I.

A 25 year old man presents to your office complaining of an intermittent bulge in his
right groin. It is not present all the time, but is most noticeable and sore at the end of the
day.
Study Questions:
1. What is the differential diagnosis of this patients chief complaint?
2. What other history is important to elicit from this patient?
3. On physical examination, a finger placed through the upper scrotum into the external ring
palpates a bulge with Valsalva maneuver. What is the most likely diagnosis?
4. At the time of surgery the patient is noted to have a bulge through a weakness in Hesselbach's
triangle. Define Hesselbach's triangle. Is this a direct or indirect hernia? Compare and contrast
direct and indirect hernias.
5. What are your operative options for repair of this hernia defect?

II. An 80 year old woman presents to the emergency room with a three-day history of
intermittent abdominal distension and vomiting. On physical exam she appears slightly
dehydrated. Her abdomen is distended and tympanitic to percussion but without
evidence of peritonitis. A bulge is noted in the right groin, slightly inferior to the
inguinal ligament.
Study Questions:
1. What is your diagnosis?
2. What is the preoperative workup and preparation needed for this patient?
3. What other complications of hernias are possible?
III. You perform surgery for a perforated duodenal ulcer in a 70 year old man who has a
history of steroid-dependent chronic obstructive pulmonary disease. Postoperatively, he
develops an infection of his upper midline abdominal incision. After the wound is fully
healed, the patient presents back to your office several months later with complaints of a
bulge at the incision site.
Study Questions:
1. What is the differential diagnosis, and what is the most likely diagnosis in this patient?
2. What risk factors contribute to the development of this diagnosis (in this patient specifically,
and in general)?
3. What are the indications for surgical intervention? How can you minimize risk factors for
recurrence after the repair?