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fell." Being judgmental right from the start will not be good in the long run."Your husband does not hit you, does he?" (choice F) is a terrible question to askher. It is leading,biased and she will try to give you the response that she thinks that you want to hear("No, of coursehe doesn't hit me."). It is best to ask an open-ended question that allows her to tellyou whathappened. If this does not lead in the direction that you think is appropriate, youmay ask, "does yourhusband ever hit you?", but this is not the best way to start out.A 31-year-old man undergoes an uneventful standard "open" repair of the herniausing "mesh plug"technique. As planned, he is discharged home on the same day of surgery. At his firstpostoperativevisit, he complains of numbness over the upper aspect of his right thigh and the rightside of thescrotum. Physical examination reveals an incision that is clean and dry without anyevidence ofinfection. The right hemi-scrotum is moderately edematous and minimally tender,both testicles arenormal to palpation. Motor sensation of his right lower extremity is completelyintact. Sensoryexamination reveals decreased sensation to touch over the medial aspect of the thighjust below theinguinal ligament as well as over the right side of the scrotum. He is giveninstructions to observe thiscomplaint and follow up in 2 weeks. The injured nerve is most likely the A. iliohypogastricB. ilioinguinal
C. lateral femoral cutaneousD. obturatorE. pudendalExplanation:The correct answer is B. Although it is now possible to perform inguinal herniarepairslaparoscopically, the traditional approach is through an incision over the inguinalcanal. At the time ofsurgery, the inguinal canal is opened via sharp dissection through the externaloblique aponeurosis,(the anterior wall of the inguinal canal). The ilioinguinal nerve is then encounteredas it runs on theanterior aspect of the spermatic cord. If not properly identified at time of surgery, itis possible totransect the ilioinguinal nerve or to "trap" it during closure. If the ilioinguinal nerveis transected on"entrapped" in closure, the patient will complain of numbness over the nerve'sdistribution, (i.e. theupper medial aspect of the thigh and the anterior portion of the scrotum on theaffected side).The iliohypogastric nerve (choice A) is derived from L1 (as is the ilioinguinalnerve), and runs with theilioinguinal nerve as they both pierce the transversus abdominis muscle near theanterior superioriliac spine, and then pass through the internal and external oblique muscles tosupply the skin of thesuprapubic and inguinal regions and the abdominal musculature. Theiliohypogastric sends a lateralbranch to the skin of the gluteal region and then continues on, to pass through thesuperficial inguinalring.