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MBBS IV - Junior Clerkship WCS > JC80 (Surgery) - Hernia and scrotal lumps > Flashcards

JC80 (Surgery) - Hernia and scrotal lumps Flashcards

1
Q

Hernia

  • Definition
  • Contents of a hernia sac
A

Hernia: protrusion of a viscus or part of a viscus through abnormal opening in walls of its containing cavity

Composition:
□ Sac: diverticulum of peritoneum (neck and body)
□ Covering: layers of abdominal wall
□ Contents: omentum, viscera, fluid

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2
Q

Clinical classes of hernia

A

Reducible

Irreducible/ Incarcerated hernia (May be due to narrow sac or adhesions, more common in omentocele)

Obstructed hernia: trapped loop of bowel leading to luminal obstruction without compromise of blood supply

Strangulated hernia: blood supply leading to intestinal ischaemia

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3
Q

Common clinical features of hernia

A

□ Asymptomatic intermittent swelling that aggravates upon coughing or straining
→ Usually reducible upon direct pressure or lying down
→ A/w expansile cough impulse upon palpation

□ ± symptoms of IO if obstructed

□ ± acute pain, tenderness if strangulated

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4
Q

Pathogenesis of hernia

A

2 parts:

  1. Loss of mechanical integrity of abdominal wall muscles and tendons:
    - Primary collagen defect or connective tissue disease
    - Secondary to defective wound healing
  2. Increase intra-abdominal pressure cause rupture at weakest point at abdominal wall
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5
Q

Define region in abdominal wall most prone to hernia

Define the region’s borders

A

Myopectineal orifice (MPO): area of weakness in pelvic region

Boundaries:

  • Arching fibres of IO/TA (above)
  • RA and its fascial rectus sheath (medial)
  • Cooper’s (pectineal) ligament along pectineal line of pubis (below)
  • Iliopsoas muscle (lateral)

Prone to hernia because NOT reinforced by muscles like the rest of abdominal wall → inguinal or femoral hernia

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6
Q

Differentiate the following:

External vs internal hernia
Sliding hernia

A

External vs internal:
→ External: protrude outside abdomen
→ Internal: protrude into retroperitoneal fossa or foramen (eg. Petersen’s hernia)

Sliding hernia: herniation of retroperitoneal organ together with posterior peritoneum (most commonly caecum, bladder, sigmoid)

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7
Q

Differentiate the following

Littre’s hernia
Amyand’s hernia
Richter’s hernia

A

Littre’s hernia: hernia containing Meckel’s diverticulum

Amyand’s hernia: hernia containing appendix

Richter’s hernia: a type of strangulated hernia where only bowel wall is trapped and ischaemic without luminal obstruction

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8
Q

List all possible sites of hernia

groin, ventral, lumbar…etc

A

Groin hernia: most common
→ Inguinal (96%): indirect (2/3), direct, pantaloons (both)
→ Femoral (4%): below inguinal ligament through femoral ring

Ventral hernia:
→ Epigastric hernia: extraperitoneal fat protrudes through linea alba above umbilicus
→ Umbilical and paraumbilical hernia
→ Spigelian hernia: herniation along linea seminlunaris

Lumbar hernia: through Petit (inferior) triangle or Grynfeltt (superior) triangle

Incisional hernia

Parastomal hernia

Pelvic hernias:

  • Obturator hernia: protrusion through obturator foramen
  • Perineal hernia: through pelvic floor
  • Sciatic hernia: through greater or lesser sciatic foramen
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9
Q

9 layers of anterolateral abdominal wall

A

□ Skin
□ Camper’s fascia: thick fatty outer layer
□ Scarpa’s fascia: thin membranous inner layer

□ External oblique (EO) and its aponeurosis
□ Internal oblique (IO) and its aponeurosis
□ Transversus abdominis (TA) and its aponeurosis

