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MET3a > A Lump in the Groin > Flashcards

A Lump in the Groin Flashcards

1
Q

Where does the spermatic cord exit through?

A

Superficial inguinal ring

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2
Q

Where does the inguinal ligament run?

A

Between ASIS and pubic tubercle

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3
Q

What is the superficial ring?

A

External oblique aponeurosis defect

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4
Q

Where is the deep ring?

A

Midway between pubic tubercle and ASIS

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5
Q

Where is the mid inguinal point?

A

Surface marking of femoral artery (pulse)
Between pubic symphysis and ASIS
Lateral to deep ring

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6
Q

Where is the inguinal canal?

A

Between deep ring and superficial ring

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7
Q

What runs underneath the inguinal ligament?

A

Femoral vein, artery, nerve

From medial to lateral

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8
Q

Where do femoral hernias develop?

A

Femoral canal

Medial to femoral vein

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9
Q

What to ask about in a history of a lump in the groin?

A
  • site
  • duration
  • how did it start
  • pain
  • size changes
  • other symptoms
  • any other lumps
  • previous lump history
  • PMH
  • FH
  • drugs
  • social history
  • ROS
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10
Q

Examination of the lump

A

6 S’s

  • site
  • size
  • shape
  • surface
  • conSistency
  • ficSity (fixity)
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11
Q

Specific questions of lump in groin?

A
  • can I get above it (upper border, if not then arising from inside abdomen and passing into groin)
  • is it reducible (comes and goes, in morning overnight disappears)
  • how it relates to anatomical landmarks
  • does it have a cough impulse
  • is it pulsatile
  • does it transilluminate (if contain fluid they will)
  • can I feel testis separate from lump
  • other lumps
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12
Q

Soft tissue lumps

A

Lipoma
Sebaceous cyst
Abscess

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13
Q

Femoral artery lumps

A

Aneurysm - expanding and pulsatile

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14
Q

Saphena varix

A

Compressible

Palpable thrill medial to artery

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15
Q

Enlarged lymph node

A

Multiple often
Mobile
Firm and tender

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16
Q

Undescended testes

A

Empty scrotum

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17
Q

Psoas abscess

A

Fluctuant swelling lateral to artery

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18
Q

Differentials for lump in groin

A 
Hernia
Soft tissue lump
Femoral artery aneurysm
Saphena Varix
Enlarged lymph node
Undescended testes
Psoas abscess
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19
Q

Define a hernia

A

Abnormal protrusion of a viscus or part of a viscus through its normal coverings

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20
Q

What mechanism causes hernias

A

Combination of increasing abdominal cavity pressures and decreasing abdominal wall strength

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21
Q

Causes of hernias

A 
Heavy lifting
Coughing/chronic lung disease
Chronic constipation
Urinary outflow obstruction
Ascites
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22
Q

How to describe hernias

A 
location
reducible or irreducible
incarcerated
strangulated
special hernias
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23
Q

Difference between femoral and inguinal hernia

A

Femoral arises below and lateral to pubic tubercle

Inguinal arises above and medial to pubic tubercle

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24
Q

What is the hernia sac made up of?

A

Peritoneum

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25
Q

Irreducible hernia define

A

Intestine trapped into hernia sac

Contains incarcerated intestine

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26
Q

Incarcerated intestine

A

Remains irreducible but content is viable

Not yet strangulated

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27
Q

Strangulated hernia

A

Intestine contents trapped with compromised blood supply

Progression of incarceration

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28
Q

Which scenarios are an emergency?

A

Incarceration - to prevent strangulation

Strangulated - to treat gangrenous bowel

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29
Q

Complications of hernia

A

Obstruction

Strangulation

30
Q

2 commonest causes of small bowel obstructions

A

Hernia

Adhesions

31
Q

Commonest cause of small bowel obstruction for those who have not had previous surgery

A

Hernia

As adhesions are rare for these individuals

32
Q

Strangulation features

A
  • narrow neck hernia
  • tender
  • irreducible
  • red
  • tachycardia
  • pyrexia
  • WCC raised
33
Q

Tx for strangulation

A

Resus

Emergency surgery

34
Q

Which hernias are likely to get strangulated?

