40 years old lady complaining of Para umbilical hernia,examine her

abdomen?

Station 1

1)Position .2)Shape and size.3)Surface and edge. The surface is smooth and edge easy to define, except when the

patient’s abdominal wall is very fat. try to feel the upper border of the mass (to get above it):scrotal neck test*

4)Composition. The lump is firm as it usually contains omentum . If it contains bowel,

it is soft and resonant to percussion.it will be reducible unless the contents are adherent to the sac or the defect is very narrow. also auscultate for bowel sounds.

5)Cough impulse.2 times ex the cough impulsive first time with inspection ,and second

with palpation

6)Relations to skin (overlying skin;red….) 7)Ask patient to reduce the mass herself

8)Perform deep ring test*: to differentiate indirect from direct.

9)General examination ( respiratory , cardiovascular, abdominal: masses, ascites, PR: for BPH)

*Scrotal neck test: thumb ant, index and middle post to scrotal base,

try to feel the cord. If palpable>>it’s a scrotal mass, not palpable>>it’s an inguinoscrotal mass

*Deep ring test: ask pnt to b supine and reduce mass him/herself,

put ur finger 2cm above mid ing. ligament point*(point between ant. Sup. Ileac spine & pubic tubercle), keeping ur finger in place, ask pnt to stand up and cough.. If the mass did not appear (also u’ll feel cough impulse)>> it’s indirect.. If it appears>> it’s direct..

What is your diagnosis and the management ?

Station 2

(the pic is not the same pic in the exam but this one shows Strangulated Hernia with Evisceration: Strangulated hernia with eviscerated small bowel seen in center )

• Diagnosis :Strangulated hernia is incarcerated hernia with

resulting ischemia

• management : emergent surgery (to check whether the

intestinal tissue has died and to repair the hernia.)

NB:difference between types of hernia

• femoral hernia( the most type liable to be strangulated)

• indirect inguinal hernia commonest overall• Direct inguinal hernia• Umbilical hernia • Para umbilical hernia• Incision hernia• Epigastric hernia

Features Indirect Inguinal Hernia

Direct Inguinal Hernia Femoral hernia

Typical patient Young male Older male Old female

Proportion of groin hernias

60% 25% 15%

Anatomy Commence at deep ring, lateral to the inferior epigastric artery, and pass within the coverings of the spermatic cord.

Bulges medial to the inferior epigastric artery

Emerges from the femoral canal.

Relationship to the Tubercle

Start lateral to and above the tubercle,but passes superomedial to the tubercle into the scrotum.

Lies above the tubercle

Pass inferolateral to the tubercle

Descent In to the scrotum

Yes No No

Obstructs or strangulate

Yes Rarely yes

*The different between hernia & hydrocele:

hernia (indirect inguinal) Hydrocele ( non- communicating type)

cough impulse no cough impulse

reducible Irreducible

cannot get above it Can get above

testis palpable Testis not palpable

opaque translucentContain bowel and fluid only fluid

DDX:Inguinal hernia

Station 3

It is not the same pic but was Picture of swelling in inguinal region & scrotum

Station 4• 34 years old man has a mass in the

left loin, mention 5 important DDx:

DDx:• LF renal tumours• LF Pheochromocytoma• massively enlarged spleen• LF adrenal tumours• LF Hydronephrosis• LF adult polycystic kidney disease• LF renal vein thrombosis• LF acute tubular necrosis

N.B. :DDx of groin ( inguinal) swelling

1. Hernia: inguinal, femoral.2. Lymphadenopathy3. Psoas abscess/cyst4. Femoral artery aneurysm5. Saphena varix6. Testis: ectopic/undescended7. Cord: lipoma/hydrocele

NB: Hydrocele of the cord is a groin massNon-communicating hydrocele is a scrotal massCommunicating hydrocele is an inguinoscrotal mass.