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Impression:

Inguinal Hernia
An inguinal hernia happens when contents of the abdomenusually fat or part of
the small intestinebulge through a weak area in the lower abdominal wall. The
abdomen is the area between the chest and the hips. The area of the lower
abdominal wall is also called the inguinal or groin region.

Two types of inguinal hernias are

indirect inguinal hernias, which are caused by a defect in the abdominal wall that is
congenital, or present at birth
direct inguinal hernias, which usually occur only in male adults and are caused by a
weakness in the muscles of the abdominal wall that develops over time

Differentials:
Lipoma lipomas are most often asymptomatic (whereas the patient presented with
pain) though they can be frequently found in the inguinal area as an incidental
finding. Lipomas also present with slipping sign which signifies that it is not tethered
to its surrounding structures.

Femoral Hernia this is along with inguinal hernias are groin hernias. This type of
hernia however is more common in women. Unlike inguinal hernias, femoral hernias
remain lateral to the pubic tubercle. Femoral hernias compress the femoral vein
which may cause it to dilate while inguinal hernias do not compress the femoral
vein. No signs of venous compression in the patient.

Inguinal Abscess Inguinal abscess may present as a mass which is painful to touch
when it is located in the superficial area. Its common symptoms include swelling,
localized pain, redness, leukocytosis and fever. These were not found in the patient.

PLAN

Diagnostics:

Physical Examination feel for palpable herniation starting from the scrotum
following the spermatic cord to the inguinal ligament.

Complete blood count (CBC) may aid in diagnosing strangulation with


leukocytosis

Electrolyte, blood urea nitrogen (BUN), and creatinine levels useful as


preoperative assessment

Urinalysis narrow down the cause of the groin pain

Lactate levels may indicate hypoperfusion pointing to strangulation

CT scan visualize the mass and determine its location, incarceration and
strangulation; demonstrates extracoelomic location of the bowels or the bladder

Ultrasound narrowing the differential on both scrotal masses and masses


below the inguinal ligament

Surgical Treatment:
Hernias are not typically susceptible to medical therapy so surgical repair is the
main management.

Bassini repair external oblique aponeurosis is opened over the inguinal


canal and the spermatic cord is visualized. The indirect hernia sac that is seen is
then ligated followed by a triple layer repair where the transversalis fascia is
opened and included with the internal oblique muscle and transversus abdominis
aponeurosis which are then sewn to the iliopubic tract and the inguinal ligament
(Most cases however do not have transversalis fascia inclusion).

McVay repair medial portion of the iliopubic tract is excised exposing the
medial femoral sheath and the Coopers ligament for placement of sutures. A
relaxing incision at the point of fusion of external oblique aponeurosis and anterior
rectus sheath to minimize tension. The repair requires anchoring of the abdominus
aponeurosis and the transversalis fascia to Cooper's ligament. Suturing continues to
the femoral sheath and then laterally with the iliopubic tract anchoring the
transversalis fascia and transversus abdominis aponeurosis. Suture is continued
until the inguinal ring is reapproximated to about a fingertip from the spermatic
cord. The cord structures are rearranged normally inside the inguinal canal and the
external oblique aponeurosis is closed.


Shouldice repair variation involving the combination of Bassini and McVay
repair.

Tension free repair uses synthetic mesh material. It uses the meshs space
filling properties to provide tissue tension and strength to the repair. An onlay patch
is placed on the anterior surface of the posterior wall of the inguinal canal from the
pubic tubercle to above the internal ring and a slit in the mesh allows exit of the
spermatic cord. As the mesh remains in place, muscles and tendons repair and give
rise to fibrous tissue which grows through and around the mesh.

Laparoscopic repair makes use of a large mesh placed behind the defect
covering the myopectineal orifice and utilizing the forces of the abdominal wall to
support the mesh. This can be used for less pain and f