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CASE PRESENTATION CASE PRESENTATION & DISCUSSION ON & DISCUSSION ON INGUINOSCROTAL INGUINOSCROTAL
MASSMASS
martinjosephscabahugmdmartinjosephscabahugmd
General DataGeneral Data
C.P.C.P.5959--yearyear--oldold
malemaleSampalocSampaloc, Manila, Manila
Chief complaintChief complaint
InguinoscrotalInguinoscrotal mass on the rightmass on the right
History of Present IllnessHistory of Present Illness2 yrs 2 yrs bulging inguinal massbulging inguinal mass
5x8cm5x8cmstraining, prolonged standingstraining, prolonged standingreducible reducible ((--) pain, fever) pain, fever((--) changes in bowel movement) changes in bowel movement((--) urinary symptoms) urinary symptoms((--) respiratory symptoms) respiratory symptoms
10 months PTA10 months PTA increase size of increase size of mass, mass, reaches the scrotal areareaches the scrotal area
Persistence of symptomsPersistence of symptoms
ConsultConsult
AdmissionAdmission
Past Medical Past Medical HxHx::
((--) ) HypertentionHypertention((--) Diabetes Mellitus) Diabetes Mellitus((--) Bronchial Asthma ) Bronchial Asthma ((--) Heart ) Heart DisaeseDisaese
Physical ExaminationPhysical Examination
General Survey: General Survey: Conscious, coherent, ambulatoryConscious, coherent, ambulatorynot in not in cardiorespiratorycardiorespiratory distressdistress
BP130/90BP130/90 HR 81HR 81 RR 19RR 19 T 37.1T 37.1C&LC&L symmetrical chest expansionsymmetrical chest expansion
no retractions, clear breath soundsno retractions, clear breath sounds
Heart:Heart:normal rate regular rhythm, (normal rate regular rhythm, (--) thrills, ) thrills, murmurmurmur
Abdomen:Abdomen:flat, NABS, soft, non tender, flat, NABS, soft, non tender, no no organomegalyorganomegaly
InguinoInguino scrotal mass rightscrotal mass rightInguinal ring 4.5 cmInguinal ring 4.5 cmReducibleReducibleSoft Soft ((--) bowel sounds) bowel sounds((--) ) transilluminationtransillumination((--) ) erythemaerythema((--) tenderness) tenderness
Salient featuresSalient features
--5959--yearyear--old Maleold Male--inguinoscrotalinguinoscrotal massmass--ReducibleReducible--Noted when patient strains &Noted when patient strains &
prolonged standingprolonged standing--Soft, nonSoft, non--tendertender-- ((--) bowel sounds) bowel sounds-- ((--) ) transilluminationtransillumination
4.5 cm external inguinal ring
INGUINOSCROTAL MASS, RIGHT
INFLAMMATORY NON INFLAMMATORY
INGUINOSCROTAL MASS, RIGHT
INFLAMMATORY
Epididymoorchitis Inguinoscrotalabscess
Lymphadenopathy
Swelling and rapid Swelling and rapid progression of painprogression of painfever, chillsfever, chillsredness, edematousredness, edematous
Multiple, Multiple, tendertender
INGUINOSCROTAL MASS, RIGHT
NON INFLAMMATORY
Malignant Non-malignant
INGUINOSCROTAL MASS, RIGHT
NON INFLAMMATORY
Malignant Non-malignant
INGUINOSCROTAL MASS, RIGHT
NON INFLAMMATORY
Malignant
Soft tissue Soft tissue SarcomaSarcomaLarge size, Large size, superficial or deepsuperficial or deep
FibrosarcomaFibrosarcomaSubcutaneous Subcutaneous fat fat Disorganized Disorganized growthgrowth
LyposarcomaLyposarcomaDeep muscleDeep muscle
Testicular Testicular TumorTumorNodule, firm, Nodule, firm, nonnon--tendertender
INGUINOSCROTAL MASS, RIGHT
NON INFLAMMATORY
Non-malignant
Soft tissueSebaceous cystsLipomaLipoma of the cordSpermatocoeleTorsion of the testis
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
Swelling and rapid Swelling and rapid progression of painprogression of painfever, chillsfever, chills
red, edematousred, edematous
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
Multiple, tender Multiple, tender Obvious are of Obvious are of inflammationinflammation
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
Soft tissue Soft tissue SercomaSercomaLarge size, superficial Large size, superficial or deepor deep
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
FibrosercomaFibrosercomaSubcutaneous fat Subcutaneous fat Disorganized growthDisorganized growth
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
