24. Groin Lump

Question 1

Where can groin lumps occur?

Answer 1

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

Question 2

The 2 most common causes of groin lumps are?

Answer 2

Indirect inguinal hernia

Direct inguinal hernia

Question 3

What are the key features of HPC of groin lump?

Answer 3

How long has it been there?
Does it reduce when lying down?
Changed in size?
Painful?
Other lumps?

Question 4

What are important Qs if a hernia is suspected?

Answer 4

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)

Question 5

What are the main risks of hernias?

Answer 5

Bowel obstruction

Bowel strangulation

Question 6

What are important questions if infective process or malignancy are suspected?

Answer 6

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

Question 7

What are the key features on examination of a groin lump?

Answer 7

Site
Tenderness/ warmth
Solid/ fluctuant
Pulsatile: femoral aneurysm
Cough impulse
Reducible
Auscultation (bowel sounds)

Question 8

Where is the neck of an inguinal and femoral hernia?

Answer 8

INGUINAL: superior + medial to pubic tubercle
FEMORAL: inferior + lateral to the pubic tubercle

Question 9

Describe the appearance/ palpation of strangulated hernias, reducible hernias and groin abscesses, reactive lymph nodes + infected pseudoaneurysms?

Answer 9

S: Red/ inflamed
R: tender
G: warm + tender

Question 10

What happens with the cough impulse? What is this diagnostic of? Why?

Answer 10

Hernias expand in response to increased intra-abdominal pressure caused by cough

Question 11

What is saphena varix?

Answer 11

Dilated great saphenous vein due to incompetence at the saphenofemoral junction

Question 12

What happens in the cough impulse in different types of hernias?

Answer 12

Direct Inguinal: expand outwards

Indirect Inguinal: expand along the path of the inguinal canal (inferomedial direction)

Question 13

What types of groin lumps are reducible? What must be remembered?

Answer 13

Hernias, Saphena varix (rare)
Direct: superolaterally + posteriorly
Indirect: along the inguinal canal
(not all hernias are reducible)

Question 14

How can you distinguish between direct and indirect hernias?

Answer 14

Reduce hernia+ apply pressure over deep inguinal ring + ask to cough
Direct: protrude
Indirect: only reappears once pressure removed

Question 15

What is indicated by a lump that extends into the scrotum?

Answer 15

Indirect inguinal hernia

Question 16

Which type of hernia has higher risk of strangulation?

Answer 16

Femoral

Question 17

How does a hernia cause abdominal symptoms? What may a patient present with?

Answer 17

Subacute obstruction as bowel moves in + out of hernial orifice
Colicky pain 
Abdominal distension 
Vomiting 
Absolute constipation

Question 18

What is a sinus?

Answer 18

Blind-ended tract between an epithelial surface + a cavity lined with granulation tissue

Question 19

What is a stoma?

Answer 19

Artificial opening of an internal tube e.g. GIT that has been brought to the surface

Question 20

In which gender are femoral hernias more common?

Answer 20

Female

Question 21

What is the difference between a reducible and irreducible hernia?

Answer 21

Reducible: can be pushed back into the right place
Irreducible: Cant be pushed back into the right place

Question 22

A hernia be irreducible due to being…

Answer 22

Incarcerated
Obstructed
Strangulated

Question 23

What is meant by an “incarcerated hernia”?

Answer 23

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

Question 24

What is meant by an “obstructed hernia”?

Answer 24

Neck of hernia sac provides obstruction to the passage of flow through the bowel (blood supply intact)

Question 25

What is meant by a “strangulated hernia”?

Answer 25

Bowel becomes so constricted by the neck of the hernial sac that blood supply is compromised. Bowel necroses rapidly from ischaemia

Question 26

What is in the inguinal canal?

Answer 26

Ilioinguinal nerve

Spermatic cord/ round ligament

Question 27

What is a herniotomy?

Answer 27

Surgical excision of hernial sac

Question 28

What is a herniorrhaphy?

Answer 28

Repair of a hernia using locally available tissues

Question 29

What is hernioplasty?

Answer 29

Repair of a hernia using synthetic material e.g. mesh

Question 30

Where is the mid inguinal point? What is this the surface landmark of?

Answer 30

Halfway between ASIS + pubic symphysis

Femoral artery

Question 31

Where is the midpoint of the inguinal ligament? What surface landmark does this represent?

Answer 31

Halfway between ASIS + pubic tubercle

Deep inguinal ring

Question 32

What is an indirect hernia?

Answer 32

Abdominal contents pass through deep inguinal ring, through the inguinal canal + exits via the superficial ring.
No piercing of wall of inguinal canal

Question 33

What is a direct hernia caused by? What does this result in?

Answer 33

Weakness in posterior wall of inguinal canal.

Abdominal contents are forced through this defect + enter the inguinal canal.