Groin Lump 2

Question 1

What would a lump that expands and increases in tension during coughing suggest?

Answer 1

diagnostic of hernias

Question 2

How do you detect if lump has cough impulse?

Answer 2

put hands over lump and ask patient to cough

Question 3

How does a direct inguinal hernia react to a cough impulse?

Answer 3

expand outwards (through the defect in the posterior wall of the inguinal canal)

Question 4

How does an indirect inguinal hernia react to a cough impulse?

Answer 4

expand along path of the inguinal canal in an inferiomedial direction

Question 5

Which are the only reducible groin lumps?

Answer 5

1. hernias

2. saphenia varix

Question 6

How does a saphenia varix reduce?

Answer 6

rare, bluish swelling only seen when patient stands - will empty with minimal palpitation and full upon release of pressure

Question 7

How does a direct inguinal hernia reduce?

Answer 7

superior and posteriorly

Question 8

How does an indirect inguinal hernia reduce?

Answer 8

reduce superolaterally and posteriorly - tend to reduced along length of inguinal canal

Question 9

Are all hernias reducible?

Answer 9

no

Question 10

Do you percuss a groin lump?

Answer 10

no

Question 11

Why do you auscultate a groin lump?

Answer 11

audible bowel sounds likely to represent herniated bowel

Question 12

What conditions may predispose to hernia formation?

Answer 12

abdominal masses e.g ascites, tumour, faeceal loading (increases intra-abdominal pressure)

Question 13

What is a reducible inguinal hernia?

Answer 13

fluctuant mass, with cough impulse, that has origin superior and medial to pubic tubercle

Question 14

What is a bedside test to distinguish between direct or indirect hernias?

Answer 14

how sac protrudes

Question 15

How does the sac protrude in a direct inguinal hernia?

Answer 15

through a defect in trasnversalis fascia which forms posterior wall of inguinal canal

Question 16

How does the sac protrude in aa indirect inguinal hernia?

Answer 16

through the deep inguinal ring at the lateral end of the inguinal canal

Question 17

How could you reduce an indirect inguinal hernia?

Answer 17

applying pressure to the deep inguinal ring

Question 18

How do you carry out this bedside test?

Answer 18

1. Reduce hernia and then place finger over deep ring (at midpoint of inguinal ligament)
2. Ask patient to cough
3. If hernia reappears while your finger is still occluding the deep ring hernia must be direct (or finger in wrong place)
4. Indirect hernia reappear only when pressure over deep ring released

Question 19

Which type of inguinal hernia is more common?

Answer 19

75% indirect and 25% direct - can coexist as pantaloon hernia

Question 20

What is the origin of an indirect inguinal hernia?

Answer 20

lateral to the deep inferior epigastric artery (lies medial to the deep inguinal ring)

Question 21

What is the origin of a direct inguinal hernia?

Answer 21

medial to the deep inferior epigastric artery

Question 22

Which type of inguinal hernia has higher risk of strangulation and why?

Answer 22

• indirect as the hernial sac passes through a smaller defect (compared with the hole in the transversalis fascia that direct hernias pass through)
• explains why direct hernias have a greater tendancy to spontaneously reduce when patient lie down

Question 23

What is the management for a right reducible indirect inguinal hernia?

Answer 23

elective surgical repair