CASE 3CASE 3

Geronimo, Geronimo, Geronimo,

Go, Go, Go, Go,

October 8, 2009

Geronimo, Geronimo, Geronimo,

Go, Go, Go, Go,

October 8, 2009

Case 3Case 3

A 35-year old male comes to your clinic with the following problem of 10 years duration. Except for the mass, he is relatively asymptomatic

A 35-year old male comes to your clinic with the following problem of 10 years duration. Except for the mass, he is relatively asymptomatic

Salient FeaturesSalient Features

35-year old Male CC: Scrotal Lump 10 years duration Scrotal mass Relatively asymptomatic

35-year old Male CC: Scrotal Lump 10 years duration Scrotal mass Relatively asymptomatic

Differential DiagnosisDifferential Diagnosis

Inguinal HerniaInguinal Hernia

75% of all abdominal wall hernias in the inguinal area

M>F 7:1 R-sided>L-sided Indirect: Direct Hernia Ratio 2:1

75% of all abdominal wall hernias in the inguinal area

M>F 7:1 R-sided>L-sided Indirect: Direct Hernia Ratio 2:1

Indirect vs. DirectIndirect vs. Direct

INDIRECT Occurs through the internal

inguinal ring Usually reaches the

scrotum Commonly seen in children

and young adults

INDIRECT Occurs through the internal

inguinal ring Usually reaches the

scrotum Commonly seen in children

and young adults

DIRECT• Defects in the

ABDOMINAL WALL (transversalis fascia) in Hesselbach's triangle

• Only protrudes forward

• Adults

Indirect Inguinal HerniaIndirect Inguinal Hernia

Complete Sac descends to the testes and fills the side of

the scrotum

Incomplete Does not descend to the testes

Complete Sac descends to the testes and fills the side of

the scrotum

Incomplete Does not descend to the testes

Differential DiagnosisDifferential Diagnosis

CausesCauses

Anything that causes weakness or tears in the abdominal wall can cause a groin hernia, including:

Defects at birth Prolonged wear and tear (eg, lifting, straining, or

coughing) Age-related weakness of the abdominal wall History of previous surgery in the area

Anything that causes weakness or tears in the abdominal wall can cause a groin hernia, including:

Defects at birth Prolonged wear and tear (eg, lifting, straining, or

coughing) Age-related weakness of the abdominal wall History of previous surgery in the area

Risk FactorsRisk Factors

A risk factor is something that increases your chance of getting a disease or condition. Risk factors include:

Advancing age Sex: male (Groin hernias are about 10 times more common in

men. But, femoral hernias are more common in women.) Increased pressure within the abdominal cavity due to:

Lifting heavy objects Straining to urinate or pass stools Severe or prolonged coughing Obesity Pregnancy

A risk factor is something that increases your chance of getting a disease or condition. Risk factors include:

Advancing age Sex: male (Groin hernias are about 10 times more common in

men. But, femoral hernias are more common in women.) Increased pressure within the abdominal cavity due to:

Lifting heavy objects Straining to urinate or pass stools Severe or prolonged coughing Obesity Pregnancy

DiagnosisDiagnosis

Physical Exam and PEPhysical Exam and PE

InspectionInspection

Patient upright Look for

Asymmetry in inguinal area Bulge or mass at inguinal

area Mass at the scrotum Mass below the inguinal

ligament

By inspection, determine if reducible or incarcerated

Patient upright Look for

Asymmetry in inguinal area Bulge or mass at inguinal

area Mass at the scrotum Mass below the inguinal

ligament

By inspection, determine if reducible or incarcerated

PalpationPalpation

Tip of index finger placed at most dependent part of the scrotum

Direct to the external inguinal ring

Ask patient to strain Indirect hernia

Bulge will progress from a lateral to medial direction and push against the fingertip