□ Transversalis fascia
□ Pre-peritoneal fat
□ Parietal peritoneum

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10
Q

Inguinal canal

  • Formed by what structures
  • Length
A

Inguinal canal: 4-6cm oblique passage

Formed by three musculoaponeurotic arcades
1. TA attaches at lateral 1/2 of inguinal ligament → medial margin forms deep inguinal ring

  1. IO attaches at lateral 2/3 of inguinal ligament
  2. EO forms the inguinal ligament → gap medial to pubic tubercle forms superficial inguinal ring
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11
Q

Inguinal canal boundaries

A

→ Roof: musculoaponeurotic arcades of IO/TA
→ Anterior wall: EO aponeurosis
→ Floor: inguinal ligament, lacunar ligament (medial end)
→ Posterior wall: transversalis fascia, conjoint tendon (medial 1/3)

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12
Q

Inguinal canal

Content

A

→ Spermatic cord (M)

  • 3 fascial layers: external spermatic, cremasteric, internal spermatic
  • 3 arteries/veins: A/V to vas deferens, testicular A/V, cremasteric A/V
  • 3 nerves: genital br. of genitofemoral n., SN (T10) and visceral afferent, (ilioinguinal n.)
  • 3 other structures: remnants of processus vaginalis, vas deferens, testicular lymphatics

→ Round ligament of uterus (F)

→ Ilioinguinal n. (L1): supplies upper scrotum, skin over root of penis

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13
Q

Femoral canal

  • Content
  • Lining
  • Opening
A

□ Content: lymph node of Cloquet, adipose tissues

□ Lining: medial compartment of femoral sheath surrounding femoral vessels and lymphatics below inguinal ligament

□ Femoral ring: superior opening

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14
Q

Differentiate femoral vs inguinal hernia location

A

Femoral hernia: protrusion of organ via femoral canal
□ Site of neck: below + lateral to pubic tubercle

Inguinal hernia: protrusion of organs at inguinal region
□ Site of neck: above + medial to pubic tubercle

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15
Q

Differentiate direct vs indirect inguinal hernia

  • Location
  • Protruded region
  • Passage through 2 inguinal rings
  • Clinical test for differentiation
A

Inguinal hernia: protrusion of organs at inguinal region
Site of neck: above + medial to pubic tubercle

  1. Indirect inguinal hernia: lateral to inferior epigastric A/V
    Reason: organ protrudes via inguinal canal
    Passes through both deep + superficial rings
    Occlusion test +ve: can be reduced by pressing on deep inguinal ring
  2. Direct inguinal hernia: medial to inferior epigastric A/V
    Reason: organ protrudes via Hasselbach triangle
    Passes through only superficial ring
    Occlusion test -ve
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16
Q

Ddx painful vs painless groin lump

A
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17
Q

Outline history taking for groin lump

A

□ Lump: onset, duration, change in size

□ Painful vs painless

□ Reducible vs non-reducible: reducible = hernia

□ Intermittent vs constant: intermittent, esp if ↑with straining = hernia

□ Obstructive symptoms: obstructed hernia

□ Systemic illness: B symptoms, LL infections

□ RFs for hernia, eg. prev Hx, c.t. disease, chronic cough, constipation, FHx

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18
Q

Inguinal hernia

  • Demographics
  • Which side and type are more common?
A

Demographics: M:F >10:1, peak 6th-7th (M)

2/3 of inguinal hernia is indirect
2/3 of recurrent ones are direct
60% right sided, 30% left sided, 10% bilateral

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19
Q

Non-modifiable risk factors of inguinal hernia

A

FHx of hernia

Previous Hx of hernia (contralateral or ipsilateral)

Male gender

Advanced age

Abnormal collagen metabolism (A/w AAA, steroid use, smoking)

Patent processus vaginalis (indirect)

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20
Q

Modifiable risk factors of inguinal hernia

A

Increase in intrabdominal pressure

  • Obesity
  • Chronic constipation with straining
  • Chronic pulmonary disease with chronic cough
  • BPH with straining
  • Occupational heavy lifting

