A Lump in the Groin Flashcards
1
Q
Where does the spermatic cord exit through?
A
Superficial inguinal ring
2
Q
Where does the inguinal ligament run?
A
Between ASIS and pubic tubercle
3
Q
What is the superficial ring?
A
External oblique aponeurosis defect
4
Q
Where is the deep ring?
A
Midway between pubic tubercle and ASIS
5
Q
Where is the mid inguinal point?
A
Surface marking of femoral artery (pulse)
Between pubic symphysis and ASIS
Lateral to deep ring
6
Q
Where is the inguinal canal?
A
Between deep ring and superficial ring
7
Q
What runs underneath the inguinal ligament?
A
Femoral vein, artery, nerve
From medial to lateral
8
Q
Where do femoral hernias develop?
A
Femoral canal
Medial to femoral vein
9
Q
What to ask about in a history of a lump in the groin?
A
- site
- duration
- how did it start
- pain
- size changes
- other symptoms
- any other lumps
- previous lump history
- PMH
- FH
- drugs
- social history
- ROS
10
Q
Examination of the lump
A
6 S’s
- site
- size
- shape
- surface
- conSistency
- ficSity (fixity)
11
Q
Specific questions of lump in groin?
A
- 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
12
Q
Soft tissue lumps
A
Lipoma
Sebaceous cyst
Abscess
13
Q
Femoral artery lumps
A
Aneurysm - expanding and pulsatile
14
Q
Saphena varix
A
Compressible
Palpable thrill medial to artery
15
Q
Enlarged lymph node
A
Multiple often
Mobile
Firm and tender
16
Q
Undescended testes
A
Empty scrotum
17
Q
Psoas abscess
A
Fluctuant swelling lateral to artery
18
Q
Differentials for lump in groin
A
Hernia Soft tissue lump Femoral artery aneurysm Saphena Varix Enlarged lymph node Undescended testes Psoas abscess
19
Q
Define a hernia
A
Abnormal protrusion of a viscus or part of a viscus through its normal coverings
20
Q
What mechanism causes hernias
A
Combination of increasing abdominal cavity pressures and decreasing abdominal wall strength
21
Q
Causes of hernias
A
Heavy lifting Coughing/chronic lung disease Chronic constipation Urinary outflow obstruction Ascites
22
Q
How to describe hernias
A
location reducible or irreducible incarcerated strangulated special hernias
23
Q
Difference between femoral and inguinal hernia
A
Femoral arises below and lateral to pubic tubercle
Inguinal arises above and medial to pubic tubercle
24
Q
What is the hernia sac made up of?
A
Peritoneum
25
Irreducible hernia define
Intestine trapped into hernia sac
| Contains incarcerated intestine
26
Incarcerated intestine
Remains irreducible but content is viable
| Not yet strangulated
27
Strangulated hernia
Intestine contents trapped with compromised blood supply
| Progression of incarceration
28
Which scenarios are an emergency?
Incarceration - to prevent strangulation
| Strangulated - to treat gangrenous bowel
29
Complications of hernia
Obstruction
| Strangulation
30
2 commonest causes of small bowel obstructions
Hernia
| Adhesions
31
Commonest cause of small bowel obstruction for those who have not had previous surgery
Hernia
| As adhesions are rare for these individuals
32
Strangulation features
- narrow neck hernia
- tender
- irreducible
- red
- tachycardia
- pyrexia
- WCC raised
33
Tx for strangulation
Resus
| Emergency surgery
34
Which hernias are likely to get strangulated?
Femoral
Sometimes umbilical
Indirect inguinal hernias
35
Features of obstruction causing hernias
- irreducible hernia,
| - Tx = emergency, resuscitate
36
Indirect inguinal hernias
Pass through deep ring, traverse the canal and exit through superficial ring
37
Direct inguinal hernias
Directly through abdominal wall to bulge through superficial ring
38
Causes of indirect inguinal hernias
Congenital
| Acquired
39
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
40
Acquired causes of indirect inguinal hernias
Through deep and superficial rings
Occur at any age but more common in older
Often descend into scrotum
41
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
42
Hasselbach's triangle
Inguinal ligament
Lateral margin of rectus abdominus
Inferior epigastric vessels
43
Age difference direct indirect
Older Direct
| Younger indirect
44
Frequency direct vs indirect
25% direct
| 75% indirect
45
Cause direct vs indirect
Acquired direct
| Congenital indirect
46
Bilateral direct vs indirect
50% direct
| 20% indirect
47
Course direct vs indirect
Only medial 1/3 inguinal canal direct
| Whole inguinal canal indirect
48
Neck of sac direct vs indirect
Wide direct
| narrow indirect
49
Relation to inferior epigastric vessels direct vs indirect
Medial to vessels direct
| Lateral to vessels indirect
50
Inguinal hernias more common in who?
Men
51
Femoral hernias more common in who
Women
52
What type of hernia is a woman more likely to get?
Inguinal > femoral
53
Management decisions of inguinal hernias
Elective or emergency
Conservative or surgical
Laparoscopic or open
54
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
55
When is it appropriate for elective management?
Patient fit enough
Having symptoms
Reducible mostly
Elective repair
56
When is emergency treatment appropriate?
Irreducible
| Tender
57
When is conservative Tx appropriate?
Minimal symptoms
| Easily reducible
58
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
59
What do you have to be careful to protect in open mesh repair?
iliohypogastric nerve
ilioinguinal nerve
genital branch of genitofemoral nerve
60
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
61
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
62
Characteristics of a femoral hernia
Small - 2cm lump
Becomes hardened
Tender when obstructed or strangulated
If contains bowel requires immediate emergency surgery
63
What can strangulation lead to?
Ischaemia and perforation
64
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
```
65
Spigelian hernia
Emerges through linea semi lunaris (lateral border of rectus abdominus)
66
Amyand's hernia
Appendix
67
Littre's hernia
When Meckel's diverticulum protrudes into inguinal hernia
68
Meckel's diverticulum
In ileum
2 inches
2% of population
2 feet from ileo-caecal valve
69
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
70
Maydl's hernia
Part of loop of bowel is inside and part of outside
Internal loop may be strangulated
Loop is M shaped
71
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
72
Cough impulse
Increased in size of lump with coughing
