Monday, 14 March 2016

Latest 50 Abdominal wall and acute abdomen Multiple Choice Questions And Answers

  1.  The most common hernia in females is:
A.  Femoral hernia.
B.  Direct inguinal hernia.
C.  Indirect inguinal hernia.
D.  Obturator hernia.
E.  Umbilical hernia.
Answer: C

DISCUSSION: Indirect inguinal hernias are the most common hernia in both females and males. Femoral hernias are more common in females than in males.

  2.  Which of the following statements regarding unusual hernias is incorrect?
A.  An obturator hernia may produce nerve compression diagnosed by a positive Howship-Romberg sign.
B.  Grynfeltt's hernia appears through the superior lumbar triangle, whereas Petit's hernia occurs through the inferior lumbar triangle.
C.  Sciatic hernias usually present with a painful groin mass below the inguinal ligament.
D.  Littre's hernia is defined by a Meckel's diverticulum presenting as the sole component of the hernia sac.
E.  Richter's hernia involves the antimesenteric surface of the intestine within the hernia sac and may present with partial intestinal obstruction.
Answer: C

DISCUSSION: Sciatic hernias usually present with intestinal obstruction or a mass in the gluteal or infragluteal region.

  3.  Staples may safely be placed during laparoscopic hernia repair in each of the following structures except:
A.  Cooper's ligament.
B.  Tissues superior to the lateral iliopubic tract.
C.  The transversus abdominis aponeurotic arch.
D.  Tissues inferior to the lateral iliopubic tract.
E.  The iliopubic tract at its insertion onto Cooper's ligament.
Answer: D

DISCUSSION: Placement of staples inferior to (below) the lateral iliopubic tract may result in injury to the lateral femoral cutaneous nerve or the genitofemoral nerve. Staples should also not be placed within the triangle of doom, owing to the risk of major vascular injury.

  4.  The following Nyhus classification of hernias is correct except for:
A.  Recurrent direct inguinal hernia—Type IVa.
B.  Indirect inguinal hernia with a normal internal inguinal ring—Type I.
C.  Femoral hernia—Type IIIc.
D.  Direct inguinal hernia—Type IIIa.
E.  Indirect inguinal hernia with destruction of the transversalis fascia of Hesselbach's triangle—Type II.
Answer: E

DISCUSSION: An indirect inguinal hernia with destruction of the transversalis fascia of Hesselbach's triangle is classified as a Type IIIb hernia. Also classified as Type IIIb hernias are sliding, pantaloon, and massive scrotal hernias. Type II hernia is an indirect inguinal hernia with a dilated internal ring but without displacement of the inferior deep epigastric vessels or destruction of the transversalis fascia of Hesselbach's triangle.

  5.  Which of the following statements about the causes of inguinal hernia is correct?
A.  Excessive hydroxyproline has been demonstrated in the aponeuroses of hernia patients.
B.  Obliteration of the processus vaginalis is a contributing factor for the development of an indirect inguinal hernia.
C.  Physical activity and athletics have been shown to have a protective effect toward the development of inguinal hernias.
D.  Elevated levels of circulating serum elastalytic activity have been demonstrated in patients with direct herniation who smoke.
E.  The majority of inguinal hernias are acquired.
Answer: D

DISCUSSION: A correlation between cigarette smoking and an inguinal hernia formation has been demonstrated. Elevated circulating serum elastalytic activity and free active unbound neutrophil elastase has been detected in smokers.

  6.  The following statements about the repair of inguinal hernias are true except:
A.  The conjoined tendon is sutured to Cooper's ligament in the Bassini hernia repair.
B.  The McVay repair is a suitable option for the repair of femoral hernias.
C.  The Shouldice repair involves a multilayer, imbricated repair of the floor of the inguinal canal.
D.  The Lichtenstein repair is accomplished by prosthetic mesh repair of the inguinal canal floor in a tension-free manner.
E.  The laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal approach (TEPA) repairs are based on the preperitoneal repairs of Cheattle, Henry, Nyhus, and Stoppa.
Answer: A

DISCUSSION: The Bassini repair is accomplished by high ligation of the hernia sac followed by suturing the conjoined tendon and the internal oblique muscle to the inguinal ligament.

7.  Which of the following statements concerning the abdominal wall layers are correct?
A.  Scarpa's fascia affords little strength in wound closure.
B.  The internal abdominal oblique muscles have fibers that continue into the scrotum as cremasteric muscles.
C.  The transversalis fascia is the most important layer of the abdominal wall in preventing hernias.
D.  The lymphatics of the abdominal wall drain into the ipsilateral axillary lymph nodes above the umbilicus and into the ipsilateral superficial inguinal lymph nodes below the umbilicus.
Answer: ABCD

DISCUSSION: The integrity of the abdominal wall is maintained principally by the transversalis fascia. Scarpia's fascia affords little strength in wound closure, but its approximation contributes considerably to the creation of an aesthetically acceptable scar. The cremasteric muscles of the spermatic cord are a continuation of muscle fibers from the internal abdominal oblique musculature. The lymphatic supply of the abdominal wall follows a simple pattern. These superficial lymphatics run parallel to the superficial veins, which above the umbilicus drain into the ipsilateral axillary vein and below it into the ipsilateral femoral vein.

