A lump in the grion Flashcards
What is the area of the groin
- anterior superior illaic spine to the scrotum
where is the deep ring
- midpoint at the inguinal ligament
what is the midpoint of the midinguinal point
- femoral artery
What should you ask in a history for the lump in a groin
- site of swelling
- duration
- how did it start
- pain
- changes in size
- associated symptoms
- any other lumps elsewhere
- previous history of lumps
- past medical history
- family history
- drugs
- social history
- review of systems
How do you examin the lump
6 Ss
- site
- size
- shape
- surface
- conSistency
- fieSity (fixity - attached to any other structures)
What questions should you ask yourself on groin examination
- can i get above it
- is it reducible
- does it relate to anatomical landmarks
- does it have a cough impulse
- is it pulsatile
- does it transilluminate
- can i feel the testis separate from the lump
- other lumps - such as lypmhadenoapthy
What are the differential diagnosis for lumps in the groin
- Soft tissue lumps - lipoma, sebaceous cyst, abscess
- hernia - femoral or inguinal
- femoral artery aneurysm - expanding and pulsatile
- saphena varix - comproendable, palpable thrill medial to femoral artery
- enlarged lymph node - often multiple, mobile, firm and tender
- undescended tested - empty scrotum
- psoas abscess - fluctuant swelling lateral to an artery
what is a saphena varix
- varice vein at the saphena femoral junction
What is a hernia
- the abnormal protrusion of a viscus or part of a viscus through its normal coverings
what are the types of hernia
- femoral
- inguinal
- incisional
- umbilical
What are hernias caused by
Combination of increasing abdominal cavity pressures and decreasing abdominal wall strength
E.g.
- heavy lifiting
- cough/chronic lung disease
- chronic constipation
- urinary outflow obstruction
- ascities
What do you describe when talking about a hernia
- location
- reducible or irreducible
- incacerated
- strangulated
- special hernias
what are the two types of inguinal hernia
- Direct
- Indirect
What is the difference between a femoral hernia and inguinal hernia in relation to the pubic tubercle
Femoral hernia
- lateral and below to the pubic tubercle
Inguinal
- medial and above the pubic tubercle
What is an incacerated irreducible hernia
- intestine is trapped within the hernia sac and cannot be pushed back but the content is viable as it still recieves a blood supply
What is a strangulated hernia
- Intestine is trapped and the vascular supply to that loop of bowel is compromised therefore ischaemia occurs
- if the hernia is stuck in the sac the blood can enter but if the venous drainage is reduced swelling occurs and the blood supply is cut of
What are the complications of hernia
- Small bowel obstruction
What should you do if hernia causes small bowel obstruction
- Typical symptoms of obstruction
- Hernia irreducible
- resuscitate
- emergency surgery
What are the typical symptoms of obstruction
- vomiting
- abdominal pain
- abdominal distension
- absolute consitpation
What happens if the straugulated hernia is not repaired
- Narrow necked hernia
- tender irreducible red
- tachycardia and pyrexia
- WCC raised
- gangerous
Define an indirect inguinal hernia
- inguinal hernias pass through the deep ring, transverse the canal and exit through the superficial ring
Define a direct hernia
- direct hernia pass directly through the abdominal wall to bulge through the superficial ring
describe how an indirect inguinal hernia is caused
Congential
- passes through patent processus vaginalis whcih should close before birth, following path of the testes during intra uterine development
- hernia usually descend into the scrotum
- males>females
Acquired
- passes through the deep and superficial ring
- can occur at any age but more common in older people
- often descend into scrotum
What happens in a direct inguinal hernia
- protrude through abdominal wall in hasselbach’s triangle
- traversalis fascia forms a hernia sac
- abdominal wall is slightly thinner here
- usually occurs in middle age and eldelry who have weaker abdominal wall
What makes up hasselbacks triangle
- inguinal ligament
- inferior epigastric vessels
- rectus abdominis
inguinal hernias are commoner than
inguinal hernias are commoner than femoral hernias in women
What is the management of inguinal hernias
- Elective or emergency
- conservatively or surgical
- laparoscopic or open surgery
How does open mesh repair work for inguinal hernias
- can be performed under local anaesthetic
- hernia sac is reduced or excised
- mesh is inserted to reinforce the posterior inguinal canal
What is laparoscopic repair of an inguinal hernia recommended for
- recurrent and bilateral inguinal hernia
- reduced risk of chronic pain due to nerve injuries
- more expensive
what happens to cause a femoral hernia
femoral hernia goes through the femoral canal and femoral ring
when do you get symptoms of a femoral hernia
- when they strangulate or incarcerate
What is risk of strangulation of a femoral hernia
- 22% at 3 months and 45% at 21 months
Describe the lump in a femoral hernia
- approximatley 2cm
what can strangulation lead to
- ischaemia and perforation
What is the managemnet of femoral hernias
