Hernias Case Presentation

Surgery CaseMohamed Razeem

Monday, November 21, 11

Mr G, 67y, M, Retired farmer

PC - Enlarged scrotums (bilateral), discomfort

HPC - Going on for 2yrs. No pain, only discomfort, no effect on coughing/ straining

L side first, shortly followed by R

Persistent Cough

Systems review unremarkable


PMHx

Ongoing bilateral inguinal hernia for past 10yrs, Increases with coughing/ straining. Been managed with a truss

2009- R eye cataracts removed

2004- Allergic asthma diagnosed

2001- Type II DM diagnosed

1964- Open appendicectomy


DHx

NKDA

Aspirin 75mg OD, Ramipril 10mg OD, Rosuvastatin 20mg OD

Symbicort inhaler 200mg+6ug BD

Glicazide 40mg OD


FHxMaternal grandfather & uncle - TII DM

SHxSmokes 30cigs/d since 16y (76 pack years)

Drinks Alcohol occasionally

Lives with wife. ADL unremarkable


O/EGeneral: Looks well & comfortable, BP 130/78, HR 64bpm, RR 16/min, Apyrexial, No clubbing, stigmata of liver disease, icterus, pallor.

Abdo: Lanz scar on RF, Bilateral inguinal lumps, Soft & Non tender, no organomegaly, masses/ascites, +BS

Inguinal lumps: Increases on coughing, soft & non-tender, neck med. & Sup. to PT, Reducible (not maintained by pressure over DIR), +Cough impulse, +BS

Bilateral scrotal lumps, Soft & non tender, not reducible, can get above it, separate from testis, +cough impulse

CVS, RS, CNS & MSS unremarkable


Ix

Na K U Cr Hb MCV Pl WCC

141 4.1 4.3 63 16.4 96 232 8.8

FBC & Electrolytes


Dx & PlanBilateral Inguinal hernia extended to scrotum (previously diagnosed)

Bilateral inguinal hernia through abdo. wall (previously diagnosed)

Plan - Elective laparascopic repair of all hernias at the same time

Surgery went as planned. All hernia repaired without any complications

Pt discharged home after 2 days post-op


Hernias

Inguinal

Terms QuizFemoral

DDx Lump in groin

Causes

Congenital

Hiatus Unusual

Diaphragmatic

Eponyms


Defining Terms


Defining Terms1. Mr A noticed a lump in the groin that is reducible (?)



likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position)




2. It was medial & superior to pubic tubercle (?)





Inguinal hernia





Inguinal hernia

3. This went on for years. Then, one day, the lump became irreducible (?)





Inguinal hernia


Incarcerated





Inguinal hernia


Incarcerated

4. Few days later, the lump then became painful & overlying skin reddened (?)





Inguinal hernia


Incarcerated

4. Few days later, the lump then became painful & overlying skin reddened (?)

Strangulated


Defining Terms


5. Mr A complained of abdominal pain, vomiting and constipation (?)

Defining Terms



Obstruction

Defining Terms



Obstruction

6. Mr A was taken in to theatre and hernia sac was ligated and excised (?)

Defining Terms



Obstruction


Herniotomy

Defining Terms



Obstruction


Herniotomy

7. Mr A had a hernia arisen from an open appendisectomy scar 5 years ago (?)

Defining Terms



Obstruction


Herniotomy


Incisional hernia

Defining Terms



Obstruction


Herniotomy


Incisional hernia

8. This hernia was repaired without excision (?)

Defining Terms



Obstruction


Herniotomy


Incisional hernia

8. This hernia was repaired without excision (?)

Herniorrhaphy

Defining Terms


CausesChronic cough

Chronic Constipation

Straining to void urine

Surgery

Severe muscular effort

Obesity

Weakening with age


Inguinal Hernias

Clinically Oriented Anatomy, Sixth Edition

Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur


Direct Vs IndirectIndirect Direct

Origin

Cong. V Acq

Control by pressure over DIR

Strangulates

Extends to scrotum

Reduces on lying

Recurrence

Occurrence

Pass through DIR lat. to inf. epigastric v.

pass post. wall of canal med. to inf. epigastric v

may be congenital always acquired

yes no

commonly rarely

often rarely

not readily spontaneously

uncommon more common

2/3 1/3


Femoral Hernias

Clinically Oriented Anatomy, Sixth Edition

Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur


Other abdo. hernias

Incisional hernia

Umbilical, para-umbilical, supra-umbilical

Epigastric

Spigelian

Recurrent inguinal


Diaphragmatic Hernias

Congenital diaphragmatic

Congenital hiatus


Diaphragmatic Hernias

Acquired Hiatus


Eponymous Hernias Terms

Richter’s hernia

Littre’s hernia

Maydl’s hernia


Unusual hernias

Obturator hernia

Sciatic

Lumbar

Gluteal


DDx of a lump in the

groin


Thank you

References:

Clinically Oriented Anatomy, Sixth Edition, Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur (ebook)

General Surgery Lecture Notes, 12th edition, Ellis, Calne & Watson


Hernias Case Presentation

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