LyposercomaLyposercomaDeep muscleDeep muscle
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Lipoma of the cord
•Sebaceous cysts
hernia
Testicular TumorTesticular TumorNodule, firm, nonNodule, firm, non--tendertender
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Sebaceous cysts
•Lipoma
•Lipoma of the cord
•Spermatocoele
•Torsion of the testis
hernia
No cough impulseNo cough impulse
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Sebaceous cysts
•Lipoma
•Lipoma of the cord
•Spermatocoele
•Torsion of the testis
hernia
Cyst of Cyst of reterete testestestesCystic massCystic mass+ transillumination+ transilluminationbilateralbilateral
Inguinoscrotal mass right
inflammatory Non-inflammatory
Epididymoorchitis
Inguinoscrotal abscess
Lymphadenopathy
malignant Non-malignant
Soft tissue
•Sebaceous cysts
•Lipoma
•Lipoma of the cord
•Spermatocoele
•Torsion of the testis
hernia
Sudden onset of painSudden onset of painScrotal enlargement Scrotal enlargement with edemawith edema
Hernia
direct indirectHistory:
•55M, Recurrent bulging mass, inguinosrotal area, R
•Aggravated by straining, relieved by lying down
PE:
•inguinoscrotal mass, R•Soft, non-tender, reducible
•No transillumination
•+ cough impulse
•No bowel sound
Prevalence
•Indirect, more common
•Rutledge report, 1,437 patients
•60% indirect
•36% direct
•4% femoral•Lichtenstein report
• 44.4% Indirect•43.1% direct•12.5% others
SurgicalSurgical5%5%
Secondary Secondary
Direct InguinalDirect Inguinal
HerniaHernia
SurgicalSurgical95%95%
PrimaryPrimary
Indirect Indirect Inguinal Inguinal
HerniaHernia
TreatmentTreatmentCertaintyCertaintyImpressionImpression
ParaclinicalParaclinical Diagnostic ProcedureDiagnostic Procedure
Do I need Do I need paraclinicalparaclinical procedure?procedure?
Certain of my primary diagnosis Certain of my primary diagnosis pattern recognitionpattern recognitionprevalenceprevalence
NO.NO.
Goal of TreatmentGoal of Treatment
Reduce herniated organ/bowelReduce herniated organ/bowel
repair defect repair defect ≥≥4cm4cmLigation of the sacLigation of the sac
Treatment OptionsTreatment Options
There are at present three general options for There are at present three general options for the surgical repair of indirect inguinal hernia, the surgical repair of indirect inguinal hernia, namely: namely:
open repair with mesh grafting, open repair with mesh grafting, open repair without mesh grafting, open repair without mesh grafting, laparoscopic repair with mesh grafting laparoscopic repair with mesh grafting
Not availableNot availableP 8000P 8000--P10000P10000
Intra Intra abdominal abdominal complicationcomplication
samesameLAPAROLAPARO--SCOPICSCOPIC
Available most of Available most of the timethe timeP 5000P 5000Graft rejectionGraft rejection
RR 0.2%RR 0.2%Low Low
recurrence raterecurrence rateLess postLess post--op op
painpainEasy to Easy to
performperformEarly back to Early back to
workwork
OPEN WITH OPEN WITH MESHMESH
AvailableAvailableP 2000P 2000InfectionInfectionrecurrencerecurrence
Repair floor Repair floor anatomicalanatomical
OPEN OPEN WITHOUT WITHOUT MESHMESH
AVAILABILITYAVAILABILITYCOSTCOSTRISKRISKBENEFITBENEFIT4 cm internal 4 cm internal ringring
At present, although open repair with mesh At present, although open repair with mesh and laparoscopic repair are now commonly and laparoscopic repair are now commonly done especially in developed countries, the done especially in developed countries, the controversy is far from being settled because controversy is far from being settled because of the tendency for blanket recommendations of the tendency for blanket recommendations and randomized controlled trials and metaand randomized controlled trials and meta--analyses showing conflicting results, some analyses showing conflicting results, some favoring open repair without mesh (1,5,7).favoring open repair without mesh (1,5,7).
others favoring open repair with mesh (9others favoring open repair with mesh (9--10) 10) and still others, laparoscopic approach (11and still others, laparoscopic approach (11--13). 13).