Direct hernia Bulge will push against the

pulp of the finger through the floor of the inguinal canal

Tip of index finger placed at most dependent part of the scrotum

Direct to the external inguinal ring

Ask patient to strain Indirect hernia

Bulge will progress from a lateral to medial direction and push against the fingertip

Direct hernia Bulge will push against the

pulp of the finger through the floor of the inguinal canal

IncarceratedIncarcerated

Irreducible mass Manipulation not

effective Taxis

Cute or chronic Omentum and fascia

are the structures that herniate

Irreducible mass Manipulation not

effective Taxis

Cute or chronic Omentum and fascia

are the structures that herniate

StrangulatedStrangulated

Vascularity of the herniated viscus is compromised, usually at the neck

Hernias with small orifices and voluminous sacs

Severe pain, tenderness, erythema Initially incarcerated Testis has no rugae Auscultate the scrotum

Vascularity of the herniated viscus is compromised, usually at the neck

Hernias with small orifices and voluminous sacs

Severe pain, tenderness, erythema Initially incarcerated Testis has no rugae Auscultate the scrotum

Asymptomatic patient PE and history enough

Symptomatic patient Dull ache in groin or body area with lifting or

straining but without an obvious lump Cough

Incerase abdominal pressure to palpate the mass

Asymptomatic patient PE and history enough

Symptomatic patient Dull ache in groin or body area with lifting or

straining but without an obvious lump Cough

Incerase abdominal pressure to palpate the mass

UltrasonographyUltrasonography

Differentiate masses in groin or abdominal wall or in differentiating testicular sources of swelling

Incarcerated or strangulated hernia Upright chest radiograph to

exclude free air (rare) Flat and upright abdominal

film to diagnose small bowel obstruction

Identify areas of bowel outside the abdominal cavity

Differentiate masses in groin or abdominal wall or in differentiating testicular sources of swelling

Incarcerated or strangulated hernia Upright chest radiograph to

exclude free air (rare) Flat and upright abdominal

film to diagnose small bowel obstruction

Identify areas of bowel outside the abdominal cavity

CT ScanCT Scan

Diagnose a spigelian or obturator hernia

Inability to obtain a good examination because of body habitus

Diagnose a spigelian or obturator hernia

Inability to obtain a good examination because of body habitus

HerniographyHerniography

When clinical diagnosis is uncertain

Injection of contrast material into abdominal or peritoneal cavity

Diagnostic radiography of pelvic region to outline the anatomy of the pelvic floor and its peritoneal reflections

When clinical diagnosis is uncertain

Injection of contrast material into abdominal or peritoneal cavity

Diagnostic radiography of pelvic region to outline the anatomy of the pelvic floor and its peritoneal reflections

The contrast medium fills a right-sided direct inguinal hernia with a narrow neck, extending from the medial inguinal fossa. (Courtesy O. Ekberg, MD, Department of Radiology, University Hospital, Malmo, Sweden.)

Nyhus ClassificationNyhus ClassificationType Description

Type I Indirect hernia, normal internal ring

Type II Indirect hernia, enlarged internal ring, inguinal floor intact

Type IIIA Direct hernia

Type IIIB Indirect hernia, enlarged internal ring, destruction of internal floor

Type IIIC Femoral hernia

Type IV Recurrent hernia

Gilbert ClassificationGilbert ClassificationType Description

Type I Small, indirect (<1.5 cm)

Type II Medium, indirect, (1.5 cm to 4 cm)

Type III Large, indirect (>4cm)

Type IV Entire floor, direct

Type V Diverticular, direct

Type VI Combined

Type VII Femoral

Differential DiagnosisDifferential Diagnosis

Lymphoma Testicular tumor Varicocoele Epididymitis Testicular torsion Hydrocoele Undescended testis Lipoma of the cord

Lymphoma Testicular tumor Varicocoele Epididymitis Testicular torsion Hydrocoele Undescended testis Lipoma of the cord