Previous pelvic surgery
- Eg. prostatectomy with damage to deep inguinal ring

Abdominal wall weakness (direct)

  • Cachexia
  • Ilioinguinal n. palsy (in appendicectomy)
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21
Q

2 clinical classification systems for inguinal hernia

A

□ Nyhus classification: designed for posterior approach based on size of inguinal ring and integrity of posterior wall

□ EHS groin hernia classification

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22
Q

Diagnostic tests for inguinal hernia

A

Clinical physical exam

Imaging:

  • USG groin**
  • Herniography (contrast into abdomen, rare)
  • CT abdomen (rare)

Diagnostic laparoscopy

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23
Q

Treatment options for inguinal hernia (interventional and watchful/ preventative measures)

A

Watchful waiting: ↓intra-abdominal pressure:
→ Lifestyle changes, eg. weight loss, change jobs, avoid heavy lifting
→ Treat predisposing conditions, eg. COPD, chronic constipation

Surgical definitive treatment:

  • Herniotomy: excision of hernia sac with ligation of neck and reduction of content
  • Herniorrhaphy: herniotomy + meshless repair of posterior wall of inguinal canal
  • Hernioplasty: herniotomy + mesh repair of posterior wall of inguinal canal ***** GOLD STANDARD **
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24
Q

Surgical repair of inguinal hernia

Compare 2 major approaches

A

Open repair: usually anterior approach, can be done under GA, SA, LA
- Lichtenstein’s tension-free mesh repair: gold standard

Laparo-endoscopic approach: always posterior approach, always done under GA:

  • Total extraperitoneal repair (TEP)
  • Trans-abdominal pre-peritoneal repair (TAPP)
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25
Q

Advantages and disadvantages of Laparo-endoscopic approach inguinal hernia repair vs open repair

A

Advantage:
↓post-op pain and faster recovery
Similar recurrence, morbidity and mortality rate
Similar operative time and risk of perioperative Cx
Less wound complications than Lichtenstein repair

Disadvantage:

  • TEP a/w more Vascular injuries
  • TAPP a/w more VIsceral injuries
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26
Q

Indicators for laparoendoscopic inguinal hernia repair

A

 Bilateral hernia (no need two incisions)
 Female (r/o undiagnosed femoral hernia, a/w ↓pain)
 Recurrent if prev repair is open (avoid adhesions)
 High pre-operative pain (a/w ↓post-op pain)
 Diagnosis in doubt

27
Q

Indicators for open inguinal hernia repair

A

 High GA risk (perform under LA, lap usu need GA)

 Bleeding risk (easier haemostasis)

 Recurrent if prev repair is laparoscopic

 Previous lower abdominal wall surgery

 Large scrotal or irreducible hernia

 Complicated hernia

28
Q

Immediate and early complications of inguinal hernia repair

A

□ GA risks: acute MI, CVA

□ Immediate to early:
→ AROU
→ Bleeding: bruising, bleeding/scrotal haematoma
→ Iatrogenic injury to surrounding structures: paraesthesia, impotence

□ Early:
→ Infection of wound/mesh
→ Haematoma 
→ Wound dehiscence
→ Pain: discharge patient with adequate analgesia
29
Q

Late complications of inguinal hernia repair

A

→ Chronic post-operative inguinal pain (CPIP)

→ Recurrence (<0.5%) from inadequate ring and posterior wall closure

→ Sexual dysfunction (~5-7%): nerve damage, ischaemic orchitis and testicular atrophy (testicular A/V damage)

30
Q

Femoral hernia

  • Demographics
  • Risk of untreated hernia
A

Demographics: 70% is female, mostly in elderly F
Multiparity is a RF → loosening of pelvic ligaments

Clinical significance: most liable to strangulation

31
Q

Femoral canal

  • Course
  • Content
  • Boundaries
A

Course: septum crurale (closed superiorly) → femoral ring→ cribriform fascia (inferiorly)

