1. GROIN MASS
CASE 1

2. A 63-year old man with chronic bronchitis is brought to the UST Hospital Emergency Room because of a right inguino-scrotal mass. For the last 7 years, the mass would appear on standing or exertion and disappear on lying down. However, after attempting to lift a sack of rice 6 hours ago, it enlarged, became tense and painful, and would not disappear anymore despite lying down and manual massage.

3. On examination, the mass occupies the entire R inguinoscrotal area; it is tense and tender.

4. DIRECT INGUINAL HERNIA, INCARCERATED
What is the most likely diagnosis?
DIRECT INGUINAL HERNIA, INCARCERATED

5. An incarcerated hernia cannot easily be returned to its original compartment.
Overlying skin should appear to be normal, the contents should not be tense, and bowel sounds can sometimes be heard.
The incarcerated tissue may be bowel, omentum, or other abdominal contents.
A smaller aperture of herniation and adhesions can precipitate incarceration.
An incarcerated hernia can often be reduced manually, especially with sufficient anesthesia.

6. What would you do at the Emergency Room?
The initial treatment, in the absence of signs of strangulation, is taxis.
Taxis is performed with the patient sedated and placed in the Trendelenburg position.
The hernia sac neck is grasped with one hand, with the other applying pressure on the most distal part of the hernia.
The goal is to elongate the neck of the hernia so that the contents of the hernia may be guided back into the abdominal cavity with a rocking movement.
Mere pressure on the most distal part of the hernia causes bulging of the hernial sac around the neck that can occlude the neck and prevent its reduction.
Reference: Schwartz Principles of Surgery, 8th edition

7. Reference: Schwartz Principles of Surgery, 8th edition

8. Emergency Department Care Reduction of a hernia
Provide adequate sedation and analgesia to prevent straining or pain. The patient should be relaxed enough to not increase intra-abdominal pressure or to tighten the involved musculature.
Place the patient supine with a pillow under his or her knees.
Place the patient in a Trendelenburg position of approximately 15-20° for inguinal hernias.
Apply a padded cold pack to the area to reduce swelling and blood flow while establishing appropriate analgesia.

9. Place the ipsilateral leg in an externally rotated and flexed position resembling a unilateral frog leg position.
Place 2 fingers at the edge of the hernial ring to prevent the hernial sac from riding over the ring during reduction attempts.
Firm, steady pressure should be applied to the side of the hernia contents close to the hernia opening, guiding it back through the defect.
Applying pressure at the apex, or first point, that is felt may cause the herniated bowel to "mushroom" out over the hernia opening instead of advancing through it.
Hernia content balloons over the external ring when reduction is attempted.
Hernia can be reduced by medial pressure applied first.

10. Call the surgeon if reduction is unsuccessful after 1 or 2 attempts; do not use repeated forceful attempts.
The spontaneous reduction technique requires adequate sedation/analgesia, Trendelenburg positioning, and padded cold packs applied to the hernia for a duration of minutes. This can be attempted prior to manual reduction attempts.

11. One hour later, he complains of nausea and vomits once
One hour later, he complains of nausea and vomits once. The mass becomes more tender and the R side of the scrotum becomes more swollen with the overlying skin becoming reddened and edematous. Further examination reveals a flat abdomen with absent bowel sounds and tenderness and guarding at the RLQ.

13. DIRECT INGUINAL HERNIA, STRANGULATED
What is your diagnosis now?
DIRECT INGUINAL HERNIA, STRANGULATED

14. A strangulated hernia is a surgical emergency in which the blood supply to the herniated tissue is compromised.
Strangulation stems from herniated bowel contents passing through a restrictive opening that eventually reduces venous return and leads to increased tissue edema, which further compromises circulation and stops the arterial supply.
Such a hernia may be recognized in early stages by severe pain and by tenderness, induration, and erythema over the herniation site.

15. Mortality is high and treatment should be initiated immediately.
As tissue necrosis ensues, findings may include leukocytosis, decreased bowel sounds, abdominal distension, and a patient who appears to be toxic, dehydrated, and febrile.
Mortality is high and treatment should be initiated immediately.

16. Manual reduction is contraindicated in strangulated hernias.
What should you do now?
Manual reduction is contraindicated in strangulated hernias.
Rapid resuscitation with intravenous fluids is essential, along with electrolyte replacement, antibiotics, and nasogastric suction.
Urgent surgery is indicated once resuscitation has taken place.
If the diagnosis of strangulated hernia is missed and manual reduction is performed, necrotic bowel may be introduced into the abdomen. This could result in clinical deterioration and could require urgent reduction in the operating room.