- should be referred promptly for repair as an elective proceudre
- femoral hernias are not suitable for truss
- usually requires suture>mesh>laproscopic
What is richters hernia
- part of the bowel well incarcerated in hernia and can strangulate
- strangulated but not obstructed
what is an incarceration hernia
- Contents of hernia sac are stuck inside by adhesions
Describe the types of surgery that can be used for repair of a femoral hernia
- Herniotomy - ligation and excision of the sac
- Herniorrhaphy - repair of hernia defect
Why is a femoral hernia likely to be irreducible and strangulated
- due to the rigidity of the canal’s borders
How does the femoral hernia present
- mass in the upper thigh or above the inguinal ligament where it points down the leg
What are the differential diagnosis of a femoral hernia
- inguinal hernia
- saphena varix
- enlarged Cloquet’s node
- Lipoma
- femoral aneurysm
- Psoas abscess
Where does a paraumbilical hernia occur
- occurs just above or below the umbilicus - omentum or bowel herniates through the defect
What are the risk factors for a paraumbilical hernia
- obesity
- ascites
How do you treat a paraumbilical hernia
- repair of the rectus sheath (mayo repair)
Where does an epigastric hernia pass
- passes through the line alba above the umbilicus
what is an incisional hernia
- following breakdown of muscle closure after surgery
How do you repair an incisional hernia
- mesh repair decreases recurrence but increases risk of infection over sutures
What is a spigelian hernia
- occur through the line semilunaris at the lateral edge of there rectus sheath, below and lateral to the umbilicus
What is a lumbar hernia
- occur through the interior or superior lumbar triangles in the posterior abdominal wall
What is Maydl’s hernia
- involves a herniating double loop of bowel; the strangulated portion may reside as a single loop inside the abdominal cavity
What is Littres hernia
- hernial sacs containing strangulated Meckel’s diverticulum
What is an obturator hernia
- occur through the obturator canal; typically presents as pain along the medial side of the thigh in a thin women
What is a sciatic hernia
- pass through a lesser sciatic foramen; GI obstruction and +- gluteal mass
What is a sliding hernia
Contain a partially extra-peritoneal structure (e.g. caecum on the right and sigmoid colon on the left); sac does not completely surround the contents
What is gastroschisis
protrusion of abdominal contents through a defect in anterior abdominal wall to the right of the umbilicus; prompt surgical repair required
What is exomphalos
Abdominal contents found outside the abdomen, covered in a three-layer membrane consisting of peritoneum, Wharton’s jelly, and amnion; surgical repair less urgent because the bowel is protected by these membranes
Where is the deep ring
- this is the mid-point of the inguinal ligament - 1.5cm above the femoral pulse
Where is the superficial ring
= split in the external oblique aponeurosis just superior and medial to the pubic tubercle
What are the predisposing conditions to inguinal hernias
- males
- chronic cough
- constipation
- urinary obstruction
- heavy lifting
- Ascites
- past abdominal surgery (e.g. damage to the iliohypogastric nerve during appendectomy)
How should you conduct an examination for inguinal hernias
- look for previous scars
- feel the other side (more common on the right)
- examine the external genitialia
- is the lump visible - if so, ask if the patient can reduce it, if he cannot make sure it is not a scrotal lump, ask the patient to cough - appears above and medial to the pubic tubercle
- if no lump is visible feel for cough impulse
- repeat examination with the patient standing
How do you distinguish direct from indirect hernias
- reduce the hernia and occlude the deep inguinal ring with two fingers
Ask the patient to cough or stand
- if the hernia is restrained it is indirect
- if the hernia is not it is direct
- Gold standard for determining type of inguinal hernia is at surgery; direct hernias arise medial to the inferior epigastric vessels, indirect hernia are lateral
What lifestyle advice do you give someone with a hernia
- weight loss
- stop smoking
What should patients be warned about pre op to a hernia
- warn that hernias may recur
- patients should be counselled about possibility of chronic pain post-op
When is a mesh repair of a hernia contraindicated
- strangulated hernia
- contamination with pus/bowel contents
How does a mesh repair work
- Polypropylene mesh reinforces the posterior wall
- Recurrence rate is less than with other methods (eg <2% vs 10%)
How long does it take to return to work after a hernia
- rest for 4 weeks and convalescence over 8 weeks with open approaches
- laparoscopic repairs may allow return to manual work and driving in less than 2 weeks if all is well
What are the complications of a strangulated hernia
- Ischaemia
- perforation
- sepsis
What is the only treatment for strangulated hernia
- Surgical emergency
What are the complications with an open repair of a hernia
- Early: Bruising and wound infections
- Late: chronic pain and recurrence
with hernias you should treat…
Medically fit patients even if they are asymptomatic
