Inguinal And Scrotal Masses Flashcards
PPV that allows peritoneal fluid to accumulate around the testis within the PPV, but which is not big enough to allow
bowel in, is called what?
Hydrocele
Or fluid hernia
How does the size of the baby determine the risk of abdo hernia in the case of Patent Processus Vaginalis
The smaller the child the higher the risk
What is the main borthersome complication of inguinal hernias in boys
Testicular infarction may occur in 10% of obstructed hernias due to pressure on the testicular vessels. It
appears as a necrotic testis on surgical exploration or testicular atrophy later.
Symptoms of an inguinal hernia on hx
There is usually a history of a mass in the inguinal area which increases with
coughing or crying.
• A reliable history from the mother is occasionally the only real clinical indication
in a spontaneously reducing hernia in an asymptomatic baby
• Symptoms of bowel obstruction and septicaemia may be present if the bowel
cannot be reduced
Features of an uncomplicated inguinal hernia
• Swelling in the inguinal area and scrotum
• Thickening of the spermatic cord
• “Silk sign” - feels as if two pieces of silk are rubbed together; indicative of fluid
in the processes vaginalis sac. May be of value in very small hernias but
unreliable
• Palpation of bowel in the hernia or the presence of bowel sounds
• Cannot get above it (differentiates from hydrocoele)
• Increased intra-abdominal pressure on crying increases size of hernia
Features of an irreducible inguinal hernia
A hernia with contents persisting outside the abdominal cavity that cannot be
manually pushed back into the abdominal cavity it is irreducible.
• Swelling in the inguinal area and scrotum that cannot be reduced
• Abdominal distension and signs of bowel obstruction
Features of a strangulated inguinal hernia
An obstructed hernia in which ischaemia with or without necrosis of the contents
develops.
• pain, redness, tenderness & oedema of overlying skin ± abdominal wall
• Intestinal obstruction: Obstructed inguinal hernia is one of the 2 most common
causes of small bowel obstruction
• Fluid lost from vomiting as well as into third space may lead to dehydration
and shock.
• An incarcerated hernia which contains an ovary or fallopian tube may
strangulate but will not have signs of bowel obstruction.
List the differential diagnosis of a groin swelling
• Lymphadenitis (external iliac)/ abscess (from suppurating lymphadenitis)
• Undescended testis
• Hydrocoele/ fluid hernia
• Hydrocoele of the cord
• Buried penis
• Varicocoele
Differential diagnosis for scrotal swelling
Congenital causes
• Inguinal hernia
• Hydrocele
Infections
• Epidydimo-orchitis (see: Acute Scrotum)
• Viral orchitis
Trauma
• Testicular rupture
• Scrotal or para-testicular haematoma
Torsion of testis or testicular appendage (see: Acute Scrotum)
Neoplasms
• Germ cell tumour
• Paratesticular rhabdomyosarcoma
‘Medical’ causes
• Oedema and anasarca
• Idiopathic scrotal oedema
• Henoch-Schönlein Purpura
Discuss management of uncomplicated inguinal hernia
• Urgent elective surgical repair on the next available list in small babies. The
age of the child is not a valid reason to wait. Neonates and premature babies
are at higher risk of complications.
• The only contraindication to surgery is the presence of associated problems
(e.g. pneumonia) In this event, the medical condition is treated first and the
herniotomy performed when the child is better-usually before discharge from
hospital.
• Older children can be placed on a waiting list if the symptoms and signs of
complications have been explained.
• The operation of choice for hernias in children is a herniotomy.
Discuss management of irreducible hernias
• Emergency operations run the risk of a higher incidence of wound infections,
haematoma, recurrent hernias as well as possible damage to the vas
deferens or veins. For this reason, attempt is made to initially reduce the
hernia provided that no signs of strangulation of present.
• Resuscitation and nasogastric tube drainage are commenced.
• Sedation is given
• The hernia may reduce spontaneously with gentle manipulation of the
scrotum or scrotal neck.
• Surgery is carried out as an emergency if conservative management has
been unsuccessful.
• Should the reduction be successful, surgery is carried out up 24 to 48 hours
later when the swelling and oedema have subsided.
Discuss management of a strangulated inguinal hernia
• A strangulated hernia with necrotic bowel is a surgical emergency as the
mortality is high.
• No attempt should be made to reduce ischaemic sac contents
• These patients require active resuscitation with intravenous fluid, broad-
spectrum antibiotics, and correction of electrolyte deficits.
• Once resuscitation is completed emergency surgery is carried out.
• At surgery, the surgeon will resect ischaemic bowel if present and perform at
primary anastomosis. A herniotomy is performed.
• High care/ICU is generally required postoperatively.
Discuss the surgical procedure to repair an hernia
The operation to repair an inguinal hernia in childhood is a herniotomy. This is
performed under general anaesthetic. A groin skin crease incision is made and the
inguinal canal is opened. The ilioinguinal and iliohypogastric nerve are identified
and preserved. The hernia sac identified, dissected from spermatic cord, divided
and ligated after which the layers are sutured closed. Should the sac have contents
in it at the time of operation, these are returned to the abdomen or resected and
anastomosed through the same wound if necrotic.
There is an increasing role for laparoscopic surgery
List some of the complications of hernia repair
Surgical complications (<1%):
• injury to vas deferens & testicular vessels, bladder
• wound infection
• haematoma
• recurrence
Anaesthetic complications:
• high risk of post-operative apnoea in premature infants <60 weeks corrected
gestational age (=gestational age + age since birth in weeks
• require 24-48h post-operative apnoea monitoring ± caffeine to decrease risk.
Are femoral hernias common in girls or boys
Femoral hernias are also rare in children and are managed along the same lines as
in adults. They are more common in girls and usually present with a bulge below the
groin crease.
Clinical features of a hydrocele
. Swelling in the scrotum that may increase and decrease in size over the day
• The swelling feels cystic
• Can get above the fluid filled scrotum
• Usually not reducible
• Transillumination