Content: LN of Cloquet, lymphatics, adipose tissues

Boundaries: inguinal ligament (anteriorly), Cooper’s ligament/pectineus (posteriorly), lacunar ligament (medially), femoral v (laterally)

32
Q

Femoral hernia

  • Presentation
A

□ Groin bulge: usually Rt-sided but 20% bilateral
→ Neck is located below + lateral to pubic tubercle
→ Often irreducible due to narrow neck

□ Strangulation: initial presentation in up to 40%

33
Q

D/dx femoral hernia

A

□ Inguinal hernia: neck medial and above inguinal ligament, usually reducible with expansile cough impulse

□ Saphena varix: cough impulse +, fluid thrill when patient coughs or when saphenous vein below varix is tapped, ± venous hum

□ Femoral lymphadenopathy: Hx of LL infection/malignancy

□ Skin lumps: sebaceous cyst, lipoma

□ Femoral artery aneurysm: expansile pulsation

□ Others: psoas bursa (disappear when hip flexed), obturator hernia, ectopic testis

34
Q

Femoral hernia

Treatment options

A

Early elective repair due to higher risk of complications

  1. Open techniques
    - Lockwood’s infrainguinal approach
    - Lotheissen’s transinguinal approach
    - McEvedy’s high approach
  2. Laparoscopic techniques:
    → Total extraperitoneal approach (TEP)
    → Transabdominal preperitoneal approach (TAPP)
35
Q

True umbilical and paraumbilical hernia

Compare the structures protruded through in these 2 hernias

A

True umbilical hernias: herniation through umbilical scar
→ Usually occurs in infants secondary to a congenitally weak umbilicus

Paraumbilical hernias: herniation through linea alba just above or below the umbilicus
→ Usually occurs in adulthood due to weakened linea alba

36
Q

Infantile umbilical hernia

  • Cause
  • S/S
  • Mx
A

□ Cause: congenitally weak umbilicus (no true fascial defect)
□ S/S: asymptomatic, conical bump at umbilicus, rarely strangulates
□ Mx: conservative if <5y + asymptomatic (95% resolve spontaneously), or herniorrhaphy

37
Q

Adult umbilical hernia

  • Cause
  • S/S
A

Cause: ↑abd pressure with weakened linea alba, eg. obesity, multiparity, ascites

S/S:
→ Paraumbilical lump (can be very large)
→ GI symptoms (traction on stomach/transverse colon)
→ Transient colics due to partial obstruction
→ Often strangulates (narrow neck compared to large sac) with risk of enterocutaneous fistula if ruptured

38
Q

Management options for adult umbilical hernia

A

surgical repair usually indicated (high risk of strangulation)
→ Umbilical herniorrhaphy:surgical repair usually indicated (high risk of strangulation)

39
Q

Management options for adult umbilical hernia

A

Umbilical herniorrhaphy: surgical repair usually indicated (high risk of strangulation)

Mayo’s operation for defect <4cm
Mesh repair preferred after herniorrhaphy if defect >4cm

40
Q

Incisional hernia

Risk factors

A

Patient RF:

  • Poor wound healing
  • Chronic high intra-abdominal pressure

Surgical RF:

  • Wound complications
  • Poor fascial closure (e.g. tension, broken sutures…etc)
  • Large incision on abdomen (e.g. AAA repair)
41
Q

Incisional hernia

Diagnostic Ix
D/dx

A

Imaging: CT abdomen for pre-op planning

D/dx:
→ Rectus diastasis: similar bulge when tensing RA but NOT a/w fascial defect
→ Others: rectus haematoma, abdominal wall tumours

42
Q

Incisional hernia

Management options
Prevention of recurrence

A

□ Conservative: truss wearing, RF control
□ Surgical: herniorrhaphy ± mesh repair
→ Open: onlay (commonest, easiest), sublay or inlay mesh
→ Laparoscopic with intraperitoneal onlay mesh (IPOM)

