Lump in the Groin – PBL 28

Definition & Types A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Types Inguinal Femoral Umbilical Incisional Diaphragmatic

Degrees of hernia A reducible hernia- occurs when a hernia can be pushed back into the abdomen, either spontaneously or with manipulation. An irreducible hernia- occurs when a femoral hernia becomes stuck hernial orifice. An obstructed hernia- occurs when a part of the intestine becomes intertwined with the hernia, causing an intestinal obstruction. The obstruction may grow and the hernia can become increasingly painful. A strangulated hernia- occurs when the blood supply to the herniated bowel gets blocked causing it to get ischemic. 

Inguinal Hernias The inguinal canal is a fascial tunnel leading from the abdomen to the scrotum/labia. This is a weak point in the bowel wall.

Inguinal hernias occur above the inguinal ligament

Direct Usually Occur in a Hesselbach’s triangle (defined by the edge of the rectus abdominis muscle, the inguinal ligament and the inferior epigastric artery). They can exit through the superficial ring but cannot extend into the scrotum. Indirect Travel through both the deep and superficial inguinal rings and are often due to the deep inguinal ring not closing properly. They can extend into the scrotum/labia.

Femoral Hernias Occur just below the inguinal ligament in the femoral triangle. They often get strangulated.

Para-umbilical A protrusion of the intestines or gut into the abdomen through a weak point of the muscles or ligaments near the navel.

Incisional Abdominal contents can herniate through surgical scars as they represent weakpoints in the abdominal wall.

Diaphragmatic A defect in the diaphragm allows abdominal contents to enter the thorax. E.g. Hiatus hernia- When the stomach or part of it enters the thorax through the eosophageal hiatus. Sliding- the gastro-oesophagual junction enters the thorax Rolling- the gastric fundus enters the thorax

Examination of a lump part 1 Exposure Area of the lump should be adequately exposed. This should include area of lymphatic drainage for that part of the body Diagnosis of a lump Depends on 3 main things: Determining which layer of the body in which the lump lies, i.e. skin, subcutaneous tissue, fat or deep organ Knowledge of the anatomy of that part of the body Knowledge of pathological abnormalities affecting the anatomical structures in that area Layer First determine if the lump is mobile or attached to skin Then determine if lump is deep or superficial to the muscle or tethered to the muscle Ask the patient to tense the muscle in that area If lump disappears it is deep to the muscle If lump becomes fixed this indicates the lump is attached to the muscle Is the lump inflammatory or due to infection? If it is hot or tender or if there is inflammation or redness of the overlying skin this indicates that it is inflammatory

Examination of a lump – part 2 Is the lump benign or malignant Signs of malignancy include a hard fixed lump with an irregular outline. It may be invading or ulcerating the overlying skin A benign lump is normally smooth and well defined with a distinct edge. If the lump is cystic then it may be trans illuminable. A soft spongy lump is more likely to be benign. Is the lump a hernia The lump should be tested for a cough impulse or reducibility. This indicates a hernia. Is the lump vascular The lump should be palpated and if it is pulsatile this would indicate it is arterial in nature If the lump is expansile this suggests an aneurysm Auscultate the lump for a bruit, which would indicate underlying stenosis Examination of the field of lymphatic drainage and regional lymph nodes Check for surrounding lymphadenopathy. This may be a sign of infection of metastatic cancer General Examination Examine the whole patient for other similar lumps or relevant abnormalities

Case Study Mr X – 45 yo construction worker Presented to ED with a gradual onset pain beginning one week prior Pain is in the epigastric and umbilical area Has spent week prior building a house No past history of any major illnesses or surgeries

O/E There is a small hard lump above the umbilicus approx 1-2 cm in diameter. The lump is just below the skin and is hard. The lump is not reducible but increases in size on coughing. The lump is not warm but there is redness in the overlying skin. The lump has quite a marked outline on palpation. The lump is not pulsatile on palpation and no surrounding lymphadenopathy.

Diagnosis The lump is a small hernia through rectus abdominis defect of the omental fat. The hardness of the lump is most likely due to inflammation of the omental fat.

Treatment The patient will have surgery to remove the hernia as it is not reducible and can’t be manoeuvred back to its normal position. http://www.youtube.com/watch?v=R6pwlIVQPVA http://www.youtube.com/watch?v=lFC0AWkY1p0&feature=related

Complications of hernias Inflammation of the herniated viscera Irreducibility – causing a permanent lump Obstruction – bowel obstruction Strangulation – constriction of blood vessels blocking blood flow to the organ causing ischaemia Hydrocele of the hernial sac – serous fluid accumulation in the cavity Haemorrhage