A

Femoral
Sometimes umbilical
Indirect inguinal hernias

35
Q

Features of obstruction causing hernias

A
  • irreducible hernia,

- Tx = emergency, resuscitate

36
Q

Indirect inguinal hernias

A

Pass through deep ring, traverse the canal and exit through superficial ring

37
Q

Direct inguinal hernias

A

Directly through abdominal wall to bulge through superficial ring

38
Q

Causes of indirect inguinal hernias

A

Congenital

Acquired

39
Q

Congenital cause of indirect inguinal hernia

A
  • Through patent processus vaginalis (should be closed before birth) following testes
  • hernia usually descends into scrotum
  • females can get it but more common in males
40
Q

Acquired causes of indirect inguinal hernias

A

Through deep and superficial rings
Occur at any age but more common in older
Often descend into scrotum

41
Q

Direct inguinal hernia mechanism

A

Protrude through abdominal wall in Hasselbach’s triaingle
Transversalis fascia forms hernia sac
Abdominal wall slightly thinner here
Usually in middle age and elderly who have weaker abdominal walls

42
Q

Hasselbach’s triangle

A

Inguinal ligament
Lateral margin of rectus abdominus
Inferior epigastric vessels

43
Q

Age difference direct indirect

A

Older Direct

Younger indirect

44
Q

Frequency direct vs indirect

A

25% direct

75% indirect

45
Q

Cause direct vs indirect

A

Acquired direct

Congenital indirect

46
Q

Bilateral direct vs indirect

A

50% direct

20% indirect

47
Q

Course direct vs indirect

A

Only medial 1/3 inguinal canal direct

Whole inguinal canal indirect

48
Q

Neck of sac direct vs indirect

A

Wide direct

narrow indirect

49
Q

Relation to inferior epigastric vessels direct vs indirect

A

Medial to vessels direct

Lateral to vessels indirect

50
Q

Inguinal hernias more common in who?

A

Men

51
Q

Femoral hernias more common in who

A

Women

52
Q

What type of hernia is a woman more likely to get?

A

Inguinal > femoral

53
Q

Management decisions of inguinal hernias

A

Elective or emergency
Conservative or surgical
Laparoscopic or open

54
Q

TRUSS

A

Pad placed over hernia
For elderly mostly
Patient told hernia must be reduced before put on truss otherwise will not help at all as still risk of complications

55
Q

When is it appropriate for elective management?

A

Patient fit enough
Having symptoms
Reducible mostly
Elective repair

56
Q

When is emergency treatment appropriate?

A

Irreducible

Tender

57
Q

When is conservative Tx appropriate?

A

Minimal symptoms

Easily reducible

58
Q

Open mesh repair

A

Inguinal indirect and direct
Local anaesthetic or sometimes prefer general/spinal
Hernia sac reduced or excised
Insert mesh to reinforce posterior inguinal canal

59
Q

What do you have to be careful to protect in open mesh repair?

A

iliohypogastric nerve
ilioinguinal nerve
genital branch of genitofemoral nerve

60
Q

Laparoscopic repair

A

Recurrent and bilateral inguinal hernias
3 small incisions = 1 at umbilicus for camera and 2 lateral ports
Reduced chronic pain due to nerve injuries
More expensive
Smaller incisions than bilateral open repair

61
Q

Features of femoral hernias

A

Rarer
Females more common
Through femoral canal and femoral ring
Often symptomless until strangulate or incarcerate
Higher risk of strangulation
Recommended repair promptly to avoid complications

62
Q

Characteristics of a femoral hernia

A

Small - 2cm lump
Becomes hardened
Tender when obstructed or strangulated
If contains bowel requires immediate emergency surgery

63
Q

What can strangulation lead to?

A

Ischaemia and perforation

64
Q

Management of femoral hernias

A 
Referred promptly for elective repair
Dissection of sac and content reduction
Then ligation of sac an closure
Open suture favoured then mesh then laparoscopic
Strangulated is surgical emergency
Truss not suitable for femoral
65
Q

Spigelian hernia

A

Emerges through linea semi lunaris (lateral border of rectus abdominus)

66
Q

Amyand’s hernia

A

Appendix

67
Q

Littre’s hernia

A

When Meckel’s diverticulum protrudes into inguinal hernia

68
Q

Meckel’s diverticulum

A

In ileum
2 inches
2% of population
2 feet from ileo-caecal valve

69
Q

Pantaloon hernia

A

Inguinal hernia with direct and indirect component
Hernia sac through deep ring and weakness in Hasselbach’s triangle
Always check at deep ring for indirect as well as direct

70
Q

Maydl’s hernia

A

Part of loop of bowel is inside and part of outside
Internal loop may be strangulated
Loop is M shaped

71
Q

Richter’s hernia

A

Part of bowel incarcerated in hernia and can strangulate
Anti-mesenteric border
Strangulated but not obstructed
Lumen remains patent
needs partial resection then anastomoses of healthy parts

72
Q

Cough impulse

A

Increased in size of lump with coughing

MET3a (38 decks)

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