Dr.B.Selvaraj MS;MCh;FICSProfessor of Surgery

Melaka Manipal Medical collegeMelaka Malaysia 75150

GROIN SWELLINGS

INGUINAL HERNIA

Inguinal Hernia- Overview

Causes of groin swellings Classical Clinical Vignette of Inguinal Hernia Inguinal Hernia in detail- one pathology in each

episode Mind map of Inguinal Hernia Algorithm to clinch the correct diagnosis Tabular column of differential diagnosis depicting

their characteristic features to differentiate them from Inguinal Hernia

Causes of Groin swellings

Inguinal hernia- Indirect & direct Femoral hernia Undescended testis Inguinal lymphadenitis Lipoma of spermatic cord Encysted hydrocele Saphena varix Femoral artery aneurysm Psoas abscess Femoral nerve neuroma

Classical Clinical Vignette

40 years old male patient, a manual labourer by occupation, presented with a swelling in his right groin and scrotum for last 2 years and pain over the swelling for last 6 months.

The swelling appeared insidiously, initially in the right groin and gradually increased in size for last 2 years and descended into the right scrotum.

The swelling disappears completely when the patient lies down, but the swelling reappears on standing and increases in size as the patient walks & coughs

Bladder and bowel habits are normal. No history of chronic constipation, or difficulty in micturition.

Classical Clinical Vignette

Patient complains of chronic cough and breathlessness for last 3 years, which particularly aggravates during the winter season.

O/E: The swelling is pyriform in shape and there is visible peristalsis and expansile impulse over the swelling.

It is not possible to get above the swelling and there is palpable expansile impulse. The swelling lies above and medial to the pubic tubercle.

The content of the swelling reduces with a gurgling sound. The deep ring occlusion test is positive.

Bowel sounds are audible over the swelling. Lt inguinoscrotal region is normal

Inguinal Hernia

Inguinal Hernia

Hernia is an abnormal protrusion of the whole or a part of a viscus through an opening in the wall of the cavity which contains it

Inguinal hernia occurs either through the deep inguinal ring (indirect) or through the posterior wall of inguinal canal (direct hernia).

The hernia sac consists of mouth, neck, body, and fundus

Inguinal Hernia- Etiology

Pediatric congenital hernias due to patent PV Indirect inguinal hernia due to increased intra abdominal pressure Direct inguinal hernia due to weakness of posterior wall of inguinal

canal Classification: The European Hernia Society has recently suggested a

simplified system of classification Primary or recurrent (P or R); Lateral, medial or femoral (L, M or F); Defect size in finger breadths assumed to be 1.5 cm. A primary, indirect, inguinal hernia with a 3-cm defect size would be

PL2.

Inguinal Hernia- Indirect

Indirect inguinal hernia is a herniation of abdominal contents through the deep inguinal ring into the inguinal canal. As it traverses the inguinal canal, it is invested by the following

coverings from outside within 1. Skin 2. Superficial fascia/dartos muscle in scrotum. 3. External spermatic fascia derived from external oblique muscle. 4. Cremasteric fascia derived from the internal oblique muscle. 5. Internal spermatic fascia derived from fascia transversalis and 6. The peritoneum which forms the sac.

Inguinal Hernia- Indirect Types Bubonocele: Hernial sac stops within

inguinal canal after entering internal ring Funicular: Hernial sac after emerging

out of external ring stops just above the testis

Complete Scrotal: Processus vaginalis is patent throughout being continuous with tunica vaginalis of the testis. It is a congenital hernia, commonly seen in children but it may appear in adult or adolescent life.

Inguinal Hernia- Clinical Features

Swelling in the inguinal region, this is gradually increasing in size. History of dragging pain indicates pull on mesentry in enterocele

and pull on omentum in omentocele Age—It occurs in all ages from birth to elderly. Direct hernia is

more common in elderly people while indirect hernia is more common in younger and adult life.

Expansile impulse on coughing is present. Indirect Pyriform shape; Direct Globular shape Direct hernia pops out as soon as patient stands. Presence of a scar indicates recurrent hernia

Inguinal Hernia- Clinical Features Swelling is soft and gurgles if it is enterocele. It may be firm or

granular if omentocele An expansile impulse is felt at the root of scrotum. Getting above the swelling is not possible Reducibility: The direct hernia usually reduces immediately and

spontaneously but indirect hernia may require manipulation Internal or deep ring occlusion test: swelling does not reappear

in case of indirect hernia; swelling reappears immediately in case of direct hernia

Inguinal Hernia- Clinical Features Ziemann’s Test: (Three fingers test):Index finger is kept at the

deep ring, Middle finger, at the superficial ring and Ring finger, at fossa ovalis. Depending on the type of hernia, indirect, direct and femoral, impulse is felt by the index, middle and ring fingers respectively.

Examination of respiratory system is done to rule out chronic bronchitis/ COPD

Leg raising test (Head raising test): Weakness of the oblique muscles is manifested by Malgaigne’s bulging- the precursor of a direct inguinal hernia.

Inguinal Hernia- Clinical Features

Inguinal Hernia- Clinical Features

Indirect Vs Direct Inguinal

Hernia

Indirect Vs Direct Inguinal

Hernia

Inguinal Hernia-Special Types

Dual/Pantaloon/Saddle Hernia: Both direct and indirect sacs +

Sliding Hernia: (Hernia-en-glissade) Retroperitoneal organ is part of hernial sac

Richter’s Hernia: only part of circumference of the small gut is obstructed

Maydl’s Hernia: “W” shaped hernia Littre’s Hernia: Meckel’s diverticulum Amyand’s Hernia: Appendix

Inguinal Hernia-

Complications

Irreducible: Hernia is no more reducible Obstructed: Lumen of hollow viscera is

blocked. Can not happen in omentocele. Strangulated: The blood supply to the

content of hernial sac is cut off Gangrene Perforation Peritonitis

Incarcerated: The block of the lumen of hollow viscera is due to thick fecal matter/ adhesions

Reduction-en-mass: Taxis is normal maneuver to reduce; If you forcibly reduce this complication can occur

Inguinal Hernia-

Complications

Inguinal Hernia-

Treatment

Pediatric congenital: High ligation of sac/ Herniotomy Young adults: Herniorraphy- suturing together patient’s

tissues 1. Bassini’s repair 2. Shouldice repair 3. Maloney’s repair Darning of posterior wall 4. Desarda repair Strip of external oblique aponeurosis is used to strengthen posterior wall

Inguinal Hernia-

Treatment

Old people: Hernioplasty Litchtenstein’s tension free mesh repair

Prolene Hernia System: PHS- Gilbert’s open suture less repair

Open pre-peritoneal repair- Stoppa’s Laparoscopic repair: TAPP & TEP Indications: 1.Recurrent Hernias 2.Bilateral inguinal hernias

Inguinal Hernia-Complications Of Surgery

Seroma/ Hematoma Urinary retention Wound infection Recurrence Chronic neuralgic pain due to nerve injury or entrapment Testicular atrophy due to testicular artery injury

Inguinal Hernia- Mindmap

Algorithm for Groin Swellings

D/D for Groin Swellings Compare & Contrast; Vertical reading