Group 1

Preceptor: Dr. Batucan

Margas, Anna Dominique Misoles, Ben Mark

Masendo, Herlene Mohanty, Anica Serbina
Masulot, Isfahan Mokamad, Ken Alden
Mendiola, Gail Eunice Muhammad, Sohair Areez
Mirasol, Pilar Isabel Mundo, Jxyp Alfe
General Data

Patient X
Age: 37 years old
Nationality: Filipino
Occupation: Farmer
Address: Davao del Sur
Chief Complaint

Right Scrotal Enlargement for 1 year

History of Present Illness
1 year prior to admission (PTA), patient noted to have right inguinal bulge, reducible, and
was noted upon straining. Patient claimed dull pain on prolonged standing, which usually
happens after a day’s work. Patient denies having fever, voiding or bowel habit changes.
In the interim, there was persistence of symptoms until three months prior, patient had
noted sudden “popping” sensation with occurrence right scrotal enlargement. Patient
denied pain. No note of urinary and bowel changes. Patient claimed it usually goes away
in the morning.
There was no consult done until few hours prior when the scrotal enlargement was no
longer reducible, noted since two days prior. Patient still denied pain.
Persistence of symptoms prompted consult at the ER, hence, this admission.
Past Medical History

No known comorbidity
Family Medical History

Father – Hypertension, controlled

Mother – hypertension, controlled
Personal and Social History

Occasional smoker (1 pack year)

Works as a farmer and labor worker
Review of Systems

Skin: No pallor, no redness or flushing

Head: No dizziness, no headache
Eyes: No visual dysfunction, no ptosis
Ears: No discharge, no vertigo
Nose: No nasal congestion, no epistaxis or rhinorrhea
Mouth/Throat: No mouth sores or bleeding gums
Neck: No lymph node enlargement
Review of Systems

Respiratory: No shortness of breath, cough, dyspnea

GastroIntestinal: No nausea, no diarrhea
Cardiovascular: No palpitations, no edema
Musculoskeletal: No muscle and joint pain, no stiffness
Endocrine: No heat or cold intolerance
Genitourinary: no increase in urinary frequency
Neurologic: No syncope, no convulsion
Physical Examination
General: Patient was awake, cooperative, and not in respiratory distress.
Vital Signs:
•BP – 120/90 mmHg
•RR – 20 cpm
•HR – 90 bpm
•Temp – 37C
Skin: Warm to touch; no yellowish discoloration; no abnormal lesions and
mass.
HEENT: normocephalic, anicteric sclerae, pink palpebral conjunctivae, no
tonsillopharyngeal congestion, no cervical lymphadenopathy
Chest/Lungs: no flail chest, clear breath sounds, no retractions
Physical Examination

CVS: adynamic precordium, normal rhythm, tachycardic, distinct S1 & S2, no

murmurs
Abdomen: flabby abdomen, normoactive bowel sounds, Non-tender
Genitals: Noted right inguinoscrotal enlargement, (-) transillumination test, noted
bowel sound on auscultation, non-erythematous, non-tender, non reducible;
palpable testis, bilateral.
DRE: no visualized masses, intact anal sphincter, (-) blood or stool on examining
finger, Extremities: essentially normal
Neuro Exam: GCS 15, Cranial nerves intact, and sensory and motor systems
intact.
Salient Features: History
Pertinent Positive Pertinent Negative
● 37 years old ● No fever
● Male ● No voiding and bowel changes
● Occupation: Farmer and Labor worker ● No consultation was done
● 1 year PTA, onset of right inguinal bulge - ● No known comorbidity
which was reducible, and was noted upon ● No scrotal pain
straining.
● Dull pain on prolonged standing
● 3 months PTA, sudden “popping”
sensation with occurrence of right scrotal
enlargement.
● 2 days PTA, the scrotal enlargement was
no longer reducible.
● Both parents are hypertensive (controlled)
● Occasional smoker (1 pack year)
Salient Features: Physical Examination
Pertinent Positive
● Genitalia: Right inguinoscrotal enlargement,
bowel sound on auscultation and non-
reducible, (-) transillumination test
Pertinent Negative
● Vital Signs: BP - 120/90 mmHg, RR - 20
cpm, HR - 90 bpm, Temp - 37°C
● Genitalia:non-erythematous, non-tender,
palpable testis
● Abdomen: unremarkable
● DRE: unremarkable
Impression

Incarcerated Indirect Right Inguinal Hernia; Nyhus Classification IIIB

Differential Diagnosis
1. Testicular cancer

Rule in Rule out

- Age as risk factor ( between 20- 40 - Bowel sound on auscultation

years old)
- testicular mass associated with dull
pain
- (-) transillumination test
- Occasional smoker (1 pack year)
- DRE: unremarkable
- further diagnostic tests are warranted
(alpha-fetoprotein, beta hCG, LD,
imaging)

2. Epididymo- orchitis

- scrotal bulging associated with dull - no fever, nausea, vomiting, urinary

pain symptoms, tenderness, erythema on
site
- symptoms elapsed a year (chronic
course)
Differential Diagnosis
3. Testicular Torsion

Rule in Rule out

- Unilateral (right) scrotal enlargement - Not sudden onset of pain at a distinct

- PE: non-erythematous, non-reducible
, palpable testis, bilateral
point in time
- No excessive pain
- No nausea/ vomiting
- Nontender scrotal mass
- Bowel sounds upon auscultation
- no paresthesia on thigh

4. Hydrocele

- Inguino-scrotal swelling - Negative transillumination test

- No pain - Bowel sounds upon auscultation
- non -erythematous, non-tender, non- - Palpable testis, bilateral
reducible
Admitting Orders
Secure consent to care under (Dr. Batucan)
Admit patient to Surgery ward.
IVF: PLR 30cc/hr
Diet: NPO
Diagnostics:
● CBC
● Urinalysis
Monitor:
● Vital Signs every 4 hours
● I&O every 8 hours
● Watch out for signs of strangulation
Refer accordingly
DISCUSSION

INGUINAL HERNIA
Inguinal hernia

An opening in the myofascial plain of the oblique and transversalis muscles that can allow
for herniation of intraabdominal or extraperitoneal organs
Etiology
Congenital Acquired
- More common in young - More common in older
- Often one - sided - Often both sided
- Descends into the scrotum - Rarely falls into the scrotum
- Pear shaped - Round shaped
- Hernia sac is located outside of the - Hernia sac is located inside of the
spermatic cord
spermatic cord
Etiology

- Genetics (4X more likely to have an inguinal hernia with positive family history)
- Diseases (Chronic obstructive pulmonary disease (COPD), Ehlers-Danlos syndrome
and Marfan syndrome)
- Obesity
- Chronic cough
- Heavy lifting
- Straining due to constipation
History

● Groin mass that protrudes while standing, coughing, or straining (most common symptom)
● Reducible while lying down
● Extrasanguinal symptoms: (less common)
○ Change in bowel habits
○ Urinary symptoms
● Most have associated pain or vague discomfort; ⅓ - no symptoms
● Extremely painful (incarceration or strangulation)
● Pain due to compression/ irritation of inguinal nerves by the sac:
○ Paresthesias,
○ Generalized pressure,
○ Localized pain, or
○ Referred pain
History

● Important consideration:
○ Duration and timing of symptoms
■ Sudden onset of symptoms are concerning
● Reducing the hernia provides temporary relief
● Hard to reduce:
○ Defect size increases
○ More intra-abdominal contents fill the hernia sac
● Review of systems:
○ Chronic constipation,
○ Cough, or
○ Urinary retention
○ (prompt a through workup to r/o any underlying malignancy)
P.E. Findings

● Physical examination
○ Essential to the diagnosis of inguinal hernia
○ Examined in standing position
■ Increase intra-abdominal pressure
○ Groin and scrotum fully exposed
● Inspection
○ Performed first
○ Asymmetry, bulges, or a mass
○ Goal: identify abnormal bulge along groin or within scrotum
○ If obvious bulge not detected, palpation is performed
P.E. Findings

● Palpation
○ Advancing index finger through the scrotum towards the external inguinal ring
■ Exploration of inguinal canal
○ Valsalva maneuver - to increase intra-abdominal pressure
■ Reveal abnormal bulge
■ Determine if hernia is reducible or not
○ Examine contralateral side
■ Compare presence and extent of herniation of both sides
■ Especially useful in small hernia
P.E. Findings
● Inguinal occlusion test
○ Blocking the internal inguinal ring with a finger
○ Patient instructed to cough
○ Indirect hernia:
■ Controlled impulse
■ Transmission of cough impulse to tip of finger
○ Direct hernia:
■ Persistent herniation
■ Impulse palpated on dorsum of finger
● Femoral hernia:
○ Palpable below inguinal ligament, lateral to the pubic tubercle
○ May be missed or misdiagnosed in obese
○ Femoral pseudohernia - prominent inguinal fat pad in thin patients
P.E. Findings
Diagnostic Test

● Radiologic investigations
○ Adjunct to history and physical examination
■ Cases of ambiguous diagnosis
● Most common radiologic modalities:
○ Ultrasound (US)
○ Computed Tomography (CT)
○ Magnetic Resonance Imaging (MRI)
Diagnostic Test

● Ultrasound
○ Can aid in diagnosis
○ Least invasive and not impart any radiation
○ Positive intra-abdominal pressure
■ to elicit herniation of abdominal contents
○ (+) Movements of abdominal contents through the canal
■ Essential for diagnosis with US
○ 86% sensitivity, 77% specificity
Diagnostic Test

● CT Scan
○ Provide static images that able to delineate groin anatomy
○ 80% sensitivity, 65% specificity
○ Maybe useful for diagnosis of obscure and unusual hernia as well as atypical groin masses (Abdominal
& Pelvic CT)
● MRI
○ Provide static images that able to delineate groin anatomy
○ Most commonly utilized in cases where PE detects groin bulge, but inconclusive ultrasonography
○ 95% sensitivity, 96% specificity
Pathophysiology
Types of Abdominal Wall Hernia
Anatomy of Groin

● From ANTERIOR to POSTERIOR

○ Skin and subcutaneous tissues
○ Below, superficial circumflex iliac, superficial epigastric and external pudendal arteries and
accompanying veins
● Vessels arise from Proximal Femoral artery and drain to Proximal Femoral veins
Anatomy
● External Oblique Muscle and Aponeurosis
○ Most superficial of lateral abdominal wall muscles
○ Aponeurosis of External Oblique Muscle: superficial and deep layer
○ Fiber: directed inferiorly and medially and lie deep to subcutaneous tissues
○ Anterior Rectus Sheath: aponeurosis along with bilateral aponeurosis of internal oblique + transversus abdominis
○ Inguinal ligament or Poupart’s ligament
■ Inferior edge of external oblique aponeurosis and extends from Anterior Superior Iliac Spine to pubic
tubercle
○ Lacunar ligament
■ Fan-shaped medial expansion of inguinal ligament \inserts into pubis and forms medial border of femoral
space
○ External (Superficial Inguinal Ring)
■ Ovoid opening of external oblique aponeurosis positioned superiorly and slightly laterally to pubic tubercle
■ Spermatic cord exits
● Internal Oblique Muscle and Aponeurosis
○ Forms the middle layer of lateral abdominal musculoaponeurotic complex
○ Fiber: superior and lateral in upper abdomen
○ Serves as superior border of inguinal canal
○ Conjoined tendon:
■ Fusion of internal oblique aponeurosis + transversus abdominis aponeurosis
○ Cremaster muscle Fibers:
■ Arise from internal oblique and encompass spermatic cord
■ Attaches to tunica vaginalis of testis
■ Essential to maintain cremasteric reflex
■ Innnervated by genital branch of genito femoral nerve
● Transversus Abdominis muscle and aponeurosis and transversalis fascia
○ Transversus abdominis muscle layer
■ Fibers: slightly oblique and downward direction
■ Strength and continuity of this muscle and aponeurosis are important for prevention and
treatment of inguinal hernia
○ Transversus abdominis aponeurosis
■ Covers anterior and posterior surfaces
○ Transversalis fascia or endoabdominal fascia
■ Connective tissue layer that underlies abdominal wall musculature
○ Iliopubic tract
■ Aponeurotic band formed by transversalis fascia + transversus abdominis muscle and fascia
■ Posterior to inguinal ligament, crosses over femoral vessels, inserts to ASIS and inner lip of
wing of ileum
● Pectineal (Cooper Ligament)
○ Formed by periosteum and aponeurotic tissues along superior ramus of the pubis
○ Posterior to iliopubic tract and forms posterior border of femoral canal
○ Approximately 75% of patients: vessel crosses lateral border of Cooper ligament that is a branch of
obturator artery
○ Important landmark for open and laparoscopic repairs and is useful in anchoring structure particularly
in laparoscopic repairs
● Inguinal Canal
○ About 4 cm in length, located cephalad to inguinal ligament
○ Canal extends between interna; (deep) inguinal and external (superifcaial) inguinal rings
○ Contains spermatic cord in men and round ligament of uterus in women
○ Spermatic Cord
■ Composed of cremaster muscle fibers, testicular artery and accompanying vein, genital branch of
genitofemoral nerve, vas deferens, cremasterc vessels , lymphatics and processus vaginalis
■ Structures enter the cord at internal inguinal aring ane vesels and vas deferens exits the external
inguinal ring
○ Boundaries:
■ Anterior wall – aponeurosis of the external oblique.
■ Posterior wall or floor– transversalis fascia and aponeurosis of transversus abdominis
muscle
■ Roof – transversalis fascia, internal oblique, and transversus abdominis
musculoaponeurosis
■ Inferior wall – inguinal ligament and the lacunar ligament
● Inguinal Canal
○ Hesselbach triangle:
■ Refers to the margin of the floor of the inguinal canal
■ Superolateral: inferior epigastric vessels
■ Medial: rectus sheath
■ Inferior: inguinal ligament and pectineal ligament
■ Indirect Hernia: arise lateral to the triangle
■ Direct Hernia: arise within the triangle
○ Iliohypogastric and ilioinguinal nerves
■ Provides sensation to the skin of the groin, base of the penis, and ipsilateral upper medial thigh
Triangle of Doom

