Download MBBS Final Year Surgery Case Presentation Direct Hernia Case Clinical Examination Discussion and Treatment

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HISTORY OF PRESENTING COMPLAINTS

• A 59 year old male, Mr. Shanmugam, from Perungudi, Watchman by occupation.

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• Presented with c/o swelling and pain in the left groin – 1 month.
• Swelling in the left groin - present for 1 month, insidious in onset, started as a small swelling & gradually increased in size to reach the present size & confined to the inguinal region, increases in size on physical activity, standing and coughing, partially decreases on lying down, fully reducible by the patient manually.
• Pain in the left groin- for 1 month, insidious onset, dragging pain confined to the swelling, on and off, relieved with rest.
• No h/o abdominal pain/abdominal distension/vomiting/constipation.
• No h/o chronic cough/difficulty in micturition/difficulty in defecation.

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• No h/o sudden heavy weight lifting.
• No h/o trauma.
• No h/o sudden increase in size of swelling.
• No h/o discolouration of skin over the swelling.
• No h/o irreducibility.

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• No h/o swelling elsewhere in the body.
• PAST HISTORY
• H/o similar swelling in the right side for which elective open hernia surgery was done 3 yrs back and the post op period was uneventful.
• No h/o Diabetes Mellitus/Hypertension/Bronchial Asthma/TB/ epilepsy/jaundice/IHD.
• No h/o previous other surgeries.

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• PERSONAL HISTORY
• Consumes non vegetarian diet.
• Smoker for the past 30 years.
• Consumes alcohol occasionally.
• Normal bladder and bowel habits.

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• Family history – Not relevant.
• GENERAL EXAMINATION
• Conscious, Oriented, moderately built and moderately nourished.
• No pallor /Icterus/cyanosis/clubbing/pedal edema/ generalised lymphadenopathy.
• VITAL SIGNS

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• Pulse rate - 78/min, Regular rhythm, Normal volume, no specific character, felt equally in all peripheral palpable vessels, no vessel wall thickening, No radio-radial or radio-femoral delay.
• BP-120/80 mm Hg left upper limb, sitting posture.
• Respiratory rate -24/min regular in rhythm, abdominothoracic.
• Afebrile.
• LOCAL EXAMINATION

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• EXAMINATION OF THE LEFT INGUINAL REGION
• Inspection on standing :
• 4x4 cm hemispherical swelling visible in left inguinal region, limited to the inguinal region, not extending into the scrotum, surface smooth, margins well defined.
• Skin over the swelling appears normal.
• No dilated veins/ redness/scars.

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• No visible peristalsis.
• Visible cough impulse seen.
• Penis normal in position.
• Urethral meatus normal.
• Scrotum appears normal.

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• Inspection in supine position ;
• Swelling disappears, reappears during coughing.
• EXAMINATION OF THE RIGHT INGUINAL REGION
• A 5 cm scar of previous hernia surgery, seen 2 cm above the groin crease.
• PALPATION

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• Not warm/ non tender.
• Inspectory findings of site/size/shape of swelling confirmed.
• Extent : 7 cm from ASIS and 1 cm from pubic tubercle.
• Expansile cough impulse +.
• Cannot get above the swelling.

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• Consistency- Elastic.
• Swelling reducible manually, with initial difficulty and reduces with gurgling.
• 1.RING OCCLUSION TEST
• After reducing the swelling on standing position, Deep ring was occluded with left thumb, swelling appears on medial side of the occluded finger on coughing.
• 2.RING INVAGINATION TEST

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• After reducing the content, in the recumbent position, fold of scrotum invaginated into left external ring using left little finger, and impulse is felt over the pulp of little finger, direction of finger being upwards, backwards.
• Superficial ring patulous and admits 2 fingers.
• 3.ZIEMAN'S TECHNIQUE
• After reducing the swelling, on standing position, Left index finger placed over left deep ring, middle finger over the superficial ring and ring finger over the saphenous opening, impulse felt over the left middle finger on coughing.
• PERCUSSION

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• Over the swelling, resonant note is heard.
• AUSCULTATION
• Bowel sound heard over the swelling.
• EXAMINATION OF RIGHT INGUINAL REGION normal.
• EXAMINATION OF REGIONAL LYMPH NODES not enlarged.

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• EXAMINATION OF TESTES, SCROTUM, PENIS normal.
• EXAMINATION OF THE ABDOMEN
• Abdomen is normal in shape, not distended, umbilicus in midline, flanks free.
• No dilated veins/scars/sinuses.
• No palpable mass.

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• On head raising test- No Malgaigne's bulges.
• No divarication of recti.
• Abdominal muscle tone normal.
• Other hernial orifices -free.
• PR- to be done.

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• SYSTEMIC EXAMINATION
• RS- Normal vesicular breath sounds heard, no added sounds.
• CVS- S 1 S2 +, no murmur.
• CNS- no focal neurological deficit.
• EXAMINATION OF SPINE AND CRANIUM : normal.

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• DIAGNOSIS
• LEFT SIDED REDUCIBLE DIRECT INCOMPLETE INGUINAL HERNIA, WITH BOWEL AS CONTENT WITHOUT ANY COMPLICATION.
• European Hernia Society Classification PM2.
• INVESTIGATIONS
• BASE LINE:

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• COMPLETE HAEMOGRAM, ?,?.
• URINE ROUTINE.
• CHEST X RAY.
• ECG, ECHO.
• RENAL FUNCTION TEST.

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• LIVER FUNCTION TEST.
• SPECIFIC :
• USG-ABDOMEN AND PELVIS.
• TREATMENT
• LICHTENSTEIN'S TENSION FREE OPEN HERNIOPLASTY ON LEFT INGUINAL REGION.

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