EV, a 55 year old Male Married Self-employed Zamboanga City.

Right Inguinoscrotal mass

2 years PTA, onset of inguino scrotal mass on the right, reducible, with no other associated signs and symptoms. 2 days PTA, inguinoscrotal mass noted but this time associated with pain, dragging sensation and a pain scale of 6/10 non-radiating and irreducible.
A few hours PTA, prompted consult at the ER for persistence of symptoms hence admission.

No previous surgery and no known allergy to food and drugs

No known Heredo- familial diseases

has a son and a wife Smoker Non-alcohol drinker A retired driver

General: (-) weight loss Skin: (-) rashes, (-) itchiness, (-) changes of color Head: (-) dizziness, (-) headache Eyes: (-) redness, (-) visual changes, (-) blurring of vision Ears: hearing good, (-) tinnitus, (-) vertigo Nose: (-) nosebleed, (-) nasal congestion, (-) sinus trouble Mouth and Throat: (-) dry lips, (-) bleeding gums Neck: (-) neck pain, (-) stiffness, (-) swollen glands Respiratory: (-) colds Cardiovascular: (-) dyspnea, (-) orthopnea, (-) chest pain, (-) palpitations Gastrointestinal: (-) dysphagia, (-) heartburn, (-) abdominal pain, (-) constipation, (-) diarrhea

Urinary: (-) oliguria, (-) flank pain Peripheral Vascular: (-) varicose veins, (-) leg cramps Musculoskeletal system: (-) bone or joint pains and muscle cramps (-) bipedal edema, (-) tremors or involuntary movements Neurologic system: memory good, (-) fainting, (-) numbness and tingling, (-) weakness, paralysis and loss of sensation,(-) involuntary movements Hematologic: (-) anemia, (-) easy bruising or bleeding Endocrine system: (-) excessive sweating, hunger or thirst, (-) polyuria, (-) heat or cold intolerance

GENERAL SURVEY Conscious, coherent, cooperative , NIRD VITAL SIGNS Temperature - 36.2 C, Respiration - 22 bpm, Blood pressure - 100/ 60 mmHg and a Pulse Rate - 71 bpm. SKIN No jaundice noted. No pallor. HEENT
Eyes: Anicteric sclerae. Conjunctivae is pink, , reactive to light. Ears: (-) discharges, With good acuity to whispered voice. Nose: No alar flaring. (-) discharges Throat: Oral mucosa is pink, tongue midline. Tonsils (-) infection / inflamed. Pharynx: (-) exudates NECK Trachea midline. No palpable lymph nodes.

THORAX AND LUNGS Thorax are symmetrical. Clear breath sounds. No rales or wheezes noted.
CARDIOVASCULAR SYSTEM AP, NRRR, distinct sounds with no heart murmurs. ABDOMEN flat, soft, normoactive bowel sound, percussed and revealed a dull sound, palpated with tenderness on hypogastric area, 6 x9 cm.

RECTAL AND GENITALIA No discharges/ulcers noted on genitalia, inguino-scrotal mass on the right, no cyanosis noted, (-) transillumination, 6x7cm.

EXTREMITIES Warm to touch, no edema, CRT < 2 secs. MUSCULOSKELETAL No deformities and with good range of motion.
NEUROLOGIC Oriented to time and place, is conscious and has a stable gait.

Indirect Inguinal Hernia Right, Incarcerated

BASIS: Hx of scrotal mass that was formerly reducible PE: Irreducible scrotal mass with inguinal component, no cyanosis noted. No tachycardia.

Admitted Secure consent NPO IVF D5lr 1 L at 40 gtts/ min Labs: cbc, platelet, blood typing Chest xray and 12 lead ECG for CP evaluation Meds: Cefoxitin 2 gm IVTT ANST 1 hour before induction For emergency Hernioplasty right mesh inguinal Notify OR/ Anesthesiologist Insert FBC and attach to urine bag collector Insert NGT

-hgb -hct -rbc -wbc -plt -bt

15.2 0.45 4.64 19.7 284 O+

MGH with home meds of:

1. Cefuroxime 500mg BID x 7 days 2. Celecoxib 200mg BID PRN pain 3. MV tab OD

Indirect Inguinal Hernia Right with incarcerated small bowel;

Hernioplasty Right with Inguinal Mesh Indirect Inguinal Hernia Right with incarcerated small bowel; Hernioplasty Right with Inguinal Mesh

Hernia- is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.

Inguinal hernias may be considered congenital or acquired. Congenital hernias, w/c make up the majority of pediatric hernias, can be considered an impedance of normal development, rather than an acquired weakness Normal Course of development: The testes descend from the intraabdominal space into the scrotum in the 3rd trimester.

