CASE PRESENTATION BY:

Dr.Tanzina Shabrin

On Behalf of,
Department of Surgery
Dhaka Central International Medical
College and Hospital
❖ PARTICULARS OF THE PATIENT
• NAME : Mr.Delwar Hossain Gazi
• AGE : 65YEARS
• RELIGION : Muslim
• Occupation: Works in a general store
• NATIONALITY : Bangladeshi
• ADDRESS : Mehendiganj, Barishal
• DATE OF ADMISSION : 20.10.2022
• DATE OF EXAMINATION : 20.10.2022
 ❖ CHIEF COMPLAINT:

➢Swelling in the left groin for 1 year.

❖ HISTORY OF PRESENTING ILLNESS:
• According to the patient’s statement, he was reasonably
well 1 year back.
• He then noticed a painless swelling in the left groin,
which was gradually increasing in size.
• The swelling becomes visible on standing/ straining and
disappears on lying down. The swelling is more
prominent towards the end of the day.
• He has a history of chronic constipation, as well as
difficulty in micturition (having poor flow, increased
frequency and mild nocturia).
• However, he has no history of chronic cough or
bronchial asthma. He generally does not perform heavy
labour.
• There were no associated systemic symptoms.
Patient was otherwise healthy. He is
normotensive and non diabetic.

• Now he got admitted to this hospital for

definitive management.
❖ HISTORY OF PAST ILLNESS:

• There was a history of similar swelling on

other side of the groin, for which he
underwent right sided hernioplasty 2 years
back.
• No history of any other major operation/
illness.
❖ DRUG HISTORY:
• Nothing significant
❖ PERSONAL HISTORY:
• Nothing significant
❖ Occupational History :
• He works in his own general store
❖ SOCIO-ECONOMIC HISTORY:
• He belongs to low socio-economic group.

❖ FAMILY HISTORY:
• All the members of his family are apparently healthy.

❖IMMUNIZATION HISTORY:
• He has received covid 19 vaccine.
❖ GENERAL EXAMINATIONS:
• Appearance : Normal
• Decubitus : on choice
• Co-operation : co-operative
• Body built : average
• Anemia : absent
• Jaundice : absent
• Cyanosis : absent
• Clubbing : absent
• Koilonychia : absent
• Leukonychia : absent
• Dehydration : absent
• Lymph node : not palpable

Vital signs
• Blood Pressure : 130/80 mmHg
• Pulse : 86 beats/min and regular
• Temperature : 98.6 *F
• Respiratory rate : 18breaths/min
❖ LOCAL EXAMINATIONS:
✓ INSPECTION :
▪ Site : There is a swelling in the left inguinal region
which is situated above and medial to the pubic
tubercle.
▪ Size : approximately 3 x 4 cm.
▪ Shape : Globular
▪ Number : single
▪ Overlying skin condition : normal
▪ Visible peristalsis : absent
▪ Visible cough impulse : present
✓PALPATION:

▪ Temperature : not raised

▪ Tenderness : non-tender
▪ Surface : smooth
▪ Consistency : doughy
▪ Palpable cough impulse : present
▪ Reducibility test : reducible
▪ Deep ring occlusion test : Negative
• Draining lymph nodes : not palpable
• Examination of the pulse : femoral, popliteal,
anterior, posterior tibial and arteria dorsalis
pedis were palpable.
• Percussion : Dull
• Auscultation: No peristaltic sound can be
heard.
• Other system reveals no abnormality.
❖ SALIENT FEATURES :
• Mr. Gazi, 65 years old male from Barishal, presented
with a painless left groin swelling for 6 month. Swelling
appears on standing and disappear on lying down. He
has a history of chronic constipation and symptoms of
prostatism.
• He has had a hernioplasty on the right side 2 years back.
• General examination was unremarkable.
• local examination revealed a globular 3x4 cm reducible
swelling in the left inguinal region, with visible & palpable
cough impulse. Deep ring occlusion was negative.
 ❖ WHAT MAY BE THE
PROVISIONAL DIAGNOSIS?
❖ PROVISIONAL DIAGNOSIS :

➢LEFT SIDED INCOMPLETE REDUCIBLE

DIRECT INGUINAL HERNIA .
❖ WHAT MAY BE THE
DIFFERENTIAL
DIAGNOSIS?
❖ DIFFERENTIAL DIAGNOSIS:

1. LEFT FEMORAL HERNIA

2. LEFT INGUINAL LYMPHADENOPATHY
3. LEFT SAPHENA VARIX
❖ INVESTIGATIONS:
• Baseline investigations to assess the
fitness of the patient before surgery:
1. USG of the whole abdomen with prostate and PVR
2. CBC WITH ESR
3. RBS
4. S.CREATININE
5. HBsAg
6. Anti-HCV
7. Chest x-ray (P/A view)
8. ECG
Investigation report:
• HB% : 12.9 g/dl
• RBS: 4.7 mmol/l
• S.Creatinine : 0.66 mg/dl
• HBsAg: Negative
• Anti HCV : Negative
• CXR : Normal finding.
• ECG : Normal
USG of whole
abdomen with
prostate and
PVR:
• Prostate is
normal in size
• PVR : 21.0 ml
• Fatty change in
liver ( Grade –II )
• Left renal
cortical cyst.
Confirmatory Diagnosis :

➢LEFT SIDED INCOMPLETE REDUCIBLE DIRECT

INGUINAL HERNIA .
Treatment:
• Counselling
• Hernioplasty
• Follow up
➢ Picture showing Hernial sac, spermatic cord,
inguinal canal, inguinal ligament and deep ring.
➢ Pictures showing Hernioplasty with prolene
mesh.
Operation note:
• Indication: Left Sided Incomplete, Reducible,
Direct inguinal Hernia.
• Name of Operation : Left Hernioplasty
• Date of operation :20.10.22
• Time of operation : 10.30 Am
• Anaesthesia: Spinal anaesthesia.
Operation Procedure and findings:
• Procedure: With all aseptic precaution after
proper painting and draping, an 8 cm left
inguinal incision was given. Inguinal canal was
opened. Spermatic cord was separated and
Hernial sac was reduced. Hernioplasty was done
by placing prolene mesh. Ilio-inguinal & ilio-
hypogastric nerves were identified and
preserved. Proper hemostasis was ensured and
wound was closed in layers.
• Surgeon : Dr. Tamjeed Alam
• Anesthesiologist : Dr. Kamol Krishna Karmakar.
 ❖ Post operative order:
• NPO for 4 hours
• Inf. Hartsol 1L + 5%DNS +5% DA @30
drop/min
• Inj. Furocef (750mg) I/V – Stat, then Oral
• Inj. Sergel (40 mg) 1 vial ,I/V – Stat, then oral
• Inj. Napa(1gm) 1 bottle, I/V – Stat, then oral
• Suppo. Voltalin (50 mg) 1stick P/R – SOS
Post-operative Events :
• His post-operative period was uneventful.
After operation, his condition was improving.
He was discharged on 21.10.22 (1st POD) with
medication and advice.
❖ DISCHARGE ORDER:
✓ Medications:
• Cap. Cefixime-400mg-(1+0+1) for 7 days
• Tab. Esomeprazol-20mg-(1+0+1) for 10 days
• Tab. Paracetemol-500mg-(2+2+2) If pain remain
• Syp. Lactulose-2TSF TDS (if needed)
✓ Advice on discharge:
• Keep bandage dry
• Avoid heavy lifting for 4 to 6 weeks
• Avoid constipation
• Can ambulate normally
❖ FOLLOW UP:
• After 7 days.