Lovely seminar!!!

1. Wel Come To Seminar Presentation
Seminar Topic:-Scrotal Swellings and
Groin Hernias
Presenters:-
- Adato Assefa
- Alamirew Abebe
- Ashebir Zewde
Venue:-Arba Minch Hospital
Moderator:- Dr. Bizuayehu

2. Outline
Definition of hernia
Type of hernia
Anatomy of groin hernia
Etiology of groin hernia
Clinical presentation
Differential diagnosis
Investigation
Complication
management

3. • Scrotal swelling
• Hydrocele
• Hematocele
• Varicocele
• Epididymal cyst
• Testicular tortion
• Testicular tumors

6. Hernia

7. Definition of hernia
• A hernia is a protrusion of a viscus or part
of a viscus through an abnormal opening in
the walls of its containing cavity
• It is commonly used to describe a weakness
in the abdominal wall

8. General features common to all
hernias
1. Aetiology
• Weakness of abdominal wall
• Any condition that raises intra-abdominal
pressure,such as
■ Coughing
■ Straining (Constipation ,Prostatism)
■ Obesity
■ Intra-abdominal malignancy
Pregnancy

9. …cont…
Family history a hernia
Ascites
Upright position
Congenital connective tissue disorders
Defective collagen synthesis
Previous right lower quadrant incision
Arterial aneurysms
Cigarette smoking
Heavy lifting

10. ….cont….
Composition of a hernia
• the sac,
• the coverings of the sac and
• the contents of the sac.

11. Classification
• Based on site:
Epigasteric
Para umbilical
umbilical
Lumbar
spigelian
Groin area

13. GROIN HERNIA
• Classified into:
Inguinal hernia
Femoral hernia

14. Inguinal hernia
Surgical anatomy
1. The superficial inguinal ring:
-a triangular aperture in the aponeurosis of the
external oblique muscle
-lies 1.25 cm above the pubic tubercle
2. deep inguinal ring:
- U-shaped condensation of the transversalis
fascia

15. …cont..
• it lies 1.25 cm above the inguinal ligament
-midway b/n p.symphisis and ASIS
• NB :the competency of the deep inguinal
ring depends on the integrity of this fascia

16. …CONT..
3. inguinal canal
• It lies from the deep to the superficial
inguinal ring
• is about 3.75 cm long
• directed downwards and medially from the
deep to the superficial inguinal ring
• anterior boundary-EOA
• The posterior boundary-TF
• Superior wall(roof)-conjoint tendon
• Inferior wall(floor)-inguinal ligament

17. …CONT…
CONTENTES OF INGUINAL CANAL
- spermatic cord(male)
- ilioinguinal nerve
- Genitofemoral nerve
- round ligament of uterus(female)

18. …cont…

19. TYPES OF INGUINAL
HERNIA
• A.INDIRECT IH
• B.DIRECT IH

20. Indirect(oblique) IH
• It travels down the canal on the outer
(lateral and anterior) side of the spermatic
cord.
• Its neck is lateral to the inferior epigastric
vessels
• most common form of hernia(young)
• In adult males, 65% of inguinal hernias are
indirect and 55% are Rt sided.

21. …cont..
• In the first decade of life, it is more
common on the right side in the male
b/c:
- failure of closure of processus
vaginalis
- later descend of Rt testis

22. ...

23. Types of indirect inguinal hernia
• 1 Bubonocele. The hernia is limited to the
inguinal canal.
• 2 Funicular. The processus vaginalis is closed
just above the epididymis. The contents of the
sac can be felt separately from the testis, which
lies below the hernia.
• 3 Complete ( scrotal) The testis appears to lie
within the lower part of the hernia.

24. Direct inguinal hernia
• It comes out directly forwards through
the posterior wall of the inguinal canal
- emerges medial to inferior epigastric
vessles.
- In adult males,it acounts 35% of
inguinal hernias
• Women practically never develop a
direct inguinal hernia.

25. …Cont…
• A direct inguinal hernia is always
acquired.
• The sac passes through a weakness of
the transversalis fascia in theposterior
wall of the inguinal canal.
• Often the patient has poor lower
abdominal musculature.

26. …cont…
• It do not often attain a large size or
descend into the scrotum.
• As the neck of the sac is wide, direct
inguinal hernias do not often
strangulate. .They are most common
in older men.