8.  Which of the following congenital abnormalities are correctly defined?
A.  Omphalocele represents a defect in the abdominal wall lateral to the umbilical cord.
B.  The herniated viscera associated with omphaloceles are usually covered with a membranous sac.
C.  An umbilical polyp is a small excrescence of omphalomesenteric duct mucosa that is retained in the umbilicus.
D.  Meckel's diverticulum results when the intestinal end of the omphalomesenteric duct persists and represents a true diverticulum.
Answer: BCD

DISCUSSION: Omphalocele may be seen in newborns and represents a defect in the closure of the umbilical ring. The herniated viscera are usually covered with a sac. Gastroschisis, a defect of the abdominal wall lateral to the umbilical cord, is caused by failure of closure of the body wall. The intestines protrude through the defect, and no sac is present to cover the herniated intestine. In the fetus, the omphalomesenteric duct may present as abnormalities related to the abdominal wall when the duct fails to obliterate. Meckel's diverticulum is the result of the failure of obliteration of the intestinal end of the omphalomesenteric duct. This is a true diverticulum with all layers of the intestinal wall represented. An umbilical polyp is a small excrescence of omphalomesenteric duct mucosa retained in the umbilicus. Such polyps resemble umbilical granulomas except that they do not disappear after silver nitrate cauterization. Appropriate treatment is excision of the mucosal remnant.

9.                   The following statement(s) is/are true concerning the indications for treatment of an inguinal hernia.

a.          Most adult hernias will remain stable in size, therefore delay seldom affects the technical aspects of a surgical repair
b.          There is a direct correlation between the length of time that a hernia is present and the risk of major complications
c.          The morbidity and mortality associated with emergent operation due to hernia complications is significantly greater than for elective repair of the identical hernia
d.          A truss maintains a hernia in the reduced state, therefore, minimizing the risk of incarceration and strangulation
Answer: b, c

The indications for hernia repair must be individualized for each patient and the particular situation. In general, the presence of a hernia may be considered an adequate indication for hernia repair. Certainly the presence of complications due to hernia necessitates the correction of those complications and usually the repair of the hernia. As with any treatment, the benefits of operative repair must be weighed against the natural history of the disease, the extent to which the treatment can correct the problem, the possibility of treatment-related injury, and the interference of concomitant disease with the treatment results. With a few exceptions, the natural history of an abdominal wall hernia is that the size of the defect and the sac enlarges over time, and this enlargement increases the difficulty of adequate repair and the chances of recurrence of the hernia. The risk of major complications is greater in an individual patient, the longer the exposure to a hernia and the larger the sac relative to the hernia defect. In addition, major complications necessitate an emergent operation with attended high mortality and morbidity relative to that experienced with an elective repair. The use of a truss, an external support device using a system of straps to exert regional pressure over the hernia defect, should generally be avoided. Trusses do not consistently maintain a hernia in the reduced state, and they may put an unreduced hernia in greater jeopardy of strangulation. The pressure exerted induces edema by decreasing lymphatic and venous flow out of the herniated bowel. Trusses may also lead to injury to the skin overlying the hernia.

10.                Which of the following statement(s) is/are true concerning the diagnosis and management of epigastric hernias?

a.          A large peritoneal sac containing abdominal viscera is common
b.          At the time of surgical repair, a careful search for other defects should be performed
c.          Recurrent epigastric hernias after simple closure is uncommon
d.          Patients with symptoms of a painful midline abdominal mass frequently will contain incarcerated small bowel
Answer: b

Epigastric hernias are usually small but they vary considerably in size. Most of these defects occur in the midline. The small defects contain only preperitoneal fat with no sac. With increasing size, fat in the falciform ligament and eventually a peritoneal sac and abdominal viscera may be contained within the hernia. The preperitoneal fat in the small defect is usually incarcerated. Multiple defects may be present in up to 20% of patients. Surgical treatment is recommended in all adult patients with symptoms or with a hernia defect greater than 1.5 to 2 cm. in diameter. Methods of repair depend upon the size of the defect. For small defects, simple closure with obliquely placed sutures after reduction or removal of the preperitoneal fat from the defect has been recommended. However recurrent epigastric hernias in up to 10% of the cases have been reported with this method, most likely as a result of additional undetected or unrepaired weaknesses in the epigastric midline.

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