1. SGD Case 2
Riccel and Von

2. A 25-year old male waiter comes to the Emergency Room because of a R inguinal mass. Since two years ago, the mass would appear when lifting heavy objects, coughing, or sneezing and spontaneously disappear upon lying down aided by gentle manual manipulation

3. SALIENT FEATURES 25 y/o Male Waiter Right inguinal mass
2 years ago, the mass would appear when lifting heavy objects, coughing, or sneezing
Spontaneously disappear upon lying down aided by gentle manual manipulation

4. DIFFERENTIAL DIAGNOSIS
Inguinal hernia   
Hydrocele   
Inguinal adenitis   
Varicocele   
Ectopic testis   
Lipoma   
Hematoma   
Sebaceous cyst   
Hidradenitis of inguinal apocrine glands   
Psoas abscess   
Lymphoma   
Metastatic neoplasm   
Epididymitis   
Testicular torsion   
Femoral hernia   
Femoral adenitis   
Femoral artery aneurysm or Pseudoaneurysm

5. What is your diagnosis?
Inguinal Hernia

6. HERNIA Hernia is derived from the Latin word for rupture.
It is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls.
Although a hernia can occur at various sites of the body, these defects most commonly involve the abdominal wall, particularly the inguinal region.

7. Abdominal wall hernias occur only at sites where the aponeurosis and fascia are not covered by striated muscle.
These sites most commonly include the inguinal, femoral, and umbilical areas, the linea alba, the lower portion of the semilunar line, and sites of prior incisions.
The so-called neck or orifice of a hernia is located at the innermost musculoaponeurotic layer, whereas the hernia sac is lined by peritoneum and protrudes from the neck. There is no consistent relationship between the area of a hernia defect and the size of a hernia sac.

8. Irreducible or incarcerated Strangulated hernia
When its contents can be replaced within the surrounding musculature
Irreducible or incarcerated
When it cannot be reduced
Strangulated hernia
compromised blood supply to its contents, which is a serious and potentially fatal complication
Occurs more often in large hernias that have small orifices
In this situation, the small neck of the hernia obstructs arterial blood flow, venous drainage, or both to the contents of the hernia sac
Adhesions between the contents of the hernia and the peritoneal lining of the sac can provide a tethering point that entraps the hernia contents and predisposes to intestinal obstruction and strangulation
Richter's hernia
A more unusual type of strangulation
A small portion of the antimesenteric wall of the intestine is trapped within the hernia, and strangulation can occur without the presence of intestinal obstruction

9. External hernia Internal hernia Interparietal hernia
Protrudes through all layers of the abdominal wall
Internal hernia
Protrusion of intestine through a defect within the peritoneal cavity
Interparietal hernia
Occurs when the hernia sac is contained within a musculoaponeurotic layer of the abdominal wall
In broad terms, most abdominal wall hernias can be separated into inguinal and ventral hernias

10. Types of abdominal wall hernias.
(From Dorland's Illustrated Medical Dictionary, 26th ed, Philadelphia, WB Saunders, 1985, plate XXI.)

11. INGUINAL HERNIAS
Inguinal hernias are classified as either direct or indirect.
INDIRECT
The sac passes from the internal inguinal ring obliquely toward the external inguinal ring and ultimately into the scrotum
DIRECT
The sac protrudes outward and forward and is medial to the internal inguinal ring and inferior epigastric vessels
Although it sometimes can be difficult to distinguish between an indirect and a direct inguinal hernia, this distinction is of little importance because the operative repair of these types of hernias is similar
Pantaloon-type hernia
Occurs when there is an indirect and direct hernia component

13. INCIDENCE
Hernias are a common problem; however, their true incidence is unknown.
It is estimated that 5% of the population will develop an abdominal wall hernia, but the prevalence may be even higher
About 75% of all hernias occur in the inguinal region
Two thirds of these are indirect, and the remainder are direct inguinal hernias

14. Men are 25 times more likely to have a groin hernia than are women
INDIRECT INGUINAL HERNIA
Most common hernia, regardless of gender
In men, indirect hernias predominate over direct hernias at a ratio of 2 : 1
Direct hernias are very uncommon in women
The female-to-male ratio in femoral and umbilical hernias, however, is about 10 : 1 and 2 : 1, respectively
Although femoral hernias occur more frequently in women than in men, inguinal hernias remain the most common hernia in women.
Femoral hernias are rare in men. Ten percent of women and 50% of men who have a femoral hernia either have or will develop an inguinal hernia

15. Both indirect inguinal and femoral hernias occur more commonly on the right side
This is attributed to a delay in atrophy of the processus vaginalis after the normal slower descent of the right testis to the scrotum during fetal development
The predominance of right-sided femoral hernias is thought to be due to the tamponading effect of the sigmoid colon on the left femoral canal

