? At the end of the discussion a student should be able to understand:
1. The features of the given history which support the diagnosis
2. The clinical examination
--- Content provided by FirstRanker.com ---
3. The differential diagnosis4. What investigations would be most useful and why
5. What treatment options are appropriate
Case 1
--- Content provided by FirstRanker.com ---
I've developed a lump in my groin'A 25-year-old builder suddenly develops a golf-ball-sized, slightly
tender lump in his right groin after lifting a 20-kg bag of sand. He states
--- Content provided by FirstRanker.com ---
that he felt a tearing sensation as it happened. He attends theemergency department.
Case 2
--- Content provided by FirstRanker.com ---
`I can't push my lump back in anymore'
A 70-year-old retired man presents to surgical outpatient clinic with a
slightly tender lump in his left groin. He has had the lump for many
--- Content provided by FirstRanker.com ---
months, but previously it would disappear overnight, or if necessary he
could gently push it back inside. His health is fine, other than a cough
--- Content provided by FirstRanker.com ---
from years of smoking. Over the last 2 weeks he has not been able toreduce the lump.
--- Content provided by FirstRanker.com ---
Case 3`My hernia is sore and I've started to vomit'
A slim 73-year-old woman has had a groin lump for some time which
--- Content provided by FirstRanker.com ---
she ignored. Over the last 3 days it has become progressively morepainful, with redness of the overlying skin. She has not passed stools or
flatus during this time (which is unusual for her), and yesterday she
--- Content provided by FirstRanker.com ---
started to vomit.
What is a hernia?
--- Content provided by FirstRanker.com ---
Where do they occur?
What can they contain?
? Omentum and small bowel
--- Content provided by FirstRanker.com ---
? Meckel's diverticulum? Appendix
Why are they important?
Case 1: I've developed a lump in my groin'
--- Content provided by FirstRanker.com ---
What is the likely differential diagnosis?
? Inguinal hernia
? Femoral hernia
--- Content provided by FirstRanker.com ---
? Enlarged inguinal lymph node? Lipoma
? Less likely: groin abscess, epididymitis, undescended testis, saphena
varix, femoral artery aneurysm, psoas abscess, tumour
--- Content provided by FirstRanker.com ---
Case 1:`I've developed a lump in my groin'
What features of the given history support the diagnosis?
--- Content provided by FirstRanker.com ---
? Heavy exertion? Tenderness
? acute onset hernia
--- Content provided by FirstRanker.com ---
? enlarged lymph node or psoas abscess (signs of systemic illness would also beexpected)
Case 1? `I've developed a lump in my groin'
--- Content provided by FirstRanker.com ---
What additional features in the history would you seek to supportyour diagnosis?
? Past H/O hernia
--- Content provided by FirstRanker.com ---
? Family H/O hernias? Past surgical history
? Has he been otherwise well?
Case 1 ? `I've developed a lump in my groin'
--- Content provided by FirstRanker.com ---
What clinical examination would you perform and why?
? Examine the groins and external genitalia.
? Cough impulse and reducibility
--- Content provided by FirstRanker.com ---
? Indirect
? Direct
--- Content provided by FirstRanker.com ---
? Distinguishing between the two types makes no difference totreatment
Case 1 ? `I've developed a lump in my groin'
--- Content provided by FirstRanker.com ---
What investigations would be most useful and why?? CBC
? Ultrasound
--- Content provided by FirstRanker.com ---
Case 1? `I've developed a lump in my groin'What treatment options are appropriate?
? Surgical:
--- Content provided by FirstRanker.com ---
? The most common approach for repair is still an open operation
? laparoscopic repair for recurrent, bilateral and unilateral inguinal
--- Content provided by FirstRanker.com ---
? Permanent synthetic mesh is implanted? Laparoscopic repair requires a general anaesthetic, while open repair
can be performed under local anaesthetic
--- Content provided by FirstRanker.com ---
? For unilateral primary groin hernias, the approaches have similarrecurrence rates, similar disability times, and similar costs
Case 2 ? `I can't push my lump back in
--- Content provided by FirstRanker.com ---
anymore'What is the likely differential diagnosis?
? Inguinal hernia
--- Content provided by FirstRanker.com ---
? Femoral hernia? Enlarged lymph node (infection, metastatic tumour)
? Femoral artery aneurysm
? Saphena varix
--- Content provided by FirstRanker.com ---
Case 2 ? `I can't push my lump back inanymore'
What features of the given history support the diagnosis?
--- Content provided by FirstRanker.com ---
? A previously reducible groin mass which is no longer so is a very clear
history of a groin hernia
Case 2 ? `I can't push my lump back in
--- Content provided by FirstRanker.com ---
anymore'
What additional features in the history wil support your
--- Content provided by FirstRanker.com ---
diagnosis?? Ask about urinary symptoms ?BPH
? Increases the risk of post-operative acute urinary retention
--- Content provided by FirstRanker.com ---
Case 2 ? `I can't push my lump back inanymore'
What clinical examination would you perform and why?
--- Content provided by FirstRanker.com ---
? Examine both groins and external genitalia
? Perform a digital rectal examination (DRE) to exclude BPH
Case 2 ? `I can't push my lump back in
--- Content provided by FirstRanker.com ---
anymore'What investigations would be most useful and why?
? Ultrasound may be useful to differentiate between clinically unclear
--- Content provided by FirstRanker.com ---
entities.
