24. Groin Lump Flashcards
Where can groin lumps occur?
Psoas sheath: psoas abscess, psoas bursa
Femoral nerve: neuroma
Femoral artery: femoral aneurysm, pseudoaneurysm
Femoral vein/ saphenous: saphena varix
Lymph nodes: lymphadenopathy (infectious or malignant)
Hernial orifices: inguinal/ femoral hernia
Testicular apparatus: ectopic testis, undescended testis, hydrocele of cord
Skin: lipoma, infected abscess, sebaceous cyst
The 2 most common causes of groin lumps are?
Indirect inguinal hernia
Direct inguinal hernia
What are the key features of HPC of groin lump?
How long has it been there? Does it reduce when lying down? Changed in size? Painful? Other lumps?
What are important Qs if a hernia is suspected?
Abdominal pain?
Straining at stool, struggling to pass urine or suffering chronic cough? Does your job involve heavy lifting? (increase intra abdo pressure)
Have you had any prior operations in groin? (presidposes to incisional hernias)
What are the main risks of hernias?
Bowel obstruction
Bowel strangulation
What are important questions if infective process or malignancy are suspected?
Trauma/ infection in lower limb? (drug use, minor injuries, STIs)
Indicators of anal, scrotal, cutaneous malignancy? (lumps/ bumps)
Fever? (infection/ B symptom of lymphoma)
FLAWS
What are the key features on examination of a groin lump?
Site Tenderness/ warmth Solid/ fluctuant Pulsatile: femoral aneurysm Cough impulse Reducible Auscultation (bowel sounds)
Where is the neck of an inguinal and femoral hernia?
INGUINAL: superior + medial to pubic tubercle
FEMORAL: inferior + lateral to the pubic tubercle
Describe the appearance/ palpation of strangulated hernias, reducible hernias and groin abscesses, reactive lymph nodes + infected pseudoaneurysms?
S: Red/ inflamed
R: tender
G: warm + tender
What happens with the cough impulse? What is this diagnostic of? Why?
Hernias expand in response to increased intra-abdominal pressure caused by cough
What is saphena varix?
Dilated great saphenous vein due to incompetence at the saphenofemoral junction
What happens in the cough impulse in different types of hernias?
Direct Inguinal: expand outwards
Indirect Inguinal: expand along the path of the inguinal canal (inferomedial direction)
What types of groin lumps are reducible? What must be remembered?
Hernias, Saphena varix (rare)
Direct: superolaterally + posteriorly
Indirect: along the inguinal canal
(not all hernias are reducible)
How can you distinguish between direct and indirect hernias?
Reduce hernia+ apply pressure over deep inguinal ring + ask to cough
Direct: protrude
Indirect: only reappears once pressure removed
What is indicated by a lump that extends into the scrotum?
Indirect inguinal hernia
Which type of hernia has higher risk of strangulation?
Femoral
How does a hernia cause abdominal symptoms? What may a patient present with?
Subacute obstruction as bowel moves in + out of hernial orifice Colicky pain Abdominal distension Vomiting Absolute constipation
What is a sinus?
Blind-ended tract between an epithelial surface + a cavity lined with granulation tissue
What is a stoma?
Artificial opening of an internal tube e.g. GIT that has been brought to the surface
In which gender are femoral hernias more common?
Female
What is the difference between a reducible and irreducible hernia?
Reducible: can be pushed back into the right place
Irreducible: Cant be pushed back into the right place
A hernia be irreducible due to being…
Incarcerated
Obstructed
Strangulated
What is meant by an “incarcerated hernia”?
stuck in abnormal position due to adhesions between the hernial sac + surrounding structures or adhesions between structures within the sac
means sac is wider than neck + unable to pass through wall defect
What is meant by an “obstructed hernia”?
Neck of hernia sac provides obstruction to the passage of flow through the bowel (blood supply intact)
What is meant by a “strangulated hernia”?
Bowel becomes so constricted by the neck of the hernial sac that blood supply is compromised. Bowel necroses rapidly from ischaemia
What is in the inguinal canal?
Ilioinguinal nerve
Spermatic cord/ round ligament
What is a herniotomy?
Surgical excision of hernial sac
What is a herniorrhaphy?
Repair of a hernia using locally available tissues
What is hernioplasty?
Repair of a hernia using synthetic material e.g. mesh
Where is the mid inguinal point? What is this the surface landmark of?
Halfway between ASIS + pubic symphysis
Femoral artery
Where is the midpoint of the inguinal ligament? What surface landmark does this represent?
Halfway between ASIS + pubic tubercle
Deep inguinal ring
What is an indirect hernia?
Abdominal contents pass through deep inguinal ring, through the inguinal canal + exits via the superficial ring.
No piercing of wall of inguinal canal
What is a direct hernia caused by? What does this result in?
Weakness in posterior wall of inguinal canal.
Abdominal contents are forced through this defect + enter the inguinal canal.