16. The prevalence of hernias increases with age, particularly for inguinal, umbilical, and femoral hernias
Strangulation, the most common serious complication of a hernia, occurs in only 1% to 3% of groin hernias and is more common at the extremes of life
The likelihood of strangulation and need for hospitalization also increase with aging
Most strangulated hernias are indirect inguinal hernias; however, femoral hernias have the highest rate of strangulation (15%-20%) of all hernias, and for this reason, it is recommended that all femoral hernias be repaired at the time of discovery

17. Anatomy of the important preperitoneal structures in the right inguinal space.  (From Talamini MA, Are C: Laparoscopic hernia repair. I
n Zuidema GD, Yeo CJ [eds]: Shackelford's Surgery of the Alimentary Tract, 5th ed. Philadelphia, WB Saunders, 2002, vol 5, p 140.)

19. SIGNS AND SYMPTOMS
A bulge in the area on either side of your pubic bone
Pain or discomfort in your groin, especially when bending over, coughing or lifting
A heavy or dragging sensation in your groin
Occasionally, in men, pain and swelling in the scrotum around the testicles when the protruding intestine descends into the scrotum

20. CAUSES
Some inguinal hernias have no apparent cause. But many occur as a result of:
Increased pressure within the abdomen
A pre-existing weak spot in the abdominal wall
A combination of the two
The abdominal wall weakness that leads to an inguinal hernia occurs at birth when the abdominal lining (peritoneum) doesn't close properly.

21. Other inguinal hernias develop later in life when muscles weaken or deteriorate due to factors such as aging, strenuous physical activity or coughing that accompanies smoking.
In men, the weak spot usually occurs along the inguinal canal. This is the area where the spermatic cord, which contains the vas deferens, the tube that carries sperm, enters the scrotum.

22. In the male fetus, the testicles form within the abdomen and then move down the inguinal canal into the scrotum. Shortly after birth, the inguinal canal closes almost completely, leaving just enough room for the spermatic cord to pass through, but not large enough to allow the testicles to move back into the abdomen.
Sometimes, however, the canal doesn't close properly, leaving a weakened area.

23. In women, the inguinal canal carries a ligament that helps hold the uterus in place, and hernias sometimes occur where connective tissue from the uterus attaches to tissue surrounding the pubic bone.
There's less chance that the inguinal canal won't close after birth in female babies. In fact, women are more likely to develop hernias in the femoral canal, an opening near the inguinal canal where the femoral artery, vein and nerve pass through.

24. Weaknesses can also occur in the abdominal wall later in life, especially after an injury or certain operations in the abdominal cavity.
Whether or not you have a pre-existing weakness, extra pressure in your abdomen can cause a hernia. This pressure may result from:
Straining during bowel movements or urination
Heavy lifting
Fluid in the abdomen (ascites)
Pregnancy
Excess weight
Even chronic coughing or sneezing can cause abdominal muscles to tear.

25. Six hours prior to admission, upon lifting a case of beer, the mass protrudes to its largest size and cannot be pushed back anymore even with manipulation. The mass this time becomes painful and tender rendering him unable to walk.
What would you recommend for him?

26. Herniorrhaphy
In this procedure, your surgeon makes an incision in your groin and pushes the protruding intestine back into your abdomen, then repairs the weakened or torn muscle by sewing it together. After the operation, you'll be encouraged to move about as soon as possible, but it may be as long as four to six weeks before you're able to fully resume your normal activities.

28. Hernioplasty
In this procedure, which is something like patching a tire, your surgeon inserts a piece of synthetic mesh to cover the entire inguinal area, including all potential hernia openings. The patch is usually secured with sutures, clips or staples. Hernioplasty can be performed conventionally, with a single long incision over the hernia. But it's often done laparoscopically, using several small incisions rather than one large one. A fiber-optic tube with a tiny camera is inserted into your abdomen through one incision, and miniature instruments are inserted through the other incisions. Your surgeon then performs the operation using the video camera as a guide.

30. LAPAROSCOPIC REPAIR ADVANTAGES DISADVANTAGES
Less discomfort and scarring after surgery and a quicker return to normal activities
DISADVANTAGES
Increased risk of complications and of recurrence following surgery. These risks are reduced if the procedure is performed by a surgeon with extensive experience in these kinds of repairs

31. COMPLICATIONS
Most inguinal hernias enlarge over time if they're not repaired surgically.
Large hernias can put pressure on surrounding tissues — in men they may extend into the scrotum, causing pain and swelling.
But the most serious complication of an inguinal hernia occurs when a loop of intestine becomes trapped in the weak point in the abdominal wall (incarcerated hernia).
This may obstruct the bowel, leading to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas.
It can also diminish blood flow to the trapped portion of the intestine — a condition called strangulation — that may lead to the death of the affected bowel tissues.
A strangulated hernia is life-threatening and requires immediate surgery.

32. REFERENCES
Sabiston Textbook of Surgery, 18th ed.
Mayoclinic.com