Case 2 ? `I can't push my lump back in
--- Content provided by FirstRanker.com ---
anymore'What treatment options are appropriate?
? Surgical: early elective repair is indicated
--- Content provided by FirstRanker.com ---
Case 3 ? `My hernia is sore and I've started tovomit'
What is the likely differential diagnosis?
--- Content provided by FirstRanker.com ---
? Inguinal hernia, with ischaemia and bowel obstruction
? Femoral hernia, with ischaemia and bowel obstruction
? Psoas abscess
? Infected lymph node
--- Content provided by FirstRanker.com ---
Case 3 ? `My hernia is sore and I've started to
vomit'
--- Content provided by FirstRanker.com ---
What features of the given history support the diagnosis?? Recent change in the groin lump
? Vomiting and constipation
? A femoral hernia is more likely to cause ischaemia as a result of the
--- Content provided by FirstRanker.com ---
tight neck of the femoral canal
Case 3 ? `My hernia is sore and I've started to
vomit'
--- Content provided by FirstRanker.com ---
What additional features in the history would you seek to support
your diagnosis?
--- Content provided by FirstRanker.com ---
? Exclude infections that would drain to the inguinal lymph nodes? Local inflammation could explain the erythema of the skin and
tenderness of the lump
--- Content provided by FirstRanker.com ---
? Systemic sepsis can secondarily cause paralytic ileus that would causevomiting
Case 3 ? `My hernia is sore and I've started to
--- Content provided by FirstRanker.com ---
vomit'
What clinical examination would you perform and why?
--- Content provided by FirstRanker.com ---
? Examine the groin carefully? Femoral hernias are seen more commonly in women than men
? Femoral hernias are felt below and lateral to the pubic tubercle
? Approximately 40 per cent of femoral hernias present with
--- Content provided by FirstRanker.com ---
strangulationCase 3 ? `My hernia is sore and I've started to
vomit'
--- Content provided by FirstRanker.com ---
What investigations would be most useful and why?? A plain abdominal x-ray
? An ABG test may show a metabolic acidosis and raised lactate,
--- Content provided by FirstRanker.com ---
suggesting ischaemia? Other investigations will be directed at readying the patient for
emergency surgery
--- Content provided by FirstRanker.com ---
Case 3 ? `My hernia is sore and I've started to
vomit'
--- Content provided by FirstRanker.com ---
What treatment options are appropriate?? Medical:
? fluid resuscitation
--- Content provided by FirstRanker.com ---
? nasogastric tube reduces the risk of vomiting and aspiration
? Surgical:
--- Content provided by FirstRanker.com ---
? emergency surgery is needed? lower midline laparotomy,
? any non-viable bowel will need to be resected
--- Content provided by FirstRanker.com ---
? repair of hernia
OSCE Counselling case 1 ? `Should I have my
hernia repaired?'
--- Content provided by FirstRanker.com ---
? Risks of treatment Vs Risk of not treating the hernia? There is strong consensus that groin hernias should usually be
repaired
--- Content provided by FirstRanker.com ---
OSCE Counselling case 1.2 ? `Why did mysurgeon suggest I see a urologist first?'
? H&E
--- Content provided by FirstRanker.com ---
? PSA? TRUS
? Prostate biopsy if necessary
--- Content provided by FirstRanker.com ---
? Cystoscopy to assess the bladder and prostatic urethra
? Medications may be all that are required to manage the symptoms
--- Content provided by FirstRanker.com ---
? TURP may be required? This assessment and treatment is best performed prior to
uncomplicated elective hernia repair
--- Content provided by FirstRanker.com ---
An 80-year old woman has lost several kgs over the last 3 months. For
the last 3 days she has not been able to eat anything, has been
--- Content provided by FirstRanker.com ---
vomiting, and was found in bed this morning confused and quite ill.
Her abdominal exam is fairly unremarkable without any previous scars.
--- Content provided by FirstRanker.com ---
? This woman likely has an obturator or possibly a femoral hernia.? Obesity can make examination of the groin difficult.
? Her management is much different than the previous case.
--- Content provided by FirstRanker.com ---
Management? Plain films of the abdomen should also
be obtained, as the patient may have
--- Content provided by FirstRanker.com ---
a bowel obstruction due to small
bowel incarceration in the hernia.
--- Content provided by FirstRanker.com ---
? How might this change yourmanagement?
--- Content provided by FirstRanker.com ---
Laparoscopic Hernia ReductionLaparoscopic Repair
Conclusion
--- Content provided by FirstRanker.com ---
? Hernias should usual y be surgical y repaired when present, in order totreat symptoms of discomfort, and to reduce the risk of serious
complications.
--- Content provided by FirstRanker.com ---
? Ultrasound is sometimes required to diagnose atypical hernias (or hernias
in unusual sites), and to exclude conditions that may mimic hernia, such as
--- Content provided by FirstRanker.com ---
lymphadenopathy.? Hernia repair may be open or laparoscopic. Each method has specific
advantages and risks, which should be discussed with the patient. Neither
--- Content provided by FirstRanker.com ---
has a fundamental advantage over the long term.
? Patients who present with bowel obstruction should be checked for hernia
--- Content provided by FirstRanker.com ---
as a possible cause.? Chronic pain is an under-recognized complication of hernia repair, and
may occur in up to 10 per cent of patients.
--- Content provided by FirstRanker.com ---