A Lump in the Groin Flashcards
Where does the spermatic cord exit through?
Superficial inguinal ring
Where does the inguinal ligament run?
Between ASIS and pubic tubercle
What is the superficial ring?
External oblique aponeurosis defect
Where is the deep ring?
Midway between pubic tubercle and ASIS
Where is the mid inguinal point?
Surface marking of femoral artery (pulse)
Between pubic symphysis and ASIS
Lateral to deep ring
Where is the inguinal canal?
Between deep ring and superficial ring
What runs underneath the inguinal ligament?
Femoral vein, artery, nerve
From medial to lateral
Where do femoral hernias develop?
Femoral canal
Medial to femoral vein
What to ask about in a history of a lump in the groin?
- site
- duration
- how did it start
- pain
- size changes
- other symptoms
- any other lumps
- previous lump history
- PMH
- FH
- drugs
- social history
- ROS
Examination of the lump
6 S’s
- site
- size
- shape
- surface
- conSistency
- ficSity (fixity)
Specific questions of lump in groin?
- can I get above it (upper border, if not then arising from inside abdomen and passing into groin)
- is it reducible (comes and goes, in morning overnight disappears)
- how it relates to anatomical landmarks
- does it have a cough impulse
- is it pulsatile
- does it transilluminate (if contain fluid they will)
- can I feel testis separate from lump
- other lumps
Soft tissue lumps
Lipoma
Sebaceous cyst
Abscess
Femoral artery lumps
Aneurysm - expanding and pulsatile
Saphena varix
Compressible
Palpable thrill medial to artery
Enlarged lymph node
Multiple often
Mobile
Firm and tender
Undescended testes
Empty scrotum
Psoas abscess
Fluctuant swelling lateral to artery
Differentials for lump in groin
Hernia Soft tissue lump Femoral artery aneurysm Saphena Varix Enlarged lymph node Undescended testes Psoas abscess
Define a hernia
Abnormal protrusion of a viscus or part of a viscus through its normal coverings
What mechanism causes hernias
Combination of increasing abdominal cavity pressures and decreasing abdominal wall strength
Causes of hernias
Heavy lifting Coughing/chronic lung disease Chronic constipation Urinary outflow obstruction Ascites
How to describe hernias
location reducible or irreducible incarcerated strangulated special hernias
Difference between femoral and inguinal hernia
Femoral arises below and lateral to pubic tubercle
Inguinal arises above and medial to pubic tubercle
What is the hernia sac made up of?
Peritoneum
Irreducible hernia define
Intestine trapped into hernia sac
Contains incarcerated intestine
Incarcerated intestine
Remains irreducible but content is viable
Not yet strangulated
Strangulated hernia
Intestine contents trapped with compromised blood supply
Progression of incarceration
Which scenarios are an emergency?
Incarceration - to prevent strangulation
Strangulated - to treat gangrenous bowel
Complications of hernia
Obstruction
Strangulation
2 commonest causes of small bowel obstructions
Hernia
Adhesions
Commonest cause of small bowel obstruction for those who have not had previous surgery
Hernia
As adhesions are rare for these individuals
Strangulation features
- narrow neck hernia
- tender
- irreducible
- red
- tachycardia
- pyrexia
- WCC raised
Tx for strangulation
Resus
Emergency surgery
Which hernias are likely to get strangulated?
Femoral
Sometimes umbilical
Indirect inguinal hernias
Features of obstruction causing hernias
- irreducible hernia,
- Tx = emergency, resuscitate
Indirect inguinal hernias
Pass through deep ring, traverse the canal and exit through superficial ring
Direct inguinal hernias
Directly through abdominal wall to bulge through superficial ring
Causes of indirect inguinal hernias
Congenital
Acquired
Congenital cause of indirect inguinal hernia
- Through patent processus vaginalis (should be closed before birth) following testes
- hernia usually descends into scrotum
- females can get it but more common in males
Acquired causes of indirect inguinal hernias
Through deep and superficial rings
Occur at any age but more common in older
Often descend into scrotum
Direct inguinal hernia mechanism
Protrude through abdominal wall in Hasselbach’s triaingle
Transversalis fascia forms hernia sac
Abdominal wall slightly thinner here
Usually in middle age and elderly who have weaker abdominal walls
Hasselbach’s triangle
Inguinal ligament
Lateral margin of rectus abdominus
Inferior epigastric vessels
Age difference direct indirect
Older Direct
Younger indirect
Frequency direct vs indirect
25% direct
75% indirect
Cause direct vs indirect
Acquired direct
Congenital indirect
Bilateral direct vs indirect
50% direct
20% indirect
Course direct vs indirect
Only medial 1/3 inguinal canal direct
Whole inguinal canal indirect
Neck of sac direct vs indirect
Wide direct
narrow indirect
Relation to inferior epigastric vessels direct vs indirect
Medial to vessels direct
Lateral to vessels indirect
Inguinal hernias more common in who?
Men
Femoral hernias more common in who
Women
What type of hernia is a woman more likely to get?
Inguinal > femoral
Management decisions of inguinal hernias
Elective or emergency
Conservative or surgical
Laparoscopic or open
TRUSS
Pad placed over hernia
For elderly mostly
Patient told hernia must be reduced before put on truss otherwise will not help at all as still risk of complications
When is it appropriate for elective management?
Patient fit enough
Having symptoms
Reducible mostly
Elective repair
When is emergency treatment appropriate?
Irreducible
Tender
When is conservative Tx appropriate?
Minimal symptoms
Easily reducible
Open mesh repair
Inguinal indirect and direct
Local anaesthetic or sometimes prefer general/spinal
Hernia sac reduced or excised
Insert mesh to reinforce posterior inguinal canal
What do you have to be careful to protect in open mesh repair?
iliohypogastric nerve
ilioinguinal nerve
genital branch of genitofemoral nerve
Laparoscopic repair
Recurrent and bilateral inguinal hernias
3 small incisions = 1 at umbilicus for camera and 2 lateral ports
Reduced chronic pain due to nerve injuries
More expensive
Smaller incisions than bilateral open repair
Features of femoral hernias
Rarer
Females more common
Through femoral canal and femoral ring
Often symptomless until strangulate or incarcerate
Higher risk of strangulation
Recommended repair promptly to avoid complications
Characteristics of a femoral hernia
Small - 2cm lump
Becomes hardened
Tender when obstructed or strangulated
If contains bowel requires immediate emergency surgery
What can strangulation lead to?
Ischaemia and perforation
Management of femoral hernias
Referred promptly for elective repair Dissection of sac and content reduction Then ligation of sac an closure Open suture favoured then mesh then laparoscopic Strangulated is surgical emergency Truss not suitable for femoral
Spigelian hernia
Emerges through linea semi lunaris (lateral border of rectus abdominus)
Amyand’s hernia
Appendix
Littre’s hernia
When Meckel’s diverticulum protrudes into inguinal hernia
Meckel’s diverticulum
In ileum
2 inches
2% of population
2 feet from ileo-caecal valve
Pantaloon hernia
Inguinal hernia with direct and indirect component
Hernia sac through deep ring and weakness in Hasselbach’s triangle
Always check at deep ring for indirect as well as direct
Maydl’s hernia
Part of loop of bowel is inside and part of outside
Internal loop may be strangulated
Loop is M shaped
Richter’s hernia
Part of bowel incarcerated in hernia and can strangulate
Anti-mesenteric border
Strangulated but not obstructed
Lumen remains patent
needs partial resection then anastomoses of healthy parts
Cough impulse
Increased in size of lump with coughing
