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EV, a 55 year old Male Married Self-employed Zamboanga City.

Right Inguinoscrotal mass

2 years PTA, onset of inguino scrotal mass on the right, reducible, with no other associated signs and symptoms. 2 days PTA, inguinoscrotal mass noted but this time associated with pain, dragging sensation and a pain scale of 6/10 non-radiating and irreducible.
A few hours PTA, prompted consult at the ER for persistence of symptoms hence admission.

No previous surgery and no known allergy to food and drugs

familial diseases .No known Heredo.

    has a son and a wife Smoker Non-alcohol drinker A retired driver .

(-) diarrhea . (-) vertigo Nose: (-) nosebleed. (-) sinus trouble Mouth and Throat: (-) dry lips. (-) nasal congestion. (-) swollen glands Respiratory: (-) colds Cardiovascular: (-) dyspnea.General: (-) weight loss Skin: (-) rashes. (-) itchiness. (-) bleeding gums Neck: (-) neck pain. (-) constipation. (-) changes of color Head: (-) dizziness. (-) blurring of vision Ears: hearing good. (-) visual changes. (-) abdominal pain. (-) tinnitus. (-) heartburn. (-) palpitations Gastrointestinal: (-) dysphagia. (-) orthopnea. (-) stiffness. (-) chest pain. (-) headache Eyes: (-) redness.

(-) fainting. (-) tremors or involuntary movements Neurologic system: memory good. (-) polyuria. (-) weakness. (-) easy bruising or bleeding Endocrine system: (-) excessive sweating.(-) involuntary movements Hematologic: (-) anemia. hunger or thirst. paralysis and loss of sensation. (-) heat or cold intolerance .Urinary: (-) oliguria. (-) flank pain Peripheral Vascular: (-) varicose veins. (-) numbness and tingling. (-) leg cramps Musculoskeletal system: (-) bone or joint pains and muscle cramps (-) bipedal edema.

No palpable lymph nodes. cooperative .    GENERAL SURVEY Conscious. HEENT Eyes: Anicteric sclerae. coherent. Tonsils (-) infection / inflamed.22 bpm. Nose: No alar flaring. No pallor. Conjunctivae is pink. Blood pressure .71 bpm. tongue midline. . (-) discharges Throat: Oral mucosa is pink. SKIN No jaundice noted. Ears: (-) discharges. Pharynx: (-) exudates NECK Trachea midline. reactive to light. Respiration .2 C. NIRD VITAL SIGNS Temperature .36.100/ 60 mmHg and a Pulse Rate .  . With good acuity to whispered voice.

. inguino-scrotal mass on the right. NRRR. 6x7cm.    RECTAL AND GENITALIA No discharges/ulcers noted on genitalia. THORAX AND LUNGS Thorax are symmetrical. distinct sounds with no heart murmurs. CARDIOVASCULAR SYSTEM AP. no cyanosis noted. percussed and revealed a dull sound. No rales or wheezes noted. 6 x9 cm. (-) transillumination. normoactive bowel sound. palpated with tenderness on hypogastric area. ABDOMEN flat. soft. Clear breath sounds.

no edema.   . MUSCULOSKELETAL No deformities and with good range of motion. EXTREMITIES Warm to touch. is conscious and has a stable gait. CRT < 2 secs. NEUROLOGIC Oriented to time and place.

  Indirect Inguinal Hernia Right. . Incarcerated BASIS: Hx of scrotal mass that was formerly reducible PE: Irreducible scrotal mass with inguinal component. No tachycardia. no cyanosis noted.

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platelet. blood typing Chest xray and 12 lead ECG for CP evaluation Meds: Cefoxitin 2 gm IVTT ANST 1 hour before induction For emergency Hernioplasty right mesh inguinal Notify OR/ Anesthesiologist Insert FBC and attach to urine bag collector Insert NGT .           Admitted Secure consent NPO IVF D5lr 1 L at 40 gtts/ min Labs: cbc.

64 19.-hgb -hct -rbc -wbc -plt -bt 15.7 284 O+ .45 4.2 0.

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MV tab OD   . Celecoxib 200mg BID PRN pain 3. Cefuroxime 500mg BID x 7 days 2.  MGH with home meds of: 1.

Hernioplasty Right with Inguinal Mesh Indirect Inguinal Hernia Right with incarcerated small bowel. Hernioplasty Right with Inguinal Mesh .Indirect Inguinal Hernia Right with incarcerated small bowel.

.is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.Hernia.

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can be considered an impedance of normal development. w/c make up the majority of pediatric hernias. Congenital hernias. . rather than an acquired weakness Normal Course of development: The testes descend from the intraabdominal space into the scrotum in the 3rd trimester.   Inguinal hernias may be considered congenital or acquired.

  The descent is preceded by the gubernaculum and a diverticulum of peritoneum.. 36-40 wks: processus vaginalis closes. w/c protrudes through the inguinal canal and ultimately becomes the process vaginalis. eliminates the peritoneal opening at the internal inguinal ring. .

