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

22 NEET-PG practice questions on Abdominal wall, inguinal canal and hernia anatomy, part of Anatomy. The first 22 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
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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
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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
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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
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Question 13 · Medium
A tender lump appears after a coughing fit at the lateral edge of the right rectus abdominis, below the level of the umbilicus, in an older woman with chronic bronchitis. Ultrasound shows a small hernia through the aponeurosis along the linea semilunaris, just at the level where the posterior wall of the rectus sheath ends. What is this hernia called?
1. AEpigastric hernia
2. BRichter hernia
3. CParaumbilical hernia
4. DSpigelian hernia
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Question 14 · Medium
Dilated veins radiate from the umbilicus over the abdominal wall of a man with alcoholic cirrhosis and ascites; when emptied and released, they fill from the umbilicus outwards. Through which veins does portal blood reach the abdominal wall here?
1. ALeft gastric veins
2. BSuperior epigastric veins
3. CParaumbilical veins
4. DRetroperitoneal lumbar veins
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Question 15 · Hard
At open repair of a large left indirect inguinal hernia in an elderly man, present for about 15 years, reaching the bottom of the scrotum and only partly reducible, the surgeon finds that part of the wall of the sac is formed by a viscus covered only partly by peritoneum, which slid down along with the parietal peritoneum. The surgeon takes care not to open the sac wall on that side. Which viscus most likely forms this part of the sac on the left side?
1. AUrinary bladder
2. BCaecum
3. CSigmoid colon
4. DIleum
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Question 16 · Medium
In a boy brought with sudden severe scrotal pain, stroking the skin of the upper inner thigh fails to raise the testis on the painful side, though it does on the other side. Which nerve carries the efferent limb of this reflex?
1. AFemoral branch of the genitofemoral nerve
2. BPudendal nerve
3. CGenital branch of the genitofemoral nerve
4. DIlioinguinal nerve
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Question 17 · Medium
During a tutorial on the inguinal canal, these statements are made: 1. The anterior wall is formed by the external oblique aponeurosis along its whole length 2. The posterior wall is formed by the fascia transversalis along its whole length 3. The roof is formed by arching fibres of the internal oblique and transversus abdominis 4. The floor is formed by the conjoint tendon. Which statements are correct?
1. A1, 2 and 3
2. B2, 3 and 4
3. C1 and 3 only
4. D1, 2 and 4
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Question 18 · Hard
After years of handling mineral oils on the spinning machines of a textile mill, a worker has an ulcerated squamous cell carcinoma on the skin of the scrotum. The testes are normal on examination and ultrasound. The surgeon examines the groin and the abdomen for spread. To which lymph nodes does this tumour first spread?
1. ASuperficial inguinal nodes
2. BDeep inguinal nodes
3. CPara-aortic nodes near the renal vessels
4. DExternal iliac nodes
Answer and explanation in LearnFree account
Question 19 · Medium
In the paediatric surgery clinic, a boy of 3 months has a groin swelling that appears when he cries and extends into the scrotum; it reduces easily and the testis is felt separately below it. At herniotomy, the sac is found within the spermatic cord. Failure of which embryological structure to close explains this?
1. AVitellointestinal duct
2. BGubernaculum
3. CProcessus vaginalis
4. DUrachus
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Question 20 · Medium
During repair of a direct inguinal hernia, the surgeon notes the sac bulging through the posterior wall of the canal medial to the inferior epigastric vessels, close to where the conjoint tendon reinforces the wall behind the superficial ring. Which muscles form the conjoint tendon?
1. ATransversus abdominis and rectus abdominis
2. BInternal oblique and transversus abdominis
3. CExternal and internal oblique
4. DExternal oblique and transversus abdominis
Answer and explanation in LearnFree account
Question 21 · Easy
The superficial inguinal ring is a triangular gap in the aponeurosis of which muscle?
1. ARectus abdominis
2. BExternal oblique
3. CInternal oblique
4. DTransversus abdominis
Answer and explanation in LearnFree account
Question 22 · Easy
A year after an appendicectomy through a gridiron incision placed rather low in the right iliac fossa, a farmer develops a right direct inguinal hernia. The surgeon suspects that the nerve supplying the lowest fibres of internal oblique and transversus abdominis, which form the conjoint tendon, was cut at the first operation. Which nerve is this?
1. ASubcostal nerve
2. BGenitofemoral nerve
3. CTenth thoracic nerve
4. DIlioinguinal nerve (L1)
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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?

Dilated veins radiate from the umbilicus over the abdominal wall of a man with alcoholic cirrhosis and ascites; when emptied and released, they fill from the umbilicus outwards. Through which veins does portal blood reach the abdominal wall here?

In a boy brought with sudden severe scrotal pain, stroking the skin of the upper inner thigh fails to raise the testis on the painful side, though it does on the other side. Which nerve carries the efferent limb of this reflex?

During repair of a direct inguinal hernia, the surgeon notes the sac bulging through the posterior wall of the canal medial to the inferior epigastric vessels, close to where the conjoint tendon reinforces the wall behind the superficial ring. Which muscles form the conjoint tendon?

The superficial inguinal ring is a triangular gap in the aponeurosis of which muscle?