5oto5ins and endoto5insthat then ulcerate the mucosa0 allo#ing *athogenic organisms to enter the#all of the a**endi5. An inflammator) *rocess follo#s that can e5tend to theserosa0 and *enetration through the serosal la)er causes generali ed

*eritonitis.

4 and older.B. 'omen aged 1@ to 4


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DI$C"$$I %: It is +er) difficult to establish a firm diagnosis of acutea**endicitis in an infant of 1 )ear or )ounger since the *atient cannot *ro+idea histor) or be hel*ful during the *h)sical e5amination. It is rare to ma3e adefiniti+e diagnosis *reo*erati+el) in such infants0 and in such cases thea**endi5 is usuall) *erforated at the time of o*eration. 'hile a**endicitis issome#hat more difficult to diagnose in the elderl) because of the reducedres*onse to inflammationG ne+ertheless0 it is usuall) *ossible to ma3e thediagnosis. 'ith *regnant #omen it is #ise to remember that the enlarginguterus in the last trimester dislocates the a**endi5 higher in the abdomen andthat the signs and s)m*toms follo# this anatomic shift accordingl).

4>. nce a diagnosis of acute a**endicitis has been made and a**endectom)decided u*on0 #hich of the follo#ing is are true(A. ro*h)lactic antibiotics should be administered.B. ro*h)lactic antibitics are not necessar) unless there is e+idence of

*erforation.C. If the a**endi5 is not ru*tured and not gangrenous0 antibiotics ma) be

discontinued after &9 hours.D. Multi*le antibiotics are in all cases *referable to a single agent.Ans#er: AC

DI$C"$$I %: It is generall) held that *atients #ith a diagnosis of acutea**endicitis should recei+e antibiotics such as cefo5itin or cefotetan.Administration can be discontinued after &9 hours if the a**endi5 is notgangrenous or ru*tured. Multi*le antibiotics are unnecessar) instraightfor#ard cases.

4?. The best t)*e of 5,ra) to locate free abdominal air is:A. A *osteroanterior +ie# of the chest.


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B. A flat and u*right +ie# of the abdomen.C. Com*uted tomogra*h 6CT7 of the abdomen.D. A lateral decubitus 5,ra)0 right side u*.Ans#er: D

4@. The most hel*ful diagnostic radiogra*hic *rocedure in small bo#elobstruction is:A. CT of the abdomen.B. Contrast stud) of the intestine.C. $u*ine and erect 5,ra)s of the abdomen.D. "ltrasonogra*h) of the abdomen.

Ans#er: C

4 . The most commonl) used imaging method for diagnosis of acutecholec)stitis is:A. CT of the abdomen.B. "ltrasonogra*h) of the gallbladder.C. ral cholec)stogram.D. -adionuclide 6HIDA7 scan of the gallbladder.

Ans#er: B

9 . Acute sal*ingitis occurs most often:A. After meno*ause.B. In *atients #ith unilateral lo#er abdominal *ain.C. During the menstrual c)cle.D. In *atients #ith cer+ical tenderness and +aginal discharge.Ans#er: D

91. Mec3el/s di+erticulitis most often occurs in the:A. ro5imal 8e8unum.B. Distal 8e8unum.C. ro5imal ileum.


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D. Distal ileum.Ans#er:D

9&. A *atient is seen in the emergenc) room #ith re*roducible right lo#er=uadrant tenderness. The a**ro5imate incidence of finding a normala**endi5 on right lo#er =uadrant e5*loration in similar nonselected *atientsis #hich of the follo#ing:

a.


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%umerous surgical causes e5ist for the *atient *resenting #ith acuteabdominal *ain. A recent re+ie# of nearl) 1& *atients *resenting foremergenc) e+aluation of abdominal *ain affords some interesting findings.The most common diagnosis #as nons*ecific abdominal *ain0 occurring in4


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Adrenal insufficienc)"remiaH)*ercalcemia

T JICInsect bites;enoms 6scor*ion0 sna3e72ead *oisoningDrugs

MI$C!22A%! "$

Hemol)tic crises-ectus sheath hematoma

%!"- !%ICHer*es oster Abdominal e*ile*s)$*inal cord tumor0 infection

%er+e root com*ression

CA-DI "2M %A-KneumoniaM)ocardial infarctionM)ocarditis!m*)emaCostochondritis

9


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A +ariet) of conditions influence the *resentation of intraabdominal *atholog). regnanc) is among these0 *rinci*all) because of dis*lacement ofad8acent normal +iscera and therefore a shift in the location of the *arietal

*ain. ral anticoagulation is associated #ith the de+elo*ment of s*ontaneousintramural hematomas of the bo#el causing *ain but not re=uiring surgicalresection. This *ain ma) be confused #ith a +ariet) of other intraabdominalemergencies.Age is li3e#ise a confounding factor0 generall) in infanc) and in the elderl).In these age grou*s0 the s)m*toms ma) be less *ronounced and the

*resentations occur later in the course of disease.

