Geronimo, Geronimo, Geronimo, Go, Go, Go, Go, October 8, 2009 CASE 3 Geronimo, Geronimo, Geronimo, Go, Go, Go, Go, October 8, 2009

Case 3 A 35-year old male comes to your clinic with the following problem of 10 years duration. Except for the mass, he is relatively asymptomatic

Salient Features 35-year old Male CC: Scrotal Lump 10 years duration Scrotal mass Relatively asymptomatic

Differential Diagnosis Groin Lump Skin Lump Glandular Fever Femoral Artery Aneurysm Undescended testis Groin Hernia Inguinal Indirect Complete Incomplete Direct Femoral Swollen Lymph nodes Varicose Veins

Inguinal Hernia 75% of all abdominal wall hernias in the inguinal area M>F 7:1 R-sided>L-sided Indirect: Direct Hernia Ratio 2:1

Indirect vs. Direct INDIRECT Occurs through the internal inguinal ring Defects in the ABDOMINAL WALL (transversalis fascia) in Hesselbach's triangle Only protrudes forward Adults INDIRECT Occurs through the internal inguinal ring Usually reaches the scrotum Commonly seen in children and young adults

Indirect Inguinal Hernia Complete Sac descends to the testes and fills the side of the scrotum Incomplete Does not descend to the testes

Differential Diagnosis Groin Lump Skin Lump Glandular Fever Femoral Artery Aneurysm Undescended testis Groin Hernia Inguinal Indirect Complete Incomplete Direct Femoral Swollen Lymph nodes Varicose Veins

Causes Anything that causes weakness or tears in the abdominal wall can cause a groin hernia, including: Defects at birth Prolonged wear and tear (eg, lifting, straining, or coughing) Age-related weakness of the abdominal wall History of previous surgery in the area

Risk Factors A risk factor is something that increases your chance of getting a disease or condition. Risk factors include: Advancing age Sex: male (Groin hernias are about 10 times more common in men. But, femoral hernias are more common in women.) Increased pressure within the abdominal cavity due to: Lifting heavy objects Straining to urinate or pass stools Severe or prolonged coughing Obesity Pregnancy

Diagnosis Physical Exam and PE

Inspection Patient upright Look for Asymmetry in inguinal area Bulge or mass at inguinal area Mass at the scrotum Mass below the inguinal ligament By inspection, determine if reducible or incarcerated

Palpation Tip of index finger placed at most dependent part of the scrotum Direct to the external inguinal ring Ask patient to strain Indirect hernia Bulge will progress from a lateral to medial direction and push against the fingertip Direct hernia Bulge will push against the pulp of the finger through the floor of the inguinal canal

Incarcerated Irreducible mass Cute or chronic Manipulation not effective Taxis Cute or chronic Omentum and fascia are the structures that herniate

Strangulated Vascularity of the herniated viscus is compromised, usually at the neck Hernias with small orifices and voluminous sacs Severe pain, tenderness, erythema Initially incarcerated Testis has no rugae Auscultate the scrotum

Asymptomatic patient Symptomatic patient PE and history enough Dull ache in groin or body area with lifting or straining but without an obvious lump Cough Incerase abdominal pressure to palpate the mass

Ultrasonography Differentiate masses in groin or abdominal wall or in differentiating testicular sources of swelling Incarcerated or strangulated hernia Upright chest radiograph to exclude free air (rare) Flat and upright abdominal film to diagnose small bowel obstruction Identify areas of bowel outside the abdominal cavity

CT Scan Diagnose a spigelian or obturator hernia Inability to obtain a good examination because of body habitus

Herniography When clinical diagnosis is uncertain Injection of contrast material into abdominal or peritoneal cavity Diagnostic radiography of pelvic region to outline the anatomy of the pelvic floor and its peritoneal reflections The contrast medium fills a right-sided direct inguinal hernia with a narrow neck, extending from the medial inguinal fossa. (Courtesy O. Ekberg, MD, Department of Radiology, University Hospital, Malmo, Sweden.)

Nyhus Classification Type Description Type I Indirect hernia, normal internal ring Type II Indirect hernia, enlarged internal ring, inguinal floor intact Type IIIA Direct hernia Type IIIB Indirect hernia, enlarged internal ring, destruction of internal floor Type IIIC Femoral hernia Type IV Recurrent hernia

Gilbert Classification Type Description Type I Small, indirect (<1.5 cm) Type II Medium, indirect, (1.5 cm to 4 cm) Type III Large, indirect (>4cm) Type IV Entire floor, direct Type V Diverticular, direct Type VI Combined Type VII Femoral

Differential Diagnosis Lymphoma Testicular tumor Varicocoele Epididymitis Testicular torsion Hydrocoele Undescended testis Lipoma of the cord Femoral artery aneurysm Lymphadenitis Hidradenitis Sebaceous cyst Psoas abscess Hematoma

Differential Diagnosis Testicular tumor Hard mass Varicocoele Dilated vessels present with increased blood flow Epididymitis Painful unlike in hernia, unless incarcerated Testicular torsion Severe pain usually at night

Indirect Inguinal Hernia Complete Type THERAPEUTIC PLANS Indirect Inguinal Hernia Complete Type

Therapeutic Plan No medical treatment, only surgical treatment While awaiting surgery, some patients may wear a device called a truss, which puts pressure on the hernia and keeps it under control

Therapeutic Plan An operation in which the hernia sac is removed without any repair of the inguinal canal is described as a 'herniotomy‘ Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous material is used for reinforcement

HERNIORRHAPY Surgical correction of an indirect inguinal hernia The surgery may be a standard open procedure through an incision large enough to access the hernia A laparoscopic procedure performed through tiny incisions, using an instrument with a camera attached (laparoscope) and a video monitor to guide the repair

HERNIORRHAPY the patient is typically given a light general anesthesia of short duration Laparoscopic procedures are conducted using general anesthesia The procedure is often performed in an outpatient facility with local anesthesia and patients can walk away the same day, with little restrictions in activity

HERNIORRHAPY the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed

HERNIORRHAPY Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region

HERNIORRHAPY some popular techniques include; Lichtenstein repair (flat mesh patch placed on top of the defect) Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch) Kugel (mesh device placed behind the defect) Prolene Hernia System (2-layer mesh device placed over and behind the defect)

HERNIORRHAPY This patient has an indirect inguinal hernia (A). To repair it, the surgeon makes an incision over the area and separates the muscle and tisses to expose the hernia sac (B). The sac is cut open (C), and the contents are replaced into the abdomen (D). The neck of the hernia sac is tied off (E), and the muscles and tissues are sutured (F). 32

HERNIORRHAPY: AFTERCARE The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon Patients should also report a fever, and men should report any pain or swelling of the testicles The surgeon may remove the outer sutures in a follow-up visit about a week after surgery

HERNIORRHAPY: AFTERCARE Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery