Hernia and Scrotal Swellings

BYPROF/ GOUDA ELLABBANDepartment of Surgery/egypt

Hernias

• Causes : 1. increased abdominal pressure 2. weakness in abdominal wall

• Chronic cough, BPH, constipation, ascites, are causes for increased in pressure

• Obesity, old age, and congenital potential spaces are causes for weakness in the abdominal wall

Types of Hernias

• Direct inguinal hernia• Indirect inguinal hernia• Femoral hernia• Obturator hernia• Sciatic hernia• Perineal hernia

• Umbilical hernia• Paraumbilical hernia• Epigastric hernia• Hiatus hernia• Diaphragmatic hernia• Incisional hernia• Spigelian hernia

Contents in a Hernia

• Usual: omentum, small bowel• Sliding hernia: content with partial peritoneal

cover such as: sigmoid colon, urinary bladder• Ritcher’s hernia: part of the small bowel wall was

in the hernia with perforation but no obstruction

Development of a hernia

• In young age group: congenital potential space• In old age group: gradual onset and slow

enlargement due to weakness in the abdominal wall

Physical Characteristics• Size of the defect of the abdominal wall• Size of the hernia• Contents of the hernia• Reducible at least at the beginning• Irreducible/incarcerated/strangulated (small neck)• Cough impulse• Cannot get above the swelling

Main Points in History• Age: young or old?• Factors for increase abdominal pressure• Started with a smaller swelling• Disappears on lying down• Gurgling noise inside the swelling• Pain and dragging discomfort• Intestinal obstruction

Physical Examination • Three important steps MUST be taken• Patient standing for the examination - cough

impulse and cannot get above the swelling• Lying down to reduce the hernia by patient• Try to hold back the hernia with the thumb at

the internal ring while standing will distinguish direct from indirect inguinal hernia

Anatomical Landmarks• Anterior superior iliac spine• Pubic tubercle• Inguinal ligament• Mid-inguinal point• Interrnal inguinal ring• To distinguish direct/indirect hernia

Indication for Surgery• Risk of complications such as strangulation and

intestinal obstruction• Pain and mass interfere with function• Conservative treatment

Principles of Surgery• Reduction of the contents• Excision of the hernial sac• Repair of the defect • Difficult in case of large hernia

and large defects

The most important in accurate diagnosis is careful clinical examination in inguinal-scrotal masses

Scrotal Masses

• Can you get ABOVE the swelling?• Where is the mass arising from?• The mass itself cystic/transilluminate?• The mass hard and the surface irregular?

Common Scrotal Masses

• Spermatic cord - varicocele, spermatocele, cyst

• Epididymis - cyst, epididymitis• Testis - tumour, torsion, orchitis• Hydrocele• Scrotal skin - sebaceous cyst• Urethra

Varicocele• Grade 1 - palpable with Valsalva• Grade 2 - palpable without straining• Grade 3 - can be seen on inspection• Bag of worms in 15% of young man• More common on the left side• 30% infertile patients have varicocele

Varicocele

• Usually cause discomfort after running• Spermatogenesis impaired due to hypoxia,

elevated temperature and reflux of metabolites• Treatment by Ligation of the veins• Varicocele in older man may indicate left renal

carcinoma with renal vein involvement

Torsion of Testis• To distinguish from Orchitis• Both are acute painful swelling of the testis• Treatment is different• Age, fever, venereal exposure…• Types of torsion - extra-vaginal, intra-vaginal,• Torsion of the undescended testis

Empty Scrotum

• Undescended testis• Ectopic testis• Retractile testis

Hydrocele

• Accumulation of fluid in the tunica vaginalis• Short history - thin wall and transilluminate• Long history - thick wall and ?previous trauma• Cystic mass, the testis is within the sac and

therefore NOT palpable• Can get above the swelling• Surgery - Jaboulay’s operation

Trauma to the Scrotum

• Haematocele of the testis• Rupture of the testis• Fracture of the penis• Trauma to the bulbous urethra• Laceration of the scrotal skin

Testicular Tumour

• Hard and irregular swelling of the testis• Spermatic cord normal• Types - germ cell, non germ cell, secondary

metastasis, paratesticular tissues• Must palpate the abdomen for central supra-

umbilical masses (lymph nodes)