Immunocom*romised *atients are a heterogenous grou* that includes thoserecei+ing allografts0 chemothera*)0 immunosu**ressi+e drugs forautoimmune disorders0 and indi+iduals #ith the ac=uired immunodeficienc)s)ndrome 6AID$7. This grou* has a +ariet) of s*ecific abdominalcom*lications that must be a**reciated and sus*ected b) the e+aluating

*h)sician.AC"T! ABD MI%A2 AI% A$$ CIATI %$ I% TH!IMM"% C M - MI$!D ATI!%T

CKT M! A2 ;I-"$ I%F!CTI %Interstitial *neumonitisMononucleosisancreatitisHe*atitisCholec)stitisastrointestinal ulceration

A%C-!ATITI$$teroidsA athio*rineC)tomegalo+irus


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$TA%DA-D ABD MI%A2 - C!$$!$A**endicitisCholec)stitisDi+erticulitisBo#el obstruction"lcer diseaseel+ic inflammator) diseaseerirectal abscess"rinar) tract infection2)m*hadenitis

%!"T- !%IC !%T!- C 2ITI$

9?. ros*ecti+e studies ha+e sho#n incidental a**endectom) to bead+antageous in #hich of the follo#ing *atient grou*s(

a. Children undergoing staging la*arotom) for malignanc) #ho are then to

enter chemothera*) b. HI; infected *atientsc. atients o+er < )ears of aged. atients #ith s*inal cord in8uriese. %one of the abo+eAns#er: e

$e+eral studies ha+e loo3ed at incidental a**endectomies in a +ariet) of *o*ulations. The deficienc) in all *ast studies of this issue is the lac3 of *ros*ecti+e long,term trials to assess the true cost and benefit.Incidental a**endectom) is clearl) not indicated in the elderl) and in *atientsundergoing la*aratom) for staging of Hodg3in s disease. These t#o s*ecificgrou*s ha+e been sho#n to ha+e increased *erio*erati+e ris3s #ith incidental


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include #hich of the follo#ing:

a. Fecaliths are res*onsible for the disease *rocess in a**ro5imatel) 4 E ofadult *atients

b. 2)m*hoid h)*er*lasia is a rare cause of a**endicitis in )oung *atientsc. Clostridium difficile is im*licated as a *athogenic organismd. Carcinoid tumors account for a**ro5imatel) E of acutea**endicitis in the )oung. In adults0 fecalith formation accounts fora**ro5imatel) 4 E of acute a**endicitis. There is no 3no#n causati+erelationshi* of Clostridium difficile or other s*ecific organisms #ith acutea**endicitis. The normal flora of the a**endi5 is consistent #ith that of thead8acent cecum.

Neoplasms of the appendix are rare, occurring in 1% to 1.3% of all appendectomyspecimens. Carcinoid

mors are the most common, followed in frequency by benign and malignant

mucoceles.

< . A &>,)ear old #oman in her first trimester of *regnanc) *resents #ith a &,

da) histor) of right lo#er =uadrant *ain and fe+er. h)sical e5aminationre+eals a tender0 *al*able0 right lo#er =uadrant mass. There is no e+idence of

*eritonitis or s)stemic se*sis. 2aborator) e+a luation is remarkable for mildleukocytosis, and abdominal ultrasound demonstrates an in ammatory mass but no

e!idence of abscess. "s the surgeon on call, your recommendation would be#

a.


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b. Intra+enous h)dration0 antibiotic *ro*h)lasis0 and urgent a**endectom)c. Intra+enous h)dration0 antibiotics0 bo#el rest0 and inter+al a**endectom)in 9 to > #ee3s

d. Intra+enous h)dration0 antibiotics0 and a**endectom) if no im*ro+ementin 1& to &9 hourse. Intra+enous h)dration0 antibiotics0 and inter+al a**endectom) #hen fe+erhas subsided0 leu3oc)te count has returned to normal0 and the *atient is *ainfreef. !mergent obstetrical consultation for e+aluation and treatment of *ossibleecto*ic *regnanc)Ans#er: a

The *atient *resented has a *erforated a**endi5 #ith a *hlegmon0 but noabscess. ne must routinel) *ro+ide resuscitation and broad s*ectrumantiobiotic co+erage in this circumstance. As she is not s)stemicall) to5ic0 it#ould be rational in a non*regnant *atient to treat this *atient nono*erati+el)initiall) and follo# this #ith inter+al a**endectom). Ho#e+er0 in thiscircumstance0 the ris3 of *reterm labor associated #ith anesthesia and *el+ic

inflammation increases #ith more ad+anced gestation0 so the best decision isto *roceed #ith intra+enous h)dration0 broad s*ectrum antibiotic co+erageand urgent a**endectom).

E of *atients


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s)m*tomatic0 and #ide resection of the *rimar) disease0 together #ithdebul3ing of *eritoneal im*lants0 is indicated. Indolent *rogression ofmetastases commonl) results in *rolonged sur+i+al rates 6< E at < )ears7

during #hich *atients ma) re=uire re*eated la*aratomies for com*lications of the disease.

hernia and acute abdomen mcq.docx

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