Hernia+scrotal mass

1 anatomygroin groin
hernia
2 ,, groin
hernia
3 abdominal hernia
4 groin hernia
5 differential diagnosis scrotal mass
Hernia
Hernia rupture
an abnormal protrusion
of an organ
or tissue
through a defect in its surrounding walls
Etiology
patent processus vaginalis
Mechanical disparity between visceral
pressure and resistance of abdominal
musculature
Nyhus classification of groin hernia
I Indirect hernia
normal size internal ring
Typically in infants children,small adult
II Indirect hernia
Dilated internal ring
Posterior wall intact
Inferior epigastric vessels not displaced
Does not extend to the scrotum
III Posterior wall defect
A Direct hernia
Size not taken into account
B Indirect hernia
dilated internal ring encroaching on
Hesselbachs triangle(massive
scrotal,slinding or pantaloon)
C Femoral hernia
IV Recurrent hernia
A Direct
B Indirect
C Femoral
D Combined
1) Epigastric
2) Diastasis (not a true hernia)
3) Supra-umbilical hernia
4) Umbilical hernia
5) Incisional hernia
6) Scar (previous inguinal hernia
op)
7) Recurrent inguinal hernia
8) Spigelian hernia (very rare)
9) Femoral hernia
10) Inguinal hernia
11) Pubic bone
12) Inguinal ligament - groin skin
crease
Anatomy
Skin
Fatty layer of superficial fascia (Campers
fascia)
Membranous layer of superrficial fascia
(scarpas fascia)

External Oblique Muscle and
Aponeurosis
1 Superficial boundary
of the inguinal canal

2 Forms the anterior
rectus sheath
+aponeurosis
internal oblique
transversus abdominis
3 Inferior edge
=inguinal ligament
(pouparts ligament)
ASIS
pubic tubercle
Lacunar ligament
(gimbernats
ligament)=
insertion of inguinal
ligament to pubis
External (superficial)inguinal

Ovoid opening of the external oblique
aponeurosis
Spermatic cord exit inguinal canal
Superiorly and slightly lateral to pubic tubercle
Internal Oblique Muscle and
Aponeurosis
Run transverse in
inguinal region

Cephalad
(superior)border of
inguinal canal
Medial aspect fuse with transversus
abdominis aponeurosis =
conjoint tendon
Cremasteric muscle
encompass the
spermatic cord
Transversus Abdominis Muscle and
Aponeurosis and
Transversalis Fascia
Prevention of inguinal
hernia
Component of
inguinal floor

Iliopubic tract forms
inferior crus of the
deep inguinal ring
Inferior to the
inguinal ligament
ASIS
Coopers ligament
= pectineal ligament
Forms by periosteum
and fascia
Along superior ramus
of pubis
Forms posterior
border of femoral
canal

Inguinal canal
4 cm in length
2-4 cm cephalad to
inguinal ligament


Deep ring=internal ring
Superficial =external ring
Inguinal canal content
Spermatic cord
Round ligament
Spermatic cord
Hesselbachs triangle
Superolateral
= inferior epigastric
vessels
Medial
= Rectus sheaths
Inferior border
= inguinal ligament
Nerves
Iliohypogastric
Ilioinguinal
Femoral canal
Anterior
=iliopubic tract
Posterior
=coopers ligament
Laterally
= femeral vein
Apex
= pubic tubercle

Symptom
Groin pain
Pressure or heaviness
Groin mass
Duration and progressive

Sign
Inspection
Palpation
Inguinal occlusion test
Differential diagnosis of groin hernia
Malignancy
-lymphoma
-retroperitineal sarcoma
-metastasis
-testicular tumor
Primary testicular
-varicocele
-epididymitis
-testicular torsion
-hydrocrle
-ectopic testicle
-undescended testis
Femeral artery
aneurysm or
pseudoaneurysm
Lymph node
Sebaceous cyst
hidradenitis
Cyst of the canal of
nuck(female)
Saphenous varix
Psoas abscess
Hematoma
Ascites
Investigation
Film
Ultrasound
Treatment
Open
Laparoscopic
Open
Tissue repair
Tension free repair
Tissue repair
Bassini
Mcvay
Shouldice
Bassini
Conjoint tendon
Inguinal ligament
3 Inferior edge
=inguinal ligament
(pouparts ligament)
ASIS
pubic tubercle
Mcvay
Conjoint
Cooper ligament

Shouldice
Multilayer repair
Recurrent rate = tension free
Tension free repair
Lichtenstein
Prosthetic
non absorbable
mesh
Laparoscopic
Tranabdominal
preperitoneal
repair (TAPP)
Totally extra
peritoneal
repair(TEP)
Results
Recurrent
Bassini
8.6%
Shouldice
6%
Mcvay
11.2%
Tension free
0.2%

Richters hernia
a portion of the circumference of
the intestine
Littres hernia
Meckels diverticulum

Indirect
Direct
Femoral
Reducible
Irreducible
Incacerated -
Obstruct
Strangulated
Femoral hernia
Most often strangurated
Mass below inguinal ligament
Coopers ligament repair
Obturator hernia
Obturator canal union of
pubic bone and ischium
Covered by membrane-
obturator nerve vessel
Weak membrane
Howship-Romberg sign
Pain in median aspect of
thigh
bowel obstruction

Incisional hernia
Complication of prior surgery
Midline and transerve incision
Treatment <3cm suture
>3cm mesh
Umbillical hernia
Infant congenital
closed spontaneus 2 years
surgery >5years
Adult acquire
small
large surgery

Hydrocele
Varicocele
Epididymo orchitis
Testicular tumor
Hydrocele

Hydrocele
Collection of fluid within the tunica or
processus vaginalis
May occur in spermatic cord

Etiology
Excessive production of fluid within the
sac
Defective absorbtion of fluid
Interfence with lymphatic drainage
Connection with hernia
Tranlucent
Get above the swelling
Beware in young men about testicular
tumor
Varicocele
Dilatation of vein that drain the testis
Left testicular vein
left renal vein
Right
inferior venacava below right renal
vein
Left 95%
Beware tumor does not decompress in
the supine position &right side
Clinical
Does not ussually cause symptom
Vague and annoying dragging discomfort
Bag of worm
The scrotun lower than normal
Surgery
Sperm concentration and motility
decrease 65-75%
Poor testicular growth
Discomfort
Epididymo orchitis
Inflamation
epididymis to body of
testis
Lumen of vas from infection of uretha
,prostate, seminal vesicle
Chamydia in young men
Clinical
Acute prostatitis
Rapid swelling ,painful
Red,edematous and shiny
Treatment
ATB 2 weeks
Testicular tumor
99% malignant
1-2% malignant tumor in men
Most common forms of cancer in young
men
Seminoma
40%
Teratoma
32%
Combine
14%
Interstitial tumor 1.5%
Lymphoma 7%
Other 5%

Scrotal lump cannot be felt separately
from testis may be malignant tumor
Lymphatic spread retroperitoneal and
intra thoracic
Pulmonary metastasis suggest teratoma

Schwartzs PRINCIPLE of SUTGERY 9
th

edition 2010
Sabiston Textbook of Surgery 18
th

edition 2008
Bailey&Loves Short practice of surgery
24
th
edition 2004
Greenfields surgery scientific principle
&practice 4
th
edition 2006