NOTE: processus vaginalis continues to close as the child ages. with most closing within the first few months of life. .  Failure of the peritoneum to close results in a ppv.

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subcutaneously and slightly above the pubic tubercle. located medial to the inferior epigastric arteries. The canal courses down along the inguinal ligament to the external ring.[ . This results from a persistent process vaginalis. located approximately midway between the pubic symphysis and the anterior iliac spine. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.follows the tract through the inguinal canal.

laterally by the inferior epigastric arteries. A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle. and medially by the conjoined tendon. The triangle is defined inferiorly by the inguinal ligament. .

  . Incarcerated hernia: An incarcerated hernia is no longer reducible. The vascular supply of the bowel is not compromised. either spontaneously or manually. however. Strangulated hernia: A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents. bowel obstruction is common. Reducible hernia: This term refers to the ability to return the contents of the hernia into the abdominal cavity.

70% of femoral hernia repairs are performed on female patients. Incidence of inguinal hernias in males has a bimodal distribution with peaks before 1 y. and then again after age 40. Aprrox.    Majority of abdominal wall hernias occur in the groin (75%) Of inguinal hernia repairs. 90% are performed in males and 10% in females.0. .

where the spermatic cord passes through a haitus in the transversalis fascia. 4 to 6 cm Anteroinferior portion of the pelvic basin Shaped like a cone.    Approx. it’s base is at the superolateral margin of the basin. it’s pex pointed inferomedially toward the symphysis pubis Begins intra-abdominally on the deep aspect of the abdominal wall. .

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Boundaries:  Anterior: external oblique aponeurosis  Posterior: transversus abdominis and transversalis fascia  Superior: internal oblique muscle  Inferior: inguinal ligament .  The haitus is termed the deep or internal inguinal ring.

and two nerves it contains the pampiniform venous plexus anteriorly and the vas deferens posteriorly. with connective tissue and remnant of the processus vaginalis .  consists of three arteries. three veins.

deferential artery. testicular nerves (sympathetic nerves) Vas deferens (ductus deferens) Pampiniform plexus Lymphatic vessels Tunica vaginalis (remains of the processus vaginalis) . cremasteric artery Nerves: nerve to cremaster (genital branch of the genitofemoral nerve).      Arteries: testicular artery.

  Inguinal ligament. iliopubic tract.lateral portion of the lacunar ligament that is fused to the periosteum of the pubic tubercle may include fibers from the transversus abdominus.is comprised of the inferior fibers of the external oblique aponeurosis. and rectus abdominus . internal oblique. The ligament stretches from the ASIS to the pubic tubercle Cooper’s ligament.

Iliopubic tract  often is confused with the inguinal ligament secondary to common origin and insertion points. .  forms on the deep side of the inferior margin of the transversus abdominus and transversalis fascia. Inguinal ligament  is on the superficial side of the musculoaponeurotic layer  The shelving edge of the inguinal ligament is a structure that more or less connects the iliopubic tract to the inguinal ligament.

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Classical Repairs (anatomic repairs) – use anatomic structures a) Marcy Simple Ring Closure – ligate the sac. and put series of sutures in the internal inguinal ring b) Bassini – Shouldice Repair (Gold Std before) – uses conjoined tendon of ext. and int. oblique c) McVay – Lotheissen Cooper Ligament Repair . Types 1.

Dissection of Inguinal Canal 2. Repair of Myopectineal Orifice (internal inguinal ring) 3. Closure of Hernial Sac . Basic Components: 1.

use of prosthetic material (prosthesis – net like inert structure) . Tension-Free Repair Lichtenstein Hernioplasty .obliterates tension . Types 2.commonly practiced nowadays .promotes fibrosis and scarring .

Laparoscopic Hernioplasty . Cheatle-Henry Midline Approach 3. Nyhus Iliopubic Tract Repair 2. Stoppa Procedure (GPRVS) 4. Types 1.

  TRANSABDOMINAL PREPERITONEAL PROCEDURE TOTALLY EXTRAPERITONEAL PROCEDURE .

many will use it only intermittently as it does not provide continuous control of the hernia and may actually lead to an increased rate of hernia incarceration. is aimed at alleviating symptoms related to the inguinal hernia.    . may also be worn. such as pain.  The definitive treatment of all hernias is surgical repair. however. an elastic belt or brief that aims to keep the hernia reduced. and protrusion of abdominal contents. which aids in self-reduction of the hernia. however. Simple maneuvers include assuming a recumbent position. A truss. pressure. its use does not prevent hernia progression or incarceration. A truss may provide relief in up to 65% of patients.

The figures were much higher for development of a strangulated femoral hernia at 3 months and 2 years. 22 and 45%.conservative management is applied to asymptomatic or minimally symptomatic inguinal hernias.8% at 3 months for an inguinal hernia. One study has calculated the cumulative probability of developing a strangulated hernia to be 2. and rising to 4.5% after 2 years. .