27. …cont…
Predisposing factors are
.smoking
• occupations that involve straining and
heavy lifting.
• Damage to the ilioinguinal nerve
(previous appendicectomy)

28. 28

29. Characteristic Direct Indirect
Weakness of anterior abdominal Patency of processus
Predisposing factors
wall in inguinal triangle vaginalis in younger
persons, the great majority
of which are males
Frequency Less common More common
Exit Peritoneum plus transversalis fascia Peritoneum of persistent
p p.vaginalis
Via superficial ring inside cord, Traverses inguinal canal within
Course
commonly passing into scrotum/labium processus vaginalis
majus
Exit from anterior Via superficial ring, lateral to Passes through or around
abdominal wall cord; rarely enters scrotum inguinal canal,

30. Clinical Evaluation: History
• Demographics
– Age
– Gender
• Presentation of bulge
– When, where, how
– Activities that make it better or worse
– Discomfort vs. pain
– Signs/symptoms of bowel obstruction

31. …cont…
• Surgery: previous repairs/operations
• Review of factors related to increased intra-
abdominal pressure
– Chronic cough
– Constipation
– Straining to urinate

32. Clinical evaluation : Physical Exam
• Inspection
– Scars in proximity
– Location of bulge
• Straining
–Standing
–Leg lift
• Size

33. …cont….
• Palpation bilaterally
– Anterior reducibility
– Size of defect
– Firmness
– Tenderness

34. Differential diagnosis.
In males
• vaginal hydrocele
• encysted hydrocele of the cord;
• spermatocele;
• femoral hernia;
• incompletely descended testis in the
inguinal canal
• lipoma of the cord

35. differential diagnosis cont…
In the female
• hydrocele of the canal of Nuck(small
invagination of parietal peritonium) –
this is the most common differential
diagnostic problem;
• femoral hernia.

36. Investigations
• Radiologic investigation is sometimes warranted to
correctly diagnose the cause of pain or a mass in the
groin.
• One radiologic diagnostic tool is heriography. Its
major drawback is its invasiveness.
• Ultrasound is useful but is highly operator
dependent.
• Cross-sectional imaging techniques are being
employed with increasing frequency. Both MRI and
CT may reveal other causes of groin pain

37. Management
Nonoperative Treatment
- The term "watchful waiting" is used to describe
this nonoperative treatment recommendation
-It is only applicable in asymptomatic or
minimally symptomatic hernias
-Patients are counseled about the signs and
symptoms of complications from their hernia

38. …contd…
• A truss is a mechanical
appliance consisting of a belt
with a pad that is applied to the
groin after spontaneous or
manual reduction of a hernia
• The purpose is twofold:
- to maintain reduction
- to prevent enlargement.

39. Treatment
• Operation is the treatment
of choice
• The basic operation is
inguinal herniotomy w/c
entails dissecting out and
opening the hernial sac
- reducing any contents
-transfixing the neck of the
sac
-removing the remainder

40. • Herniotomy and repair
(herniorrhaphy) consists of:
(1) excision of the hernial
sac
(2) repair of the stretched
internal inguinal ring and
the transversalis fascia
(3) further reinforcement of
the posterior wall of the
inguinal canal

41. Groin Hernia Repair Complications
• Recurrence
• Chronic groin pain: up to 30%
• Numbness over base of scrotum
• Neuropathic
Iliohypogastric neuralgia
Ilioinguinal neuralgia
Genitofemoral neuralgia
Lateral cutaneous neuralgia

42. …cont…
• Wound
– Hematoma: 1.0%
– Infection: 1.3%
– Seroma (a pocket of clear serous fluid that
sometimes develops in the body after
surgery)
• Infertility
– Injury to vas deferens
– Ischemic orchitis is uncommon
• Urinary retention

43. Femoral Hernia
- Is a protrusion of abdominal viscera (often a loop of
small intestine) through the femoral ring into the femoral
canal)
- The femoral ring is the usual originating site of a
femoral hernia
- The femoral canal is the way that the femoral artery,
vein, and nerve leave the abdominal cavity to enter the
thigh.
- contents of the femoral canal are fat, lymphatic vessels
and lymph nodes of Cloquet
- This hernia causes a bulge below the inguinal crease in
roughly the middle of the thigh.

44. …contd…
• is the third most common type of primary
hernia
• It accounts for about 20% of hernias in
women and 5% in men
• it cannot be controlled by a truss
• most liable to become strangulated b/c of :
-narrowness of the neck of the sac
-rigidity of the femoral ring.

45. …contd…
The femoral ring is bounded:
• anteriorly by the inguinal ligament;
• posteriorly by iliopectineal ligament, the
pubic bone and the fascia over the pectineus
muscle;
• medially by lacunar ligament,
• laterally by a thin septum separating it from
the femoral vein

47. …cont…
Pathology
• A hernia passing down the femoral canal
descends vertically as far as the saphenous
opening
• A fully distended femoral hernia assumes
the shape of a retort and its bulbous
extremity may be above the inguinal
ligament.
• they are usually irreducible and apt to
strangulate.

49. …cont…
Sex incidence
-f:m ratio is 2:1
-female patients are frequently elderly
-The condition is more prevalent in women
who have borne children than in nulliparae
-male patients are usually between 30 and 45
years of age.

