Inguino-scrotal lumps
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Inguino-Scrotal Lumps
Inguino-Scrotal Lumps
Why?
Because they’re common.
Because they’re really common.
Because the anatomy is fun to quiz people on.
Because they’re common.
Account for up to 20% of General surgical referrals.
Pathologies
Inguinal
Sebaceous Cysts/Lipoma’s
Inguinal Lymphadenopathy
Saphenous Varix
Femoral Artery aneurysm
Psoas Abscess
Undescended testes.
Inguinal Hernia
Femoral Hernia
Scrotal
Testicular tumor
Epididymal cyst
Spermatocoele
Hydatid of Morgagni
Varicocoele
Hydrocoele
Inguino-scrotal Hernia
Assessment-History
Lump When was it first noticed?
How was it noticed?
Precipitant activity
Recent illnesses
What symptoms are present? ?pain, functional impairment
GI/GU disturbance.
Systemic symptoms-fevers, night sweats etc.
Is the lump changing?
Does the lump come and go How or when?
Assessment-Exam
Lump Position, Shape and size
Surface Skin
Mass surface
Temperature
Tenderness
Composition-Solid/Fluid/Gas Consistency
Fluctuation/Fluid thrills/Resonance
Translucency
Pulsatility
Reducibility/Cough impulse
Relations to surrounding structures
Regional Lymph nodes
Assessment-Exam
Both sides
Hernia Tests Standing and lying
?Get above it
Cough Impulse
Reducibility and control
Associated structures Pulses, testes, Lymph nodes.
Special tests Transillumination
Assessment
Investigation Occasional use only
Ultrasound/duplex For early hernia’s-not so reliable.
Useful for testes/vascular assessment
CT More for assessing deeper anatomy
Herniagram
Laparoscopy
Assessment
How Not to Kill people, Don’t miss tumors
Exclude Malignancy Lymphadenopathy-Generalized, unexplained or persistent
BIOPSY!
Discrete Scrotal Lumps or unexaminable testes
Ultrasound and/or Refer
No Part time Vascular Surgery
Anatomy
Inguinal region
Inguinal Canal
Spermatic Cord
Femoral Canal and Ring
Scrotum/testes
Anatomy
Inguinal region Includes
Lower abdominal wall
Femoral Triangle Sartorius/Add Longus/
Inguinal Lig
Contains Femoral Pedicle
Lymph Nodes
Skin/fat/muscle
Anatomy
Inguinal Canal An oblique series of
defects in the layers of the abdominal wall.
Site of Inguinal Herniae
Transmits the Spermatic cord/Round ligament.
Round ligament
Runs from Uterine fundus via canal to Labia.
Anatomy
Inguinal Canal Floor
Inguinal Ligament and Lacunar ligament
Roof Arching fibres of Int Obl
& Trans abdominis and Conjoint tendon
Anterior Wall External Oblique
aponeurosis
Superficial Ring
Post Wall Conjoint tendon medially,
Transversalis fascia laterally
Deep ring
Anatomy
Femoral Canal Beneath the inguinal
ligament Iliacus muscle
Femoral Nerve
Femoral Sheath containing…
Femoral vessels
Femoral Canal
Femoral Canal Space for venous
expansion
Lymphatics.
Upper end defined by femoral ring.
Anatomy
Femoral Canal Beneath the inguinal
ligament Iliacus muscle
Femoral Nerve
Femoral Sheath containing…
Femoral vessels
Femoral Canal
Femoral Canal Space for venous
expansion
Lymphatics.
Upper end defined by femoral ring.
•Femoral Ring
•Site of Femoral Herniae
Anatomy
Eponyms Hesselbachs Triangle
Lateral border of rectus muscle
Inguinal Ligament
Inferior epigastric vessels (med border of deep ring)
Fruchauds Myopectineal Orofice Hesselbachs triangle
Deep ring
Femoral sheath/canal.
Anatomy
Spermatic cord
Pedicle of the testes
Made up of 12 things
Anatomy
Spermatic cord
Pedicle of the testes
Made up of 12 things You’re not getting
away with that!
Anatomy
3 Arteries
3 Nerves
3 Important structures
3 Coverings
Anatomy
3 Arteries Testicular
Artery to the Vas Deferens
Cremasteric
3 Nerves Sympathetic branches
Ilio-inguinal (on cord)
Genital Br of Genito-femoral nerve.
3 Important structures Vas Deferens
Pampiniform Plexus
Processus Vaginalis
3 Coverings External Spermatic Fascia
Cremasteric Muscle
Internal Spermatic Fascia
Anatomy
Spermatic cord
Only truly forms at the superficial ring.