Protocol on HerniaProtocol on Hernia
A departmental consensus was made using A departmental consensus was made using the diameter of the external inguinal ring (>4 the diameter of the external inguinal ring (>4 centimeters) as predictor for preoperative centimeters) as predictor for preoperative preparation of mesh in patients for indirect preparation of mesh in patients for indirect inguinal hernia repair. inguinal hernia repair.
Protocol on HerniaProtocol on Hernia
The protocol was then prospectively validated The protocol was then prospectively validated on adult patients with unilateral indirect inguinal on adult patients with unilateral indirect inguinal hernia from January to August, 2003 using intrahernia from January to August, 2003 using intra--operative measurement of the external and operative measurement of the external and internal inguinal ring as the indicator for mesh internal inguinal ring as the indicator for mesh grafting. grafting.
The department believes that there are The department believes that there are indications for the use of mesh in the indications for the use of mesh in the treatment of indirect inguinal hernia. treatment of indirect inguinal hernia. Recurrence and large size of hernia defect are Recurrence and large size of hernia defect are the basic indications the basic indications favoring open repair without mesh (1,5,7) favoring open repair without mesh (1,5,7) open repair with mesh (4, 13) and still others, open repair with mesh (4, 13) and still others, laparoscopic approach (3, 6, 11). laparoscopic approach (3, 6, 11).
PrePre--op preparationop preparation
Psychological supportPsychological supportScreen for previous medical problemScreen for previous medical problem
HypertensionHypertensionMetoprololMetoprolol 50mg BID x 2 weeks50mg BID x 2 weeks
Optimize patientOptimize patient’’s conditions conditionConsentConsentPreparation of materialsPreparation of materials
Operative TechniqueOperative Technique
Oblique incision over LangerOblique incision over Langer’’s lines lineExternal oblique aponeurosis openedExternal oblique aponeurosis opened
IntraIntra--op findingsop findings
HernialHernial sac located sac located anteromediallyanteromedially to the to the cord containing cord containing omentumomentumInternal ring measures 4 Internal ring measures 4 cm in widest diametercm in widest diameter
Operative Technique Operative Technique
•Spermatic cord identified
•Hernial sac identified and opened
•Hernial contents reduced
•Ligation of the hernialsac
Operative TechniqueOperative Technique
•Mesh approximated over the defect
•Medial corner of the mesh overlaps the pubic bone
•And sutured with interrupted prolene 3-0
Operative TechniqueOperative Technique
Spermatic cord placed between the two tails of the mesh
Operative TechniqueOperative Technique
Two tails crossed –over and sutured together
Operative TechniqueOperative Technique
•Hemostasis
•Instrument and sponge checked
•Fascial closure with vicryl 0
•Subcuticular skin closure with vicryl 4-0
•Dry sterile dressing
Final DiagnosisFinal Diagnosis
Indirect Inguinal Hernia, RightIndirect Inguinal Hernia, RightGrade IIIGrade III--BB
PostPost--op supportop support
AnalgesiaAnalgesiaKetoprofenKetoprofen 100mg TIV q6 x 3 doses100mg TIV q6 x 3 dosesshifted to oral Paracetamol 500mg q4shifted to oral Paracetamol 500mg q4
Early ambulationEarly ambulationDiet as toleratedDiet as toleratedDaily wound careDaily wound careDischarged on the 2nd PODDischarged on the 2nd POD
Prevention and HealthPrevention and Health
Anticipate complicationsAnticipate complicationsAdequate Adequate hemostasishemostasisAvoid vascular compromiseAvoid vascular compromiseAvoid infectionAvoid infectionAvoid dehiscenceAvoid dehiscence
Prevention and HealthPrevention and Health
Alive patientAlive patientPatientPatient’’s health problem resolveds health problem resolvedNo complaintNo complaintNo disabilityNo disabilityNo medical suitNo medical suitSatisfied patientSatisfied patient
PathophysiologyPathophysiology
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Inguinal Hernia
genetic
•Autosomal dominant
•Preferential paternal factor
•Multiple, familial or part of connective tissue disorder
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Inguinal Hernia
metabolic
•Decrease hydroxyprolene
•Altered collagen precipitability and impaired hydroxylation
•Increase elastase, decrease anti-proteolyticinhibitor capacity (emphysema)
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Inguinal Hernia
Muscle Deficiency
•Congenital or acquired insufficiency of internal oblique expose the deep ring and inguinal floor
t Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Inguinal Hernia
Physical exertion
•Increase in intraabdominal pressure
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Inguinal Hernia
Physical exertion
•Increase in intraabdominal pressure
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Inguinal Hernia
Patent Processus Vaginalis
•Evagination of the peritoneum
•60% at two months, 40% at two years, 30% adult
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Inguinal Hernia
Fascial factor
•Myopectineal Orifice Fruchaud
•Boundaries: superior, internal oblique + transverse abd muscle; lateral, iliopsoas; medial, rectus; inferior, pecten
•Transversalis fascia
Inguinal Hernia
genetic
Physical exertion
metabolic
Muscle deficiency
Fascial factor
Processus vaginalis
Myopectineal orifice of Fruchaud
Internal oblique and transverse abdominis
Ileopsoas m.
