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

2. 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

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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. Diagnosis
Physical Exam and PE

12. 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

13. 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

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

15. 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

16. 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

17. 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

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

19. 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.)

20. 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

21. 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

22. 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

23. 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

24. Indirect Inguinal Hernia Complete Type
THERAPEUTIC PLANS
Indirect Inguinal Hernia
Complete Type

25. 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

26. 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

27. 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

28. 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

29. 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

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

31. 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)

32. 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

33. 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

34. 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