Passes through the superficial ring
above and medial to the pubic tubercle.
Descends through S/C fat into the scrotum.
Anatomy
Testes
Suspended on spermatic cord,
Enveloped within Tunica vaginalis
Drain via epididymis to Vas Deferens
Made up of
Germinal elements-Seminiferous tubules
Non-Germinal elements-Stroma, Leydig cells
Pathologies
Inguinal
Sebaceous Cysts/Lipoma’s
Inguinal Lymphadenopathy
Saphenous Varix
Femoral Artery aneurysm
Psoas Abscess
Undescended testes
Inguinal Hernia
Femoral Hernia
Scrotal
Testicular tumor
Epididymal cyst
Spermatocoele
Hydatid of Morgagni
Varicocoele
Hydrocoele
Inguino-scrotal Hernia
Skin stuff
Sebaceous cysts
Retention cysts of sebaceous glands
Fixed to skin-dimple if squeezed
Can become infected-abscess.
Incise and drain
Management
excise when non-inflammed.
Skin stuff
Lipomas Benign Fatty lumps
Clinically fixed (skin and fat)
soft lumps,
usually longstanding and asymptomatic.
Management excise surgically
Inguinal Lymphadenopathy
Causes Primary Lymphatic disease-Lymphoma
Secondary Lymphadenopathy Malignant disease
Benign Physiological reaction to inflammatory
state
Management Exclude Inflammatory causes
Examine, Observe, Antibiotics etc.
Exclude obvious malignancy
Biopsy-FNA/Open
Saphenous Varix
Prominent Varicosity of Upper Long Saphenous Vein. Typical Patient
Middle aged and older
F>M
Usual Risk Factors Pregnancy, Pelvic Mass
Clinically Dragging lump over upper thigh, disappears when lying
Cough impulse +
Thrill down vein when percussing.
Management-surgical ligation.
Femoral Artery Aneurysm.
True aneurysms
Pulsatile lump in groin
Associated with other aneurysmal disease
Mx-Vascular surgical repair if >2-3cm
False aneurysm
Secondary to puncture
Dx on duplex
Mx-Call a vascular surgeon-thrombose or repair.
Psoas Abscess
Abscess within Psoas fascia that tracks to groin and presents as a lump.
Associated with Retroperitoneal infection/inflammation
Post Surgical eg. Nephrectomy
Colonic
Pancreatitis
Spinal TB
Management Drain and treat underlying cause
Undescended Testes
Rare in adults
Usually Dx and treated as children
In adults usually present as infertility
Alt painless lump in Inguinal canal
Prone to infertility and testicular cancer.
Managemant
Refer to Urologist.
Scrotal Lumps
Assessment Hx/Ex as previous
If not obvious Hernia/Varicocoele/ Hydrocoele and normal testes Ultrasound Lump origin
Solid vs cystic etc.
If still in doubt-Call a Urologist.
Surgical exploration
Scrotal Lumps
Solid lumps. Testicular origin
mostly malignant
Paratesticular origin mostly benign
Cystadenoma, Adenomatoid tumor (epididymis)
Inflammatory pseudotumor
Cystic lumps Usually benign
Epididymal cyst,
Spermatocoele,
Hydatid of Morgagni
Testicular Lumps
Testicular tumors
Usually painless lumps in 2nd to 4th decades
Germinal-95%
Seminoma/Embryonal Cell/ChorioCa/Teratoma
Non-Germinal
Stromal-Leydig Cell Tumor; Gonadoblastoma
Management
Call a Urologist
Usually multimodal Therapy
Hydrocoele
Collections of fluid in Tunica Vaginalis Typically >40yrs except infantile.
Classes Congenital-communicating
Reactive-tumor/trauma/infection
Idiopathic.
Clinically Usually dragging scrotal mass,
Can get above them, fluctuant, transilluminate well
Must exclude malignancy Clinically normal testes or ultrasound
Treatment Aspirate-tend to recur
Surgery-Jaboulet procedure.
Hydrocoele
Varicocoele
Dilatation of the Pampiniform Plexus
Usually affects 20 to 50 yo’s
L>R due to venous anatomy.
Acute varicocoele-exclude RP infiltration
May cause infertility
Painless lump Bag of worms
Cough impulse +ve
May reduce on lying down
Treatment Ligation at deep ring or excision.
Other Scrotal Lumps
Epididymal cyst Cyst arising from epididymis
Spermatocoele Sperm filled cyst arising from the testes.
