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Direct hiatal hernia
6%
9/139
Indirect femoral hernia
9%
13/139
Direct incisional hernia
1%
2/139
Isolated rectus diastasis
0%
0/139
Direct inguinal hernia
80%
111/139
Select Answer to see Preferred Response
The patient in the question stem has a direct inguinal hernia, which protrudes directly through Hesselbach's triangle and bypasses the internal inguinal ring. Direct inguinal hernias can be distinguished from indirect inguinal hernias based on where the hernia enters the inguinal canal. This occurs either at the internal ring (indirect) or the external ring (direct) via Hesselbach's triangle, which is bordered by the inguinal ligament inferiorly, the rectus muscle medially, and the inferior epigastric vessels laterally. Direct hernias are more commonly observed in older patients and are less likely to be strangulated than indirect hernias. Leblanc et al. report that inguinal hernias are one of the most common reasons primary care patients are referred for surgical intervention. The history and physical examination are usually sufficient to make the diagnosis, making imaging rarely necessary for surgical planning. Symptoms include groin pain, burning, gurgling, or an aching sensation in the groin, which worsens by the end of the day. Bax et al. discuss surgical options in the management of inguinal hernias. They note that three major types of open repair are used in addition to laparoscopy. The choice of technique depends on several factors including: the type of hernia, anesthetic considerations, cost, period of postoperative disability, and the surgeon's expertise. Complication and recurrence rates are generally low with laparoscopic techniques, making it possible for patients to return to normal activities more quickly. Illustration A shows classic sites of common hernias. Illustration B shows Hesselbach's triangle. Incorrect Answers: Only inguinal hernias are referred to as direct or indirect, so do not be distracted by this in the answer options. Answer 1: Hiatal hernias result from protrusion of the upper stomach into the thorax. Answer 2: Femoral hernias occur just inferior to the inguinal ligament through weakness in the abdominal wall at the femoral canal. The majority of femoral hernias occur in women. Answer 3: This patient has not had surgery before; thus, he would not have an incisional hernia. Answer 4: Rectus diastasis is a disorder characterized by separation of the rectus abdominis muscles into a right and left band with gap in between where abdominal contents may bulge under strain.
3.7
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