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Surgery Multiple Choice Questions on hernia
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Q1. Type III hiatus hernia hernia is?
a) GE junction migrates to the chest
b) GE junction and fundus of stomach herniates into the chest
c) Fundus of stomach migrates to the chest and GE junction remains in its original postion
d) Fundus of stomach migrates to the chest with other organs

Q2. Which of the following is a good candidtate for laparoscopic
      repair of paraesophageal hernia?
a) Previous open surgery for hiatus hernia
b) Previous laparoscopic surgery for hiatus hernia
c) Obese patients
d) Type II hernia with symptoms


Answers
1. b
A type I hernia is known as a sliding Hiatus Hernia and is characterized by upward displacement of the GE junction into the posterior mediastinum. The stomach remains in its usual longitudanal postion.
Type II—a “true” paraesophageal hernia PEH—is defined by a normally positioned intraabdominal GE junction with upward herniation of the stomach alongside it. A type III hernia is known as a “mixed” hernia and is characterized by displacement of both the GE junction and a large portion of the stomach cephalad into the posterior mediastinum.
The difference between a type I or sliding HH and a type III or mixed PEH is that with a type III hernia, a portion of the stomach lies cephalad to the GE junction.
In a type IV hernia, the esophageal hiatus has dilated to such an extent that the hernia sac also contains other organs such as the spleen, colon, or small bowel .
PEHs initially develop on the left anterior aspect of the esophageal hiatus
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Yeo: Shackelford's Surgery of the Alimentary Tract, 6th ed.

2. d
Not all patients are good candidates for laparoscopic PEH repair. Those who have previously undergone open HH repair or laparoscopic PEH repair and obese patients are poor candidates for the laparoscopic approach. This group of patients is probably best approached transthoracically.
In such cases the advantages include complete mobilization of the the esophagus with dissection of the sac.
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Paraduodenal hernia
1.They comprise of 53% of all internal hernia.
2.Pathogenesis is controversial and there are two theories
Moynihan-Paraduodenal fossa are congenital and hernia form due to gradual enlargement of of existing fossa.
Andrews-Congenital anomaly of peritoneum that occurs due to midgut rotation

The small bowel becomes trapped in the Left Mesocolon, which is unsupported and avascular. On the posterior aspect there is the posterior abdominal wall and anteriorly is the mesocolon and Inferior mesenteric vein.


Left Paraduodenal hernia
1.75% are left sided and males are 3 times more common.
2.Left PDH (Paraduodenal hernia) contains the afferent limb as the 4th part of duodenum and efferent limb is the terminal ileum.
3. The small bowel invaginates in the fossa of Landzert which lies to the left of 4th part of duodenum.
4. The colon may retain its normal position, becomes malrotated or volvulus.
Right Paraduodenal hernia
A right PDH  originates from abnormalities arising during the second phase of embryonic intestinal rotation
It  results in arrest of further rotation of the pre-arterial segment of the gut in the right side of the abdomen.
Continued rotation of the postarterial segment leads to entrapment of small bowel behind the right colonic mesentery, with the superior mesenteric artery forming the anterior edge of the hernia sac