Hydatid of Morgagni Small mobile cyst from top of testes
Embryological remnant of Mullerian duct.
Subject to torsion
Management Exclude testicular Mass-Ultrasound
Surgery if large/symptomatic.
Hernias
Inguinal herniae
Hernia Numbers 25% of males (2% F) will develop a groin hernia
65% Indirect Inguinal herniae 55% on the right
31% Direct Inguinal Herniae Although represent 80% of bilateral herniae
4% Femoral Herniae More common in women 20 % of all groin herniae c/w 2%
male.
Causes Congenital
Chronic Stress to area
Metabolic-Collagen-vasc Ds, Smoking
Hernia types
Inguinal
Direct
Indirect Pantaloon
Femoral
Also
Sliding herniae
Sliding Hernia
A Hernia in which the peritoneal wall that forms part of the sac has an organ naturally adherent to it.
Eg. If an extraperitoneal organ (usually Bladder or colon) slides out with its adherent peritoneum through the hernia defect the organ itself becomes part of the wall of the sac.
Must look out for this at the time of surgery because the organ is easily injured upon opening the sac.
Can be direct or indirect.
Sliding hernia
Non sliding hernia
Inguinal herniae
Clinically Groin pain/discomfort
Dragging, worse during the day
Lump Asymmetry-inguino-scrotal swelling
GI/GU obstruction
Incarceration/Irreducibility
Hernia examination
Direct vs indirect
Direct Diffuse bulge
Rarely into scrotum
Controlled only at superficial ring
Indirect Usually more defined
May extend into scrotum
Herniation/reduction more prominent
Controlled at deep ring.
Femoral vs inguinal
Inguinal Lie in/above groin crease
Appear above and medial to pubic tubercle.
Extend into scrotum
Femoral Lie below crease
Appear below and lateral to tubercle
Extend into thigh
Hernia Complications
Incarceration
Strangulation Risk-Indirect and Femoral>>>Direct
Surgical emergency
Call the surgeon-don’t try and reduce.
Herniated Viscera is entrapped and infarcted.
Acute, tender, painful lump +/- SBO
Richters Hernia
Reduction en-masse
Progressive growth=Natural Hx of herniae.
Hernia Management
Fix it!
Eliminates pain
Eliminates Lump
Avoids hernia growth
Avoids risk of strangulation
Esp in indirect hernia
Straightforward surgery.
Inguinal Operations
Previous
Bassini, McVay, Shouldice
Forget them
Now
Lichtenstein tension free mesh repair.
Laproscopic repair.
Hernia operations
Lichtenstein tension free mesh repair. Developed in NY at the Lichtenstein Hernia
clinic
Originally done as OP procedure under LA
Involves
Dissecting Inguinal canal and mobilising cord
Inverting/removing hernia sac
Reinforcing posterior inguinal wall with prolene mesh.
Open Hernia Repair
Hernia operations
Lichtenstein tension free mesh repair.
Results
All can be done under LA
Widely adopted
Recurrence rate 1-2%-Lichtenstein
Hernia Operations
Laparoscopic TAPP
Trans abdominal Pre-peritoneal Patch
TEPP
Totally Extraperitoneal Pre-peritoneal Patch
Both place a Mesh patch over the hernial defect inside the abdominal muscle layer, outside the peritoneum.
Lap Hernia Repair
Hernia Operations
Lap repairs Multiple RCT’s C/W open repair.
Results equivalent for Recurrence rate (? Better)
LoS
Better for Post -op pain
Return to work
?Chronic Groin pain
Worse for OP time
Cost
Tend to be reserved for Recurrent or Bilateral repairs.
Hernia Operations
Complications
Infection ~1.5%
Incl Mesh infection
Bleeding~1%
Hernia recurrence
Varies with technique, should be <2%
Nerve injury/Chronic groin discomfort 5-10%
Ischaemic orchitis/atrophy ~1-2%
Urinary retention 1-10%
Femoral Herniae
3 ways
High Approach
McEvedy-via the abdomen
Best for difficult or strangulated Herniae
Middle
Lothieson-via the Inguinal canal
Used occasionally for indeterminate herniae.
Low
Lockwood-via the upper thigh/groin
Best for small hernia and elective repairs
Summary
Remember the anatomy
Lumps can arise from any tissue.
Understand the Hernia anatomy and the clinical management is easy
Don’t kill anyone Don’t miss Malignancy-Ing LN and scrotal
lumps.
Fix the hernias