inguino scrotal swelling neo
DESCRIPTION
Inguino scrotal swellingTRANSCRIPT
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Inguino-Scrotal LumpsInguino-Scrotal Lumps
Marty Smith Saturday 30th July 2010
Western Hospital
Marty Smith Saturday 30th July 2010
Western Hospital
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Inguino-Scrotal LumpsInguino-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.
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.
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PathologiesPathologies
Inguinal Sebaceous
Cysts/Lipoma’s Inguinal
Lymphadenopathy Saphenous Varix Femoral Artery
aneurysm Psoas Abscess Undescended testes. Inguinal Hernia Femoral Hernia
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
Scrotal Testicular tumor Epididymal cyst Spermatocoele Hydatid of
Morgagni Varicocoele Hydrocoele Inguino-scrotal
Hernia
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Assessment-HistoryAssessment-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?
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?
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Assessment-ExamAssessment-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
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
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Assessment-ExamAssessment-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
Both sides Hernia Tests
Standing and lying ?Get above it Cough Impulse Reducibility and control
Associated structures Pulses, testes, Lymph nodes.
Special tests Transillumination
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AssessmentAssessment
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
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
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AssessmentAssessment
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
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
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AnatomyAnatomy
Inguinal region
Inguinal Canal Spermatic Cord Femoral Canal and
Ring
Scrotum/testes
Inguinal region
Inguinal Canal Spermatic Cord Femoral Canal and
Ring
Scrotum/testes
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AnatomyAnatomy
Inguinal region Includes
Lower abdominal wall
Femoral Triangle Sartorius/Add
Longus/ Inguinal Lig
Contains Femoral Pedicle Lymph Nodes Skin/fat/muscle
Inguinal region Includes
Lower abdominal wall
Femoral Triangle Sartorius/Add
Longus/ Inguinal Lig
Contains Femoral Pedicle Lymph Nodes Skin/fat/muscle
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AnatomyAnatomy
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.
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.
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AnatomyAnatomy
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
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
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AnatomyAnatomy
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 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.
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AnatomyAnatomy
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 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
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AnatomyAnatomy
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.
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.
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AnatomyAnatomy
Spermatic cord Pedicle of the
testes
Made up of 12 things
Spermatic cord Pedicle of the
testes
Made up of 12 things
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AnatomyAnatomy
Spermatic cord Pedicle of the
testes
Made up of 12 things
Spermatic cord Pedicle of the
testes
Made up of 12 things
You’re not getting
away with that!
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AnatomyAnatomy
3 Arteries
3 Nerves
3 Arteries
3 Nerves
3 Important structures
3 Coverings
3 Important structures
3 Coverings
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AnatomyAnatomy
3 Arteries Testicular Artery to the Vas
Deferens Cremasteric
3 Nerves Sympathetic branches Ilio-inguinal (on cord) Genital Br of Genito-
femoral nerve.
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
3 Important structures Vas Deferens Pampiniform Plexus Processus Vaginalis
3 Coverings External Spermatic Fascia Cremasteric Muscle Internal Spermatic Fascia
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AnatomyAnatomy
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.
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.
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AnatomyAnatomy
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
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
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PathologiesPathologies
Inguinal Sebaceous
Cysts/Lipoma’s Inguinal
Lymphadenopathy Saphenous Varix Femoral Artery
aneurysm Psoas Abscess Undescended testes Inguinal Hernia Femoral Hernia
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
Scrotal Testicular tumor Epididymal cyst Spermatocoele Hydatid of
Morgagni Varicocoele Hydrocoele Inguino-scrotal
Hernia
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Skin stuffSkin 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.
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.
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Skin stuffSkin stuff
Lipomas Benign Fatty lumps
Clinically fixed (skin and fat) soft lumps, usually longstanding and
asymptomatic.
Management excise surgically
Lipomas Benign Fatty lumps
Clinically fixed (skin and fat) soft lumps, usually longstanding and
asymptomatic.