Pecten pubis
NyhusNyhus ClassificationClassification
Type IType I Indirect, smallIndirect, smallType IIType II Indirect, mediumIndirect, mediumType IIIType III A. DirectA. Direct
B. Indirect, largeB. Indirect, largeC. FemoralC. Femoral
Type IVType IV RecurrentRecurrent
Type 1Type 1 Indirect, smallIndirect, small
Type IIType II Indirect, mediumIndirect, medium
Type IIIType III A. DirectA. Direct
B. Indirect, largeB. Indirect, large
Type III CType III C
Unified ClassificationUnified Classification
Unified ClassificationUnified Classification
Recurrent herniaRecurrent herniaType 4Type 4Femoral herniaFemoral herniaCC
Indirect inguinal hernia. Internal ring dilated. Posterior Indirect inguinal hernia. Internal ring dilated. Posterior wall defectivewall defectiveBB
Direct inguinal herniaDirect inguinal herniaAAPosterior wall defectPosterior wall defectType 3Type 3
Indirect hernia with dilated internal ring. Posterior wall Indirect hernia with dilated internal ring. Posterior wall intactintactType 2Type 2
Indirect hernia with normal internal ringIndirect hernia with normal internal ringType 1Type 1
NyhusNyhus Classification of Inguinal Classification of Inguinal Hernias.Hernias.
GilbertGilbert’’s Classification of Inguinal s Classification of Inguinal Hernias. Hernias.
Femoral herniaFemoral herniaType VIIType VIIPantaloon herniaPantaloon herniaType VIType VI
Direct Direct diverticulardiverticular defect 1defect 1--2 cm 2 cm suprapubicsuprapubic, but anywhere , but anywhere along flooralong floor
Type VType VDefective canal floor, ring is soundDefective canal floor, ring is soundType IVType IV
Ring > 4 cm, sliding component, displaces inferior Ring > 4 cm, sliding component, displaces inferior epigastricepigastric vesselsvessels
Type IIIType IIIIndirect, ring < 4 cmIndirect, ring < 4 cmType IIType IIIndirect, tight ring, sac any size, reducibleIndirect, tight ring, sac any size, reducibleType IType I
DescriptionDescriptionTypeType
ReferencesReferences
1.1. BarthBarth R J, R J, BurchardBurchard K W, K W, TostesonTosteson A et al. ShortA et al. Short--term outcome after mesh or term outcome after mesh or ShouldiceShouldiceherniorrhaphyherniorrhaphy: A : A randomisedrandomised, prospective study. , prospective study. Surgery. 1998; 123: 121Surgery. 1998; 123: 121--126. 126.
2.2. Cameron J. Current Surgical Therapy. VII Ed. 2001; Cameron J. Current Surgical Therapy. VII Ed. 2001; 600600--616.616.
3.3. Chung RS, Rowland Chung RS, Rowland DY.MetaDY.Meta--analyses of analyses of randomized controlled trials of laparoscopic randomized controlled trials of laparoscopic vsvsconventional inguinal hernia repairs. conventional inguinal hernia repairs. SurgSurg EndoscEndosc. . 1999; 13(7):6891999; 13(7):689--94.94.