Contents:
● External Iliac Vessels
● Deep Circumflex Iliac vein
● Femoral Nerve
● Genital branch of
genitofemoral nerve
 Triangle of Pain

Contents:
● Lateral femoral Cutaneous
nerve
● Femoral branch of
genitofemoral nerve
● Femoral nerve
Circle of Death
● Preperitoneal space
○ Contains adipose tissue, lymphatics, blood vessels, and nerves
○ Lateral femoral cutaneous nerves
■ Originates as root of L2 and L3
■ Occasionally a direct branch of the femoral nerve
○ Genitofemoral nerves
■ Arises from L2 or L1-L2 nerve roots
■ Divides into genital branch (enters inguinal canal through deep ring) and femoral branches
(enters femoral sheath lateral to artery)
○ Inferior epigastric artery and veins
■ Indirect Inguinal Hernia: lateral to inf. Epigastric vessels
■ Direct Hernia: medial to inf. Epigastric vessels
○ Deep circumflex artery and vein
■ Located below the lateral portion of iliopubic tract in the preperitoneal space
○ Vas deferens
■ Courses through preperitoneal space from caudad to cephalad and medial to lateral to join the
spermatic cord at the deep inguinal ring
Anatomy of important PREPERITONEAL STRUCTURES IN THE right Inguinal Space
● Femoral canal
○ Boundaries:
■ Anterior: iliopubic tract
■ Posterior: Cooper ligament
■ Lateral : Femoral vein
○ Pubic tubercle forms apex of femoral canal triangle
○ Contains connective tissue and lymphatic tissue
○ Femoral hernia occur through this space and medial to the femoral vessels
Management

● Nonoperative management
○ Patients with minimal symptoms
○ Those with lesser risk for incarceration and strangulation
○ Patients who later had surgery did not have increased surgical site infections or higher recurrence rates
than those who were initially assigned to early repair.
○ Truss
■ can provide symptomatic improvement
■ More commonly used in Europe
■ Spring trusses are more versatile than elastic ones
■ Correct measurement and fitting are important
■ Complications: testicular atrophy, ilioinguinal or femoral
neuritis, and hernia incarceration
Reference: Sabiston Textbook of Surgery, 20th Edition
Management

● Mesh repair (either laparoscopic or the open method) - recommended treatment for
inguinal hernia and in recurrent and bilateral conditions
● For laparoscopic mesh repair, recommended techniques are as follows:
○ Transabdominal preperitoneal (TAPP) repair
○ Total extrapreperitoneal (TePP) repair
*it is not necessary to fix the mesh during laparoscopic TAPP or TEPP inguinal hernia repair
● For open mesh repair, recommended techniques are as follows:
○ Lichtenstein
○ Plug and mesh
○ Prolene Hernia System

Reference: Evidence-Based CPG on the Management of Adult Inguinal Hernia: Primary, Recurrent and Bilateral Inguinal Hernia by Nilo C. de los
Santos, MD, FPCS et. al.; PJSS Vol. 62, No. 1, January-March, 2007
Management

Laparoscopic mesh repair Open mesh repair (Lichtenstein technique)

Management

● Antimicrobial prophylaxis is not routinely recommended for elective groin repair

using mesh.

Reference: Evidence-Based CPG on the Management of Adult Inguinal Hernia: Primary, Recurrent and Bilateral Inguinal Hernia by Nilo C. de los
Santos, MD, FPCS et. al.; 2007
Prognosis

● The mortality of all types of repair is low, and there are no significant differences
reported among the various techniques.
● There is greater mortality associated with the repair of strangulated hernias.
● The risk of death is related to individual comorbid conditions.
● Large series have suggested that recurrence ranges from 1.7% to 10%
● Tension-free repairs have a lower rate of recurrence than tissue repairs.

Reference: Sabiston Textbook of Surgery, 20th Edition