The descent is preceded by the gubernaculum and a diverticulum of peritoneum, w/c protrudes through the inguinal canal and ultimately becomes the process vaginalis.. 36-40 wks: processus vaginalis closes, eliminates the peritoneal opening at the internal inguinal ring.

Failure of the peritoneum to close results in a ppv. NOTE: processus vaginalis continues to close as the child ages, with most closing within the first few months of life.

follows the tract through the inguinal canal. This results from a persistent process vaginalis.
The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine. The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.[

A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon.

Reducible hernia: This term refers to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually.
Incarcerated hernia: An incarcerated hernia is no longer reducible. The vascular supply of the bowel is not compromised; however, bowel obstruction is common. Strangulated hernia: A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents.

Majority of abdominal wall hernias occur in the groin (75%) Of inguinal hernia repairs, 90% are performed in males and 10% in females. Aprrox. 70% of femoral hernia repairs are performed on female patients. Incidence of inguinal hernias in males has a bimodal distribution with peaks before 1 y.0. and then again after age 40.

Approx. 4 to 6 cm Anteroinferior portion of the pelvic basin Shaped like a cone, its base is at the superolateral margin of the basin, its pex pointed inferomedially toward the symphysis pubis Begins intra-abdominally on the deep aspect of the abdominal wall, where the spermatic cord passes through a haitus in the transversalis fascia.

The haitus is termed the deep or internal inguinal ring. Boundaries:

Anterior: external oblique aponeurosis
Posterior: transversus abdominis and transversalis

fascia Superior: internal oblique muscle Inferior: inguinal ligament

consists of three arteries, three veins, and two nerves it contains the pampiniform venous plexus anteriorly and the vas deferens posteriorly, with connective tissue and remnant of the processus vaginalis

Arteries: testicular artery, deferential artery, cremasteric artery Nerves: nerve to cremaster (genital branch of the genitofemoral nerve), testicular nerves (sympathetic nerves) Vas deferens (ductus deferens) Pampiniform plexus Lymphatic vessels Tunica vaginalis (remains of the processus vaginalis)

Inguinal ligament- is comprised of the inferior fibers of the external oblique aponeurosis. The ligament stretches from the ASIS to the pubic tubercle Coopers ligament- lateral portion of the lacunar ligament that is fused to the periosteum of the pubic tubercle may include fibers from the transversus abdominus, iliopubic tract, internal oblique, and rectus abdominus

Iliopubic tract often is confused with the inguinal ligament secondary to common origin and insertion points. forms on the deep side of the inferior margin of the transversus abdominus and transversalis fascia.
Inguinal ligament is on the superficial side of the musculoaponeurotic layer

The shelving edge of the inguinal ligament is a structure that more or less connects the iliopubic tract to the inguinal ligament.

Types
1. Classical Repairs (anatomic repairs) use anatomic structures a) Marcy Simple Ring Closure ligate the sac, and put series of sutures in the internal inguinal ring b) Bassini Shouldice Repair (Gold Std before) uses conjoined tendon of ext. and int. oblique c) McVay Lotheissen Cooper Ligament Repair

Basic Components:
1. Dissection of Inguinal Canal 2. Repair of Myopectineal Orifice (internal inguinal ring) 3. Closure of Hernial Sac

Types
2. Tension-Free Repair Lichtenstein Hernioplasty - use of prosthetic material (prosthesis net like inert structure) - promotes fibrosis and scarring - obliterates tension - commonly practiced nowadays

Types
1. Nyhus Iliopubic Tract Repair 2. Cheatle-Henry Midline Approach 3. Stoppa Procedure (GPRVS) 4. Laparoscopic Hernioplasty

TRANSABDOMINAL PREPERITONEAL PROCEDURE TOTALLY EXTRAPERITONEAL PROCEDURE

The definitive treatment of all hernias is surgical repair.

is aimed at alleviating symptoms related to the inguinal hernia, such as pain, pressure, and protrusion of abdominal contents. Simple maneuvers include assuming a recumbent position, which aids in self-reduction of the hernia. A truss, an elastic belt or brief that aims to keep the hernia reduced, may also be worn; however, its use does not prevent hernia progression or incarceration. A truss may provide relief in up to 65% of patients; however, many will use it only intermittently as it does not provide continuous control of the hernia and may actually lead to an increased rate of hernia incarceration.

conservative management is applied to asymptomatic or minimally symptomatic inguinal hernias.

One study has calculated the cumulative probability of developing a strangulated hernia to be 2.8% at 3 months for an inguinal hernia, and rising to 4.5% after 2 years. The figures were much higher for development of a strangulated femoral hernia at 3 months and 2 years, 22 and 45%.