1. Lump in the Groin – PBL 28

2. Definition & Types
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.
Types
Inguinal
Femoral
Umbilical
Incisional
Diaphragmatic

3. Degrees of hernia
A reducible hernia- occurs when a hernia can be pushed back into the abdomen, either spontaneously or with manipulation.
An irreducible hernia- occurs when a femoral hernia becomes stuck hernial orifice.
An obstructed hernia- occurs when a part of the intestine becomes intertwined with the hernia, causing an intestinal obstruction. The obstruction may grow and the hernia can become increasingly painful.
A strangulated hernia- occurs when the blood supply to the herniated bowel gets blocked causing it to get ischemic. 

4. Inguinal Hernias
The inguinal canal is a fascial tunnel leading from the abdomen to the scrotum/labia. This is a weak point in the bowel wall.

5. Inguinal hernias occur above the inguinal ligament

6. Direct
Usually Occur in a Hesselbach’s triangle (defined by the edge of the rectus abdominis muscle, the inguinal ligament and the inferior epigastric artery). They can exit through the superficial ring but cannot extend into the scrotum.
Indirect
Travel through both the deep and superficial inguinal rings and are often due to the deep inguinal ring not closing properly. They can extend into the scrotum/labia.

7. Femoral Hernias
Occur just below the inguinal ligament in the femoral triangle. They often get strangulated.

8. Para-umbilical
A protrusion of the intestines or gut into the abdomen through a weak point of the muscles or ligaments near the navel.

9. Incisional
Abdominal contents can herniate through surgical scars as they represent weakpoints in the abdominal wall.

10. Diaphragmatic
A defect in the diaphragm allows abdominal contents to enter the thorax.
E.g. Hiatus hernia- When the stomach or part of it enters the thorax through the eosophageal hiatus.
Sliding- the gastro-oesophagual junction enters the thorax
Rolling- the gastric fundus enters the thorax

11. Examination of a lump part 1
Exposure
Area of the lump should be adequately exposed. This should include area of lymphatic drainage for that part of the body
Diagnosis of a lump
Depends on 3 main things:
Determining which layer of the body in which the lump lies, i.e. skin, subcutaneous tissue, fat or deep organ
Knowledge of the anatomy of that part of the body
Knowledge of pathological abnormalities affecting the anatomical structures in that area
Layer
First determine if the lump is mobile or attached to skin
Then determine if lump is deep or superficial to the muscle or tethered to the muscle
Ask the patient to tense the muscle in that area
If lump disappears it is deep to the muscle
If lump becomes fixed this indicates the lump is attached to the muscle
Is the lump inflammatory or due to infection?
If it is hot or tender or if there is inflammation or redness of the overlying skin this indicates that it is inflammatory

12. Examination of a lump – part 2
Is the lump benign or malignant
Signs of malignancy include a hard fixed lump with an irregular outline. It may be invading or ulcerating the overlying skin
A benign lump is normally smooth and well defined with a distinct edge. If the lump is cystic then it may be trans illuminable. A soft spongy lump is more likely to be benign.
Is the lump a hernia
The lump should be tested for a cough impulse or reducibility. This indicates a hernia.
Is the lump vascular
The lump should be palpated and if it is pulsatile this would indicate it is arterial in nature
If the lump is expansile this suggests an aneurysm
Auscultate the lump for a bruit, which would indicate underlying stenosis
Examination of the field of lymphatic drainage and regional lymph nodes
Check for surrounding lymphadenopathy. This may be a sign of infection of metastatic cancer
General Examination
Examine the whole patient for other similar lumps or relevant abnormalities

13. Case Study Mr X – 45 yo construction worker
Presented to ED with a gradual onset pain beginning one week prior
Pain is in the epigastric and umbilical area
Has spent week prior building a house
No past history of any major illnesses or surgeries

14. O/E
There is a small hard lump above the umbilicus approx 1-2 cm in diameter.
The lump is just below the skin and is hard.
The lump is not reducible but increases in size on coughing.
The lump is not warm but there is redness in the overlying skin.
The lump has quite a marked outline on palpation.
The lump is not pulsatile on palpation and no surrounding lymphadenopathy.

15. Diagnosis
The lump is a small hernia through rectus abdominis defect of the omental fat.
The hardness of the lump is most likely due to inflammation of the omental fat.

16. Treatment
The patient will have surgery to remove the hernia as it is not reducible and can’t be manoeuvred back to its normal position.

17. Complications of hernias
Inflammation of the herniated viscera
Irreducibility – causing a permanent lump
Obstruction – bowel obstruction
Strangulation – constriction of blood vessels blocking blood flow to the organ causing ischaemia
Hydrocele of the hernial sac – serous fluid accumulation in the cavity
Haemorrhage