50. ….cont…
Clinical features
. is rare before puberty.
• b/n 20 and 40 years of age the prevalence rises
and this continues to old age.
• The Rt side is affected twice as often as the left
and in 20% of cases the condition is bilateral.
• Symptoms less pronounced than those of an
inguinal hernia

51. …cont…
• indeed, a small femoral hernia may be
unnoticed by the patient or disregarded for
years, perhaps until the day it strangulates.
• Adherence of the greater omentum
sometimes causes a dragging pain.
• Rarely, a large sac is present

52. …cont…
Differential diagnosis
- inguinal hernia
- saphena varix(a dilation of the saphenous
vein at its junction with the femoral vein in the groin)
- enlarged femoral lymph node
- Lipoma
- femoral aneurysm
- psoas abscess
- distended psoas bursa

53. …cont…
Treatment
• The constant risk of strangulation is
sufficient reason to recommend operation,
• It should be carried out soon after the
diagnosis has been made

54. Hydrocele

55. Definition:-
A hydrocele is an abnormal collection of
serous fluid in a part of the processus
vaginalis, usually the tunica.

56. Aetiology
A hydrocele can be produced in four different ways:-
• by excessive production of fluid within the sac, e.g.
secondary hydrocele;
• by defective absorption of fluid; this appears to be the
explanation for most primary hydroceles although the
reason the fluid is not absorbed is obscure;
• by interference with lymphatic drainage of scrotal
structures;
• by connection with the peritoneal cavity via a patent
processus vaginalis (congenital).

57. Classification of hydrocele
• Congenital
• Acquired

58. Congenital hydrocele :
Vaginal hydrocele : occurs when hydrocele
sac is patent only in the scrotum
True Congenital hydrocele:-processus
vaginalis is patent & connects to the
peritoneal cavity. In children <3yrs
Infantile hydrocele:- the tunica and processus
vaginalis are distended to the superficial
inguinal ring. There is no conection. Occurs in
all ages
Hydrocele of the cord:- swelling near the
spermatic cord. D/D hernia, lipoma of the
cord

60. Acquired hydrocele
-Primary(Ideopathic)
• Develop slowly
• Large
• Hard and tense
• No defined cause
• Over 40s

61. -Secondary
• Develops rapidly
• Small
• Lax
• Secondary to inflammation,trauma or tumor
of testes
• Younger age group(20-40)

62. Symptoms:
Scrotal swelling
Pain & discomfort if its secondary
Frequent &painful micturation if secondary to
epididymo-orchitis
Malaise & weight loss if secondary to tumor with
distant metastases
Don’t affect fertility

63. Physical Examination

64. U/S of hydrocele
• Done to exclude testicular tumor or
epididymitits

65. Complication of Hydrocele
• Rapture
• Transformation in to hematocele occurs
after trauma or if there is spontaneous
bleeding in to the sac
• Calcification of sac
• Pyocele

67. Epididymal Cyst

69. Ultrasound
- Must be done to confirm your diagnosis & R/O
testicular tumore
cyst
Testes

71. Hematocele

72. Testicular Tumors

79. Varicocele

83. Tesicular torsion
• This is twisting of the testis with interference to the arterial
blood supply.
• the actual torsion is usually of the spermatic cord
• Possible mechanism; it is associated with:
1. Imperfectly descended testis
2. High investment of tunica vaginalis with a horizontal lie of testis
3. Epididymis& testis are separated by a mesorchium, & twisting
occurs at the mesorchium.
• The incidence is highest between 10 & 20 years.

84. • Classification
Intravaginal torsion .
. Cord twists with in the tunica vaginalis
.Occurs in adolescents and adults
Extravaginal torsion
Cord twists outside of the tunica vaginalis
Occurs in neonates/prenatal

85. Pathogenesis
• twist of the cord
-venous and arterial occlusion
-anaerobic respiration with hypercabia, hypoxia,
and acidosis
-Ischemic pain
-oedema and haemorrhage set in
-Irreversible ischemic injury by 4 hrs
-Degrees of twisting determines the
salvagability of the testis

86. Clinical features
• Intravaginal
-pubertal males
- most occurs during sleep
-may follow exercise, straining, lifting or
masturbation
-testicular pain
.sudden onset
-nausea and vomiting
-pain referred to to the ipsilateral lower
abdominal quadrant
-usually no urinary symptoms or fever

87. . Examination
-abnormal testicular lie
-swelling
-absent cremasteric reflex
-pain increased on elevating the
testis

88. Investigation
-ultrasound
-radionuclide imaging
Treatment
scrotal exploration
-explore and fix both testis.
-remove necrotic testis.

89. References
• Bailey and love short practice of surgery
25th edition
• Manipal
• emedicine.medscape.com