Prevention:
□ Choose off-midline incision
□ Close abdominal incisions properly with abdorbable monofilament sutures
□ Prophylactic mesh replacement for high-risk (optional)

43
Q

Ddx painful scrotal swelling

A
  • Common causes
    Testicular torsion (surgical emergency)
    Acute epididymitis/epididymo-orchitis
    Torsion of appendix testis
- Uncommon causes
Incarcerated inguinal hernia
Torsion of appendix epididymis
Trauma and acute haematocele
Orchitis, eg. mumps
Infection, eg. Fournier’s gangrene
Referred pain, eg. from renal stone
44
Q

Ddx painless scrotal swelling

A

Scrotal edema

Hernia

Hydrocele
Haematocele
Varicocele

Testicular tumour / leukaemia

Epididymal cyst (spermatocele)

TB epididymitis

45
Q

History taking for scrotal swelling

A

□ Pain: onset, severity, any precipitating factors (eg. trauma, exercise)

□ Swelling: onset, progression, any variation with posture or Valsalva (hydrocele, varicocele, hernia)

□ Torsion: referred abdominal pain, ↓appetite, nausea/vomiting

□ Fever: epididymitis, orchitis

□ Urinary symptoms: flank pain/haematuria (stones), dysuria (UTI), AROU (pelvic mass)

□ Sexual Hx: may be related to epididymitis

46
Q

Outline P/E for scrotal swelling

A

Abdominal and groin examination

Examination of scrotum: 
Any tenderness?
Can get above it? 
Separable from testis?
Transluminate?

Testicular lie: high-lying testis with bell-clapper deformity suggestive of torsion

Cremasteric reflex: absent in testicular torsion

Phren’s test: ↓pain with elevation of testis in acute epididymitis

47
Q

Diagnostic Ix for scrotal swelling

A

USG scrotum

Doppler USG for testicular torsion (whirlpool sign)

48
Q

Hydrocele

  • Definition
  • Etilogies
A

Hydrocele: collection of peritoneal fluid between two layers of tunica vaginalis

Causes:

  • Congenital (spontaneous resolution)
  • Primary idiopathic (middle age, poor fluid reabsorption in tunica vaginalis)
  • Secondary reactive (old age, due to testicular diseases)
49
Q

Differentiate communicating and non-communicating hydrocele

A

Communicating (congenital) due to patent processus vaginalis

Non-communicating due to other causes
→ Infantile hydrocele
→ Vaginal hydrocele
→ Hydrocele of cord

50
Q

Symptoms and signs of hydrocele

A

Unilateral scrotal swelling ± pain, pressure sensation, scrotal skin irritation
transilluminable
Can get above the mass
Testis not well-defined

51
Q

Hydrocele

Diagnostic Ix
Tx

A

Diagnosis: usu clinical ± Doppler USG to r/o 2o cause

Options:

  • Simple aspiration +/- sclerrotherapy
  • Herniotomy for congenital hydroceles
  • Simple excision of sac (thick sac)
  • Lord’s plication of sac/ Jaboulay’s procedure for thin-walled sac
52
Q

Testicular torsion

Demographics
Pathogenesis

A

Demographics: two peaks at neonatal and adolescence

Pathogenesis:

  • Bell-clapper deformity (12% M): tunica vaginalis does not anchor the testis as usual but attaches high at the spermatic cord
  • Separation of epididymis from body of testis
  • Narrow/absent fixation of lower pole of testis to tunica vaginalis

Torsion event is often related to abdominal contraction
→ When there is abdominal straining (eg. straining, weight-lifting, coitus), cremaster contracts together w/ abdominal muscles → twisting force at testis

53
Q

Testicular torsion S/S

A
  • Sudden persistent agonizing scrotal pain ± radiation to
    groin and lower abdomen
  • Gross scrotal erythematous swelling
  • Nausea and vomiting
  • Oedematous erythematous tender swelling
  • High-riding testis with horizontal lie
  • Tender, twisted cord
  • Absent cremasteric reflex (may be normally absent if <6y) and -ve Prehn’s sign
54
Q

Diagnostic Ix and Tx of testicular torsion

A

Diagnosis: clinical ± Doppler USG

Urgent exploration indicated regardless of duration of torsion

Emergency scrotal exploration

  • Orchiectomy for non-viable gonads
  • Orchidopexy for all viable gonads
55
Q

Varicocele

Pathogenesis

A

Varicocele: varicose dilatation of pampiniform plexus of spermatic veins

Primary varicocele: Lt renal vein is compressed between aorta and SMA

Secondary varicocele: Lt renal mass or Lt Renal vein obstruction or IVC obstruction

56
Q

Describe venous drainage of testicles

Why is left varicocele more common

A

Testicular venous drainage:
→ Multiple veins drain testis forming the pampiniform plexus
→ These veins join together to form testicular vein at deep inguinal ring (often lacks valve to prevent backflow)
→ Lt testicular vein drains into Lt renal vein
→ Rt testicular vein drains into IVC directly

Lt varicocele is more common because
→ Lt testicular v. drains into Lt renal vein at perpendicular angle
→ Lt renal vein is compressed between aorta and SMA

57
Q

S/S of varicocele

A

Asymptomatic in majority
Dull, dragging discomfort, worsen with standing
Poor fertility

Soft scrotal mass, Bag of worms on palpation
Cough impulse
Primary varicocele disappear in supine
Testicular atrophy

58
Q

Diagnostic Ix and Tx of Varicocele

A

CT abdomen for isolated Rt varicocele and non-diminishing varicocele

No treatment if asymptomatic + normal semen analysis

  • scrotal support + NSAID
  • Repeat semen analysis monitoring Q1-2y

Surgical treatment if testicular atrophy/abnormal semen analysis or symptomatic

  • Surgical testicular vein ligation
  • Percutaneous gonadal vein embolization ± sclerotherapy
59
Q

Testicular tumors

List histological types

A

Germ cell:

  • Seminoma (spermatocytes)
  • Teratoma (totipotent sperm cells)
  • Mixed seminoma-teratoma
  • Other GCTs: embryonal carcinoma, yolk sac tumours, choriocarcinoma

Sex cord-stromal tumors:

  • Leydig cell tumours
  • Sertoli cell tumours

Paratesticular tumors

  • Lymphoma
  • Leukaemia and plasmacytoma
  • Mesothelioma
60
Q

Presentation of testicular tumor

A

Painless testicular nodule/swelling:
Smooth, firm, fixed enlargement ± spread to epididymis/cord
± heaviness/dull ache
± a/w reactive hydrocele

S/S of metastasis

Endocrine S/S:
→ Feminizing: gynaecomastia (5%), impotence, loss of libido, paraneoplastic hyperT (hCG)
→ Virilizing: precocious puberty

61
Q

Diagnostic Ix and Tx for testicular tumor

A

Blood: ↑β-hCG, AFP in non-germinomatous GCTs
USG scrotum
Radical inguinal orchidectomy
CT A+P + CXR for regional/systemic staging

Tx: Additional to orchidectomy
□ Retroperitoneal LN dissection (RPLND) for high-risk early (stage I) NSGCTs
□ Adjuvant RT for stage II seminomas (exquisitely radiosensitive)
□ Cisplatin-based chemotherapy for other more advanced tumours

62
Q

TAPP or TEP for inguinal hernia repair?

A

Both have comparable outcomes

TEP has longer learning curve/ more difficult
TEP has more vascular injury
TAPP has more visceral injuries

63
Q

Outline the Nyhus Classification for inguinal hernia

A

MBBS IV - Junior Clerkship WCS (131 decks)

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