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The Case of the Mysterious Mass

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1 The Case of the Mysterious Mass
Andrew Williams Ken Koncilja Aravind Reddy Meghan Kaumaya

2 Patient and Chief Complaint
12 year old male with walnut size enlargement left of pubic tubercle Enlargement changes with body position and activity level Exacerbated by weight training, “barely noticeable” in the morning Physical exam revealed normal size and position of external genitalia

3 Physical Exam Vital Signs Pulse: 80 Rhythm: Regular
Temperature: 98.4 F Respiratory Rate: 15 Height: 5’6” Weight: 110 lbs. Physical Examination HEENT: Normal Lungs: Normal Cardiovascular: Normal Abdomen: Small palpable mass in groin, lateral to pubic tabercle Genitourinary: Normal Musculoskeletal: Normal Neurological: Normal

4 Gross Anatomy Inguinal Canal
Oblique intermuscular passage through inferior anterior abdominal wall Contains spermatic cord in males, round ligament in females Extends from deep inguinal ring (lateral) to the superficial inguinal ring (medial), both rings are lateral to the pubic tubercle Boundaries Anterior: External abdominal oblique aponeurosis Posterior: Transversalis fascia, conjoined tendon Floor: Inguinal ligament Roof: Internal abdominal oblique and transverse abdominal muscles

5 Spermatic Cord Contains 3 layers
External spermatic fascia: from external oblique muscle Cremasteric muscle: from internal oblique muscle Internal spermatic fascia: from transversalis fascia

6 Possible Causes Neoplasm: Unlikely
Fluid build up: Hydrocele (communicating or non-communicating) of testis or cord, hematocele of testis, varicocele Inguinal Hernia: Direct or Indirect

7 Types of Inguinal Hernias
Indirect Leaves abdominal cavity lateral to inferior epigastric vessels Enters deep inguinal ring and runs inside spermatic cord Sac formed from persistent processus vaginalis Direct Leaves abdominal cavity medial to inferior epigastric vessels, through inguinal triangle Travels through medial portion of inguinal canal, runs parallel to spermatic cord Sac formed by peritoneum and transversalis fascia Less common

8 Congenital or Acquired?
Processus Vaginalis does not seal after the descent of the testes Fluid or intestines occupy the space in the inguinal canal left open by the patent processus The processus vaginalis remains patent in 25% of adults Indirect are far more common in younger males Acquired Exercise or strain can induce a direct hernia Direct Hernias are more common in males over 40 Problem lies in a weak falx inguinalis (conjoint tendon) either by trauma or lack of exercise.

9 Diagnosis and Plan Indirect or Direct hernia or Communicating Hydrocele. Determine with further testing, use illumination to rule out hydrocele Avoid sports and heavy lifting until repaired Requires surgical treatment: be cautious of ilioinguinal nerve and genitofemoral nerve

10 References Deveney Karen E, "Chapter 32. Hernias & Other Lesions of the Abdominal Wall" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: Albanese Craig T, Sylvester Karl G, "Chapter 43. Pediatric Surgery" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: Craig T, Sylvester Karl G, "Chapter 43. Pediatric Surgery" (Chapter). Doherty GM: CURRENT Diagnosis & Treatment: Surgery, 13e: Moore, Keith L., Dalley, Arthur F., Agur, Anne M.  Clinically Oriented Anatomy.  6th ed.  Baltimore: Lippincott Williams & Wilkins; 2010.  Moore, Keith L., Persaud, T.V.N. The Developing Human: Clinically Oriented Embryology. 8th ed. Philadelphia: Saunders; 2008. Edelman D.S., Selesnick H.: “Sports” hernia: Treatment with biologic mesh (Surgisis). A preliminary study.  Surg Endosc  2006; 20(6): Saad Samy, Duckett Olly, "Chapter 139. Urologic and Gynecologic Problems in Children" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: /content.aspx?aID=

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