4.4. Fitzgibbons R. et al. Fitzgibbons R. et al. HyhusHyhus and Condonand Condon’’s Hernia. V s Hernia. V Ed. 2002;, 3Ed. 2002;, 3--7; 717; 71--79; 14979; 149--156.156.
5. 5. FriisFriis E, E, LindahlLindahl F. The tensionF. The tension--free free hernioplastyhernioplastyin a randomized trial. Am L in a randomized trial. Am L SurgSurg. 1996; 172 (4): . 1996; 172 (4): 315315--99
6. 6. Go PM. Overview of randomized trials in Go PM. Overview of randomized trials in laparoscopic inguinal hernia repair. laparoscopic inguinal hernia repair. SeminSeminLaparoscLaparosc SurgSurg. 1998; 5(4): 238. 1998; 5(4): 238--41.41.
7.7. PavlidisPavlidis TE, TE, AtmatzidisAtmatzidis KS, KS, LazardisLazardis CN, CN, PapaziogasPapaziogas BT, BT, MakrisMakris JG. Comparison between JG. Comparison between modern mesh and conventional nonmodern mesh and conventional non--mesh mesh methods of inguinal hernia repair. Minerva methods of inguinal hernia repair. Minerva ChirChir. . 2002; 57(1): 72002; 57(1): 7--1212
8.8. PingulPingul J. et al. Health Process Evidence based J. et al. Health Process Evidence based Clinical Practice Guidelines in Patient with Clinical Practice Guidelines in Patient with Inguinal HerniaInguinal Hernia
9.9. ScottScott--ConnConn, C. , C. ChassinChassin’’ss Operative Strategy in Operative Strategy in General Surgery. III Ed. 747General Surgery. III Ed. 747
10. 10. Schwartz, S. et al. Principles of Surgery. VII Ed. Schwartz, S. et al. Principles of Surgery. VII Ed. 1999; 15851999; 1585-- 1609.1609.
11. 11. The EU Hernia The EU Hernia TrialistsTrialists Collaboration. Repair of Collaboration. Repair of groin hernia with synthetic mesh: metagroin hernia with synthetic mesh: meta--analysis of analysis of randomized controlled trials. Ann randomized controlled trials. Ann SurgSurg. 2002; . 2002; 235(3):322235(3):322--32.32.
12.12. VrijlandVrijland W W, van den W W, van den TolTol M P, M P, LuijendijkLuijendijk R W R W et al. et al. RandomisedRandomised clinical trial of nonclinical trial of non--mesh versus mesh versus mesh repair of primary inguinal hernia. Br J mesh repair of primary inguinal hernia. Br J SurgSurg. . 2002; 89: 2932002; 89: 293--297.297.
13.13. WantzWantz GE. Experience with the tensionGE. Experience with the tension--free free hernioplastyhernioplasty for primary inguinal hernias in men. J for primary inguinal hernias in men. J Am Am CollColl SurgSurg. 1996; 183(4): 351. 1996; 183(4): 351--6.6.
BassiniBassini RepairRepair
Uses interupted sutures
ShouldiceShouldice RepairRepair
Uses continuous, imbricated sutures
McVayMcVay’’ss RepairRepair
Approximates the transversusabdominis and the tranversalis fascia
ParaclinicalParaclinical Diagnostic ProcessDiagnostic Process
AvailabilityAvailabilityCostCostRiskRiskBenefitBenefitDiagnostic Diagnostic ProcedureProcedure
Not availableNot availableP500.00P500.00PeritonitisPeritonitisHypersensitiviHypersensitivityty
Will Will differentiate a differentiate a direct from an direct from an indirect hernia indirect hernia
herniographyherniography
Not readily Not readily availableavailable
P3000.00P3000.00Exposure to Exposure to radiationradiation
Will Will r/or/o other other causes of causes of groin massesgroin masses
CTCT--scanscan
AvailableAvailableP150.00P150.00Exposure to Exposure to radiationradiation
Will Will r/or/ointestinal intestinal obstructionobstruction
xx--ray ray
Not readily Not readily availableavailable
P300.00P300.00AcceptableAcceptableWill Will r/or/o other other causes of causes of groin massesgroin masses
ultrasoundultrasound
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