JC80 (Surgery) - Hernia and scrotal lumps Flashcards
Hernia
- Definition
- Contents of a hernia sac
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
Clinical classes of hernia
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
Common clinical features of hernia
□ 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
Pathogenesis of hernia
2 parts:
- Loss of mechanical integrity of abdominal wall muscles and tendons:
- Primary collagen defect or connective tissue disease
- Secondary to defective wound healing - Increase intra-abdominal pressure cause rupture at weakest point at abdominal wall
Define region in abdominal wall most prone to hernia
Define the region’s borders
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
Differentiate the following:
External vs internal hernia
Sliding hernia
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)
Differentiate the following
Littre’s hernia
Amyand’s hernia
Richter’s hernia
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
List all possible sites of hernia
groin, ventral, lumbar…etc
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
9 layers of anterolateral abdominal wall
□ 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
Inguinal canal
- Formed by what structures
- Length
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
- IO attaches at lateral 2/3 of inguinal ligament
- EO forms the inguinal ligament → gap medial to pubic tubercle forms superficial inguinal ring
Inguinal canal boundaries
→ 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)
Inguinal canal
Content
→ 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
Femoral canal
- Content
- Lining
- Opening
□ 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
Differentiate femoral vs inguinal hernia location
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
Differentiate direct vs indirect inguinal hernia
- Location
- Protruded region
- Passage through 2 inguinal rings
- Clinical test for differentiation
Inguinal hernia: protrusion of organs at inguinal region
Site of neck: above + medial to pubic tubercle
- 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 - Direct inguinal hernia: medial to inferior epigastric A/V
Reason: organ protrudes via Hasselbach triangle
Passes through only superficial ring
Occlusion test -ve
Ddx painful vs painless groin lump
Outline history taking for groin lump
□ 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
Inguinal hernia
- Demographics
- Which side and type are more common?
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
Non-modifiable risk factors of inguinal hernia
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)
Modifiable risk factors of inguinal hernia
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)
2 clinical classification systems for inguinal hernia
□ Nyhus classification: designed for posterior approach based on size of inguinal ring and integrity of posterior wall
□ EHS groin hernia classification
Diagnostic tests for inguinal hernia
Clinical physical exam
Imaging:
- USG groin**
- Herniography (contrast into abdomen, rare)
- CT abdomen (rare)
Diagnostic laparoscopy
Treatment options for inguinal hernia (interventional and watchful/ preventative measures)
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 **
Surgical repair of inguinal hernia
Compare 2 major approaches
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)
Advantages and disadvantages of Laparo-endoscopic approach inguinal hernia repair vs open repair
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
Indicators for laparoendoscopic inguinal hernia repair
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
Indicators for open inguinal hernia repair
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
Immediate and early complications of inguinal hernia repair
□ 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
Late complications of inguinal hernia repair
→ 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)
Femoral hernia
- Demographics
- Risk of untreated hernia
Demographics: 70% is female, mostly in elderly F
Multiparity is a RF → loosening of pelvic ligaments
Clinical significance: most liable to strangulation
Femoral canal
- Course
- Content
- Boundaries
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)
Femoral hernia
- Presentation
□ 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%
D/dx femoral hernia
□ 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
Femoral hernia
Treatment options
Early elective repair due to higher risk of complications
- Open techniques
- Lockwood’s infrainguinal approach
- Lotheissen’s transinguinal approach
- McEvedy’s high approach - Laparoscopic techniques:
→ Total extraperitoneal approach (TEP)
→ Transabdominal preperitoneal approach (TAPP)
True umbilical and paraumbilical hernia
Compare the structures protruded through in these 2 hernias
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
Infantile umbilical hernia
- Cause
- S/S
- Mx
□ 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
Adult umbilical hernia
- Cause
- S/S
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
Management options for adult umbilical hernia
surgical repair usually indicated (high risk of strangulation)
→ Umbilical herniorrhaphy:surgical repair usually indicated (high risk of strangulation)
Management options for adult umbilical hernia
Umbilical herniorrhaphy: surgical repair usually indicated (high risk of strangulation)
Mayo’s operation for defect <4cm
Mesh repair preferred after herniorrhaphy if defect >4cm
Incisional hernia
Risk factors
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)
Incisional hernia
Diagnostic Ix
D/dx
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
Incisional hernia
Management options
Prevention of recurrence
□ 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)
Ddx painful scrotal swelling
- 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
Ddx painless scrotal swelling
Scrotal edema
Hernia
Hydrocele
Haematocele
Varicocele
Testicular tumour / leukaemia
Epididymal cyst (spermatocele)
TB epididymitis
History taking for scrotal swelling
□ 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
Outline P/E for scrotal swelling
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
Diagnostic Ix for scrotal swelling
USG scrotum
Doppler USG for testicular torsion (whirlpool sign)
Hydrocele
- Definition
- Etilogies
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)
Differentiate communicating and non-communicating hydrocele
Communicating (congenital) due to patent processus vaginalis
Non-communicating due to other causes
→ Infantile hydrocele
→ Vaginal hydrocele
→ Hydrocele of cord
Symptoms and signs of hydrocele
Unilateral scrotal swelling ± pain, pressure sensation, scrotal skin irritation
transilluminable
Can get above the mass
Testis not well-defined
Hydrocele
Diagnostic Ix
Tx
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
Testicular torsion
Demographics
Pathogenesis
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
Testicular torsion S/S
- 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
Diagnostic Ix and Tx of testicular torsion
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
Varicocele
Pathogenesis
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
Describe venous drainage of testicles
Why is left varicocele more common
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
S/S of varicocele
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
Diagnostic Ix and Tx of Varicocele
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
Testicular tumors
List histological types
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
Presentation of testicular tumor
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
Diagnostic Ix and Tx for testicular tumor
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
TAPP or TEP for inguinal hernia repair?
Both have comparable outcomes
TEP has longer learning curve/ more difficult
TEP has more vascular injury
TAPP has more visceral injuries
Outline the Nyhus Classification for inguinal hernia