Femoral artery aneurysm

Lymphadenitis Hidradenitis Sebaceous cyst Psoas abscess Hematoma

Femoral artery aneurysm

Lymphadenitis Hidradenitis Sebaceous cyst Psoas abscess Hematoma

Differential DiagnosisDifferential Diagnosis

Testicular tumor Hard mass

Varicocoele Dilated vessels present with increased blood flow

Epididymitis Painful unlike in hernia, unless incarcerated

Testicular torsion Severe pain usually at night

Testicular tumor Hard mass

Varicocoele Dilated vessels present with increased blood flow

Epididymitis Painful unlike in hernia, unless incarcerated

Testicular torsion Severe pain usually at night

THERAPEUTIC PLANSTHERAPEUTIC PLANS

Indirect Inguinal Hernia

Complete Type

Indirect Inguinal Hernia

Complete Type

Therapeutic PlanTherapeutic Plan

No medical treatment, only surgical treatment

While awaiting surgery, some patients may wear a device called a truss, which puts pressure on the hernia and keeps it under control

No medical treatment, only surgical treatment

While awaiting surgery, some patients may wear a device called a truss, which puts pressure on the hernia and keeps it under control

Therapeutic PlanTherapeutic Plan

An operation in which the hernia sac is removed without any repair of the inguinal canal is described as a 'herniotomy‘

Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous material is used for reinforcement

An operation in which the hernia sac is removed without any repair of the inguinal canal is described as a 'herniotomy‘

Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous material is used for reinforcement

HERNIORRHAPYHERNIORRHAPY

Surgical correction of an indirect inguinal hernia

The surgery may be a standard open procedure through an incision large enough to access the hernia

A laparoscopic procedure performed through tiny incisions, using an instrument with a camera attached (laparoscope) and a video monitor to guide the repair

Surgical correction of an indirect inguinal hernia

The surgery may be a standard open procedure through an incision large enough to access the hernia

A laparoscopic procedure performed through tiny incisions, using an instrument with a camera attached (laparoscope) and a video monitor to guide the repair

HERNIORRHAPYHERNIORRHAPY

the patient is typically given a light general anesthesia of short duration

Laparoscopic procedures are conducted using general anesthesia

The procedure is often performed in an outpatient facility with local anesthesia and patients can walk away the same day, with little restrictions in activity

the patient is typically given a light general anesthesia of short duration

Laparoscopic procedures are conducted using general anesthesia

The procedure is often performed in an outpatient facility with local anesthesia and patients can walk away the same day, with little restrictions in activity

HERNIORRHAPYHERNIORRHAPY

the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis

In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed

the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis

In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed

HERNIORRHAPYHERNIORRHAPY

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region

HERNIORRHAPYHERNIORRHAPY

some popular techniques include; Lichtenstein repair (flat mesh patch placed on

top of the defect) Plug and Patch (mesh plug placed in the defect

and covered by a Lichtenstein-type patch) Kugel (mesh device placed behind the defect) Prolene Hernia System (2-layer mesh device

placed over and behind the defect)

some popular techniques include; Lichtenstein repair (flat mesh patch placed on

top of the defect) Plug and Patch (mesh plug placed in the defect

and covered by a Lichtenstein-type patch) Kugel (mesh device placed behind the defect) Prolene Hernia System (2-layer mesh device

placed over and behind the defect)

HERNIORRHAPYHERNIORRHAPY

HERNIORRHAPY: AFTERCARE

HERNIORRHAPY: AFTERCARE

The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon

Patients should also report a fever, and men should report any pain or swelling of the testicles

The surgeon may remove the outer sutures in a follow-up visit about a week after surgery

The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon

Patients should also report a fever, and men should report any pain or swelling of the testicles

The surgeon may remove the outer sutures in a follow-up visit about a week after surgery

HERNIORRHAPY: AFTERCARE

HERNIORRHAPY: AFTERCARE

Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair

To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery

Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair

To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery