A 28-year-old man has a painless hard swelling of the left testis, and orchidectomy shows a seminoma. A CT is planned to look for spread. Which group of lymph nodes is the first to receive lymph from the testis?

Para-aortic nodes near the renal vessels

Abdominal wall, inguinal canal and hernia anatomy

12 NEET-PG practice questions on Abdominal wall, inguinal canal and hernia anatomy, part of Anatomy. The first 12 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A 45-year-old man has a right groin swelling. Four findings are recorded in the surgical OPD and at operation: 1. After reduction, pressure over a point just above the midpoint of the inguinal ligament stops the swelling reappearing on coughing. 2. The swelling bulges forward through the triangle bounded by the inferior epigastric vessels, rectus edge and inguinal ligament. 3. The swelling descends into the scrotum. 4. At operation, the sac neck lies lateral to the inferior epigastric vessels. Which findings point to an indirect inguinal hernia?
1. A1, 2, 3 and 4
2. B1, 3 and 4 only
3. C2, 3 and 4 only
4. D1 and 4 only
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Answer: B · 1, 3 and 4 only
Findings 1, 3 and 4 point to an indirect hernia. An indirect hernia enters the deep ring, which lies just above the midpoint of the inguinal ligament and lateral to the inferior epigastric vessels, so pressure there after reduction controls it, and it follows the cord and often reaches the scrotum. Finding 2 describes a direct hernia, which bulges forward through Hesselbach triangle medial to the inferior epigastric vessels and is not controlled by deep ring pressure. The decisive sign is the relation of the neck to the inferior epigastric vessels at operation.
- A: Includes finding 2; a bulge through Hesselbach triangle is a direct hernia.
- C: Includes finding 2, which describes a direct hernia.
- D: Leaves out descent into the scrotum, typical of an indirect hernia.
Question 2 · Easy
A 30-year-old labourer has an indirect inguinal hernia. The surgeon explains that the hernia sac enters the inguinal canal through the deep inguinal ring. The deep ring is an opening in which layer?
1. AParietal peritoneum
2. BTransversalis fascia
3. CInternal oblique muscle
4. DExternal oblique aponeurosis
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Answer: B · Transversalis fascia
The deep inguinal ring is an oval opening in the transversalis fascia, just above the midpoint of the inguinal ligament and lateral to the inferior epigastric vessels. The transversalis fascia is drawn out from its margins as the internal spermatic fascia covering the cord. The superficial ring is a triangular gap in the external oblique aponeurosis above and lateral to the pubic tubercle. Occluding the deep ring with a finger after reducing the hernia controls an indirect hernia, a useful bedside test.
- A: The peritoneum forms the hernia sac, not the deep ring.
- C: The internal oblique arches over the canal and gives the cremaster; it has no ring.
- D: The external oblique aponeurosis contains the superficial, not deep, ring.
Question 3 · Medium
A 28-year-old man has a painless hard swelling of the left testis, and orchidectomy shows a seminoma. A CT is planned to look for spread. Which group of lymph nodes is the first to receive lymph from the testis?
1. APara-aortic nodes near the renal vessels
2. BSuperficial inguinal nodes
3. CDeep inguinal nodes
4. DExternal iliac nodes
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Answer: A · Para-aortic nodes near the renal vessels
The testis develops on the posterior abdominal wall near the kidney and descends, carrying its vessels and lymphatics with it. Its lymphatics run up with the testicular vessels in the cord to the para-aortic (lumbar) nodes at about the level of the renal vessels, which is why staging CT covers the abdomen. The scrotal skin, in contrast, drains to the superficial inguinal nodes. For this reason a testicular tumour is removed through an inguinal incision, and scrotal biopsy is avoided so as not to open a new lymphatic route.
- B: Superficial inguinal nodes drain the scrotal skin, not the testis.
- C: Deep inguinal nodes receive lymph from the lower limb and glans, not the testis.
- D: External iliac nodes are not the primary drainage of the testis.
Question 4 · Medium
A 70-year-old woman on warfarin for atrial fibrillation has a bad bout of coughing and then sudden pain with a tender mass in the right lower abdomen. The mass stays palpable when she tenses her abdominal muscles by raising her head, and it does not cross the midline. Her INR is 4.8. Which vessel has most likely bled?
1. ASuperior epigastric artery
2. BSuperficial epigastric artery
3. CInferior epigastric artery
4. DDeep circumflex iliac artery
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Answer: C · Inferior epigastric artery
A painful mass within the abdominal wall that stays palpable when the rectus contracts (Fothergill sign) and does not cross the midline is a rectus sheath haematoma, typically after coughing in an anticoagulated patient. Below the umbilicus the rectus is supplied by the inferior epigastric artery, a branch of the external iliac that enters the sheath at the arcuate line. Below the arcuate line the posterior wall of the sheath is absent, so blood can spread into the prevesical space. Reversing the anticoagulation and ultrasound or CT confirm and manage most cases.
- A: The superior epigastric artery supplies the rectus above the umbilicus.
- B: The superficial epigastric artery lies in superficial fascia and would not form a mass within the rectus sheath.
- D: The deep circumflex iliac artery runs along the iliac crest, outside the rectus sheath.
Question 5 · Medium
During open repair of an inguinal hernia in a 52-year-old man, the surgical student names the structures within the spermatic cord: 1. Ductus (vas) deferens. 2. Pampiniform plexus of veins. 3. Ilioinguinal nerve. 4. Testicular artery. Which of these lie inside the coverings of the cord?
1. A2 and 4 only
2. B1, 2 and 4 only
3. C1, 3 and 4 only
4. D2, 3 and 4 only
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Answer: B · 1, 2 and 4 only
Structures 1, 2 and 4 are correct. The spermatic cord contains the ductus deferens and its artery, the testicular artery, the pampiniform plexus, the cremasteric artery, the genital branch of the genitofemoral nerve, sympathetic fibres and lymphatics, all within the internal spermatic fascia and the other coverings. The ilioinguinal nerve enters the canal by piercing the internal oblique and runs on the cord, outside its coverings, to emerge through the superficial ring. It is easily caught in sutures or mesh, causing chronic groin pain.
- A: Leaves out the ductus deferens, the key content of the cord.
- C: Includes the ilioinguinal nerve, which lies outside the cord, and leaves out the pampiniform plexus.
- D: Includes the ilioinguinal nerve and leaves out the ductus deferens.
Question 6 · Medium
During an open mesh repair of an inguinal hernia in a 40-year-old man, the lower edge of the mesh is sutured to the structure forming the floor of the inguinal canal. Which structure is it?
1. ATransversalis fascia
2. BInguinal ligament
3. CConjoint tendon
4. DPectineal ligament
Answer and explanation in LearnFree account
Question 7 · Medium
During a Lichtenstein repair in a 45-year-old man, the surgeon opens the external oblique aponeurosis and finds a thin layer of muscle loops covering the spermatic cord. From which muscle of the abdominal wall is this layer derived?
1. AInternal oblique
2. BRectus abdominis
3. CExternal oblique
4. DPyramidalis
Answer and explanation in LearnFree account
Question 8 · Hard
Three weeks after a laparoscopic transabdominal preperitoneal (TAPP) repair of a right inguinal hernia, a 50-year-old man complains of burning pain and numbness over the outer side of the right thigh. Power and knee reflex are normal. The operation note records tacks placed lateral to the gonadal vessels, below the iliopubic tract. Which nerve was most likely injured?
1. AObturator nerve
2. BIlioinguinal nerve
3. CLateral cutaneous nerve of the thigh
4. DIliohypogastric nerve
Answer and explanation in LearnFree account
Question 9 · Easy
A 66-year-old man with chronic bronchitis has a bulge in the right groin that comes straight forward on coughing. At laparoscopy the defect lies within Hesselbach triangle. Which structures bound this triangle?
1. AInferior epigastric vessels, rectus edge, lacunar ligament
2. BDeep circumflex iliac vessels, rectus edge, inguinal ligament
3. CInferior epigastric vessels, rectus edge, inguinal ligament
4. DInferior epigastric vessels, linea alba, inguinal ligament
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Question 10 · Medium
A 58-year-old man has had visible blood in his urine for 3 weeks and has just noticed a soft swelling above his left testis that feels like a 'bag of worms'. It does not empty when he lies down. Why is a left renal tumour a likely cause?
1. AThe left pampiniform plexus drains into the internal iliac vein
2. BThe left testicular vein drains into the left renal vein
3. CThe left testicular artery arises from the left renal artery
4. DThe left testicular vein drains into the inferior vena cava
Answer and explanation in LearnFree account
Question 11 · Medium
A 72-year-old woman is operated on for a strangulated femoral hernia. The neck of the sac is tightly gripped, so the surgeon must enlarge the femoral ring by cutting the structure on its medial side. Which structure is cut, and which vessel must the surgeon watch for?
1. ALacunar ligament; the femoral vein
2. BPectineal ligament; the external iliac vein
3. CInguinal ligament; the inferior epigastric artery
4. DLacunar ligament; an abnormal obturator artery
Answer and explanation in LearnFree account
Question 12 · Medium
During a laparoscopic totally extraperitoneal hernia repair in a 46-year-old man, the trainer warns against placing tacks in the triangle bounded by the vas deferens medially and the testicular vessels laterally. What lies in this triangle?
1. AObturator nerve and vessels
2. BExternal iliac artery and vein
3. CInferior epigastric artery and vein
4. DFemoral and genitofemoral nerves
Answer and explanation in LearnFree account

Abdominal wall, inguinal canal and hernia anatomy

A 30-year-old labourer has an indirect inguinal hernia. The surgeon explains that the hernia sac enters the inguinal canal through the deep inguinal ring. The deep ring is an opening in which layer?

A 28-year-old man has a painless hard swelling of the left testis, and orchidectomy shows a seminoma. A CT is planned to look for spread. Which group of lymph nodes is the first to receive lymph from the testis?

During open repair of an inguinal hernia in a 52-year-old man, the surgical student names the structures within the spermatic cord: 1. Ductus (vas) deferens. 2. Pampiniform plexus of veins. 3. Ilioinguinal nerve. 4. Testicular artery. Which of these lie inside the coverings of the cord?

During an open mesh repair of an inguinal hernia in a 40-year-old man, the lower edge of the mesh is sutured to the structure forming the floor of the inguinal canal. Which structure is it?

During a Lichtenstein repair in a 45-year-old man, the surgeon opens the external oblique aponeurosis and finds a thin layer of muscle loops covering the spermatic cord. From which muscle of the abdominal wall is this layer derived?

A 66-year-old man with chronic bronchitis has a bulge in the right groin that comes straight forward on coughing. At laparoscopy the defect lies within Hesselbach triangle. Which structures bound this triangle?

A 58-year-old man has had visible blood in his urine for 3 weeks and has just noticed a soft swelling above his left testis that feels like a 'bag of worms'. It does not empty when he lies down. Why is a left renal tumour a likely cause?

A 72-year-old woman is operated on for a strangulated femoral hernia. The neck of the sac is tightly gripped, so the surgeon must enlarge the femoral ring by cutting the structure on its medial side. Which structure is cut, and which vessel must the surgeon watch for?

During a laparoscopic totally extraperitoneal hernia repair in a 46-year-old man, the trainer warns against placing tacks in the triangle bounded by the vas deferens medially and the testicular vessels laterally. What lies in this triangle?