Management excise surgically
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Inguinal Lymphadenopathy
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
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
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Saphenous VarixSaphenous 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.
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.
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Femoral Artery Aneurysm.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.
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.
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Psoas AbscessPsoas 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
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
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Undescended TestesUndescended 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.
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.
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Scrotal LumpsScrotal Lumps
Assessment Hx/Ex as previous
If not obvious Hernia/Varicocoele/ Hydrocoele and normal testesUltrasound Lump origin Solid vs cystic etc.
If still in doubt-Call a Urologist. Surgical exploration
Assessment Hx/Ex as previous
If not obvious Hernia/Varicocoele/ Hydrocoele and normal testesUltrasound Lump origin Solid vs cystic etc.
If still in doubt-Call a Urologist. Surgical exploration
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Scrotal LumpsScrotal 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
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
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Testicular LumpsTesticular 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
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
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HydrocoeleHydrocoele 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.
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.
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HydrocoeleHydrocoele
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VaricocoeleVaricocoele
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.
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.
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Other Scrotal LumpsOther 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.
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.
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HerniasHernias
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Inguinal herniaeInguinal 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 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
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Hernia typesHernia types
Inguinal Direct Indirect Pantaloon
Femoral
Also Sliding herniae
Inguinal Direct Indirect Pantaloon
Femoral
Also Sliding herniae
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Sliding HerniaSliding 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.
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
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Inguinal herniaeInguinal herniae
Clinically Groin pain/discomfort
Dragging, worse during the day Lump
Asymmetry-inguino-scrotal swelling GI/GU obstruction Incarceration/Irreducibility
Clinically Groin pain/discomfort
Dragging, worse during the day Lump
Asymmetry-inguino-scrotal swelling GI/GU obstruction Incarceration/Irreducibility
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Hernia examinationHernia examination
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Direct vs indirectDirect 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.
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.
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Femoral vs inguinalFemoral 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
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
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Hernia ComplicationsHernia 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.
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.
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Hernia ManagementHernia Management
Fix it! Eliminates pain Eliminates Lump Avoids hernia growth Avoids risk of strangulation
Esp in indirect hernia
Straightforward surgery.
Fix it! Eliminates pain Eliminates Lump Avoids hernia growth Avoids risk of strangulation
Esp in indirect hernia
Straightforward surgery.
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Inguinal OperationsInguinal Operations
Previous Bassini, McVay, Shouldice
Forget them
Now Lichtenstein tension free mesh repair. Laproscopic repair.
Previous Bassini, McVay, Shouldice
Forget them
Now Lichtenstein tension free mesh repair. Laproscopic repair.
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Hernia operationsHernia operations
Lichtenstein tension free mesh repair.Developed in NY at the Lichtenstein Hernia
clinicOriginally done as OP procedure under LA
Involves Dissecting Inguinal canal and mobilising cord Inverting/removing hernia sac Reinforcing posterior inguinal wall with
prolene mesh.
Lichtenstein tension free mesh repair.Developed in NY at the Lichtenstein Hernia
clinicOriginally done as OP procedure under LA
Involves Dissecting Inguinal canal and mobilising cord Inverting/removing hernia sac Reinforcing posterior inguinal wall with
prolene mesh.
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Open Hernia RepairOpen Hernia Repair
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Hernia operationsHernia operations
Lichtenstein tension free mesh repair. Results
All can be done under LAWidely adoptedRecurrence rate 1-2%-Lichtenstein
Lichtenstein tension free mesh repair. Results
All can be done under LAWidely adoptedRecurrence rate 1-2%-Lichtenstein
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Hernia OperationsHernia Operations
LaparoscopicTAPP
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.
LaparoscopicTAPP
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.
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Lap Hernia RepairLap Hernia Repair
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Hernia OperationsHernia 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.
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.
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Hernia OperationsHernia 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%
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%
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Femoral HerniaeFemoral 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
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
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SummarySummary
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
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