JC80 (Surgery) - Hernia and scrotal lumps

Question 1

Hernia

• Definition
• Contents of a hernia sac

Answer 1

Hernia: protrusion of a viscus or part of a viscus through abnormal opening in walls of its containing cavity

Composition:
□ Sac: diverticulum of peritoneum (neck and body)
□ Covering: layers of abdominal wall
□ Contents: omentum, viscera, fluid

Question 2

Clinical classes of hernia

Answer 2

Reducible

Irreducible/ Incarcerated hernia (May be due to narrow sac or adhesions, more common in omentocele)

Obstructed hernia: trapped loop of bowel leading to luminal obstruction without compromise of blood supply

Strangulated hernia: blood supply leading to intestinal ischaemia

Question 3

Common clinical features of hernia

Answer 3

□ Asymptomatic intermittent swelling that aggravates upon coughing or straining
→ Usually reducible upon direct pressure or lying down
→ A/w expansile cough impulse upon palpation

□ ± symptoms of IO if obstructed

□ ± acute pain, tenderness if strangulated

Question 4

Pathogenesis of hernia

Answer 4

2 parts:

1. Loss of mechanical integrity of abdominal wall muscles and tendons:
   - Primary collagen defect or connective tissue disease
   - Secondary to defective wound healing
2. Increase intra-abdominal pressure cause rupture at weakest point at abdominal wall

Question 5

Define region in abdominal wall most prone to hernia

Define the region’s borders

Answer 5

Myopectineal orifice (MPO): area of weakness in pelvic region

Boundaries:

• Arching fibres of IO/TA (above)
• RA and its fascial rectus sheath (medial)
• Cooper’s (pectineal) ligament along pectineal line of pubis (below)
• Iliopsoas muscle (lateral)

Prone to hernia because NOT reinforced by muscles like the rest of abdominal wall → inguinal or femoral hernia

Question 6

Differentiate the following:

External vs internal hernia
Sliding hernia

Answer 6

External vs internal:
→ External: protrude outside abdomen
→ Internal: protrude into retroperitoneal fossa or foramen (eg. Petersen’s hernia)

Sliding hernia: herniation of retroperitoneal organ together with posterior peritoneum (most commonly caecum, bladder, sigmoid)

Question 7

Differentiate the following

Littre’s hernia
Amyand’s hernia
Richter’s hernia

Answer 7

Littre’s hernia: hernia containing Meckel’s diverticulum

Amyand’s hernia: hernia containing appendix

Richter’s hernia: a type of strangulated hernia where only bowel wall is trapped and ischaemic without luminal obstruction

Question 8

List all possible sites of hernia

groin, ventral, lumbar…etc

Answer 8

Groin hernia: most common
→ Inguinal (96%): indirect (2/3), direct, pantaloons (both)
→ Femoral (4%): below inguinal ligament through femoral ring

Ventral hernia:
→ Epigastric hernia: extraperitoneal fat protrudes through linea alba above umbilicus
→ Umbilical and paraumbilical hernia
→ Spigelian hernia: herniation along linea seminlunaris

Lumbar hernia: through Petit (inferior) triangle or Grynfeltt (superior) triangle

Incisional hernia

Parastomal hernia

Pelvic hernias:

• Obturator hernia: protrusion through obturator foramen
• Perineal hernia: through pelvic floor
• Sciatic hernia: through greater or lesser sciatic foramen

Question 9

9 layers of anterolateral abdominal wall

Answer 9

□ Skin
□ Camper’s fascia: thick fatty outer layer
□ Scarpa’s fascia: thin membranous inner layer

□ External oblique (EO) and its aponeurosis
□ Internal oblique (IO) and its aponeurosis
□ Transversus abdominis (TA) and its aponeurosis

□ Transversalis fascia
□ Pre-peritoneal fat
□ Parietal peritoneum

Question 10

Inguinal canal

• Formed by what structures
• Length

Answer 10

Inguinal canal: 4-6cm oblique passage

Formed by three musculoaponeurotic arcades
1. TA attaches at lateral 1/2 of inguinal ligament → medial margin forms deep inguinal ring

2. IO attaches at lateral 2/3 of inguinal ligament
3. EO forms the inguinal ligament → gap medial to pubic tubercle forms superficial inguinal ring

Question 11

Inguinal canal boundaries

Answer 11

→ Roof: musculoaponeurotic arcades of IO/TA
→ Anterior wall: EO aponeurosis
→ Floor: inguinal ligament, lacunar ligament (medial end)
→ Posterior wall: transversalis fascia, conjoint tendon (medial 1/3)

Question 12

Inguinal canal

Content

Answer 12

→ Spermatic cord (M)

• 3 fascial layers: external spermatic, cremasteric, internal spermatic
• 3 arteries/veins: A/V to vas deferens, testicular A/V, cremasteric A/V
• 3 nerves: genital br. of genitofemoral n., SN (T10) and visceral afferent, (ilioinguinal n.)
• 3 other structures: remnants of processus vaginalis, vas deferens, testicular lymphatics

→ Round ligament of uterus (F)

→ Ilioinguinal n. (L1): supplies upper scrotum, skin over root of penis

Question 13

Femoral canal

• Content
• Lining
• Opening

Answer 13

□ Content: lymph node of Cloquet, adipose tissues

□ Lining: medial compartment of femoral sheath surrounding femoral vessels and lymphatics below inguinal ligament

□ Femoral ring: superior opening

Question 14

Differentiate femoral vs inguinal hernia location

Answer 14

Femoral hernia: protrusion of organ via femoral canal
□ Site of neck: below + lateral to pubic tubercle

Inguinal hernia: protrusion of organs at inguinal region
□ Site of neck: above + medial to pubic tubercle

Question 15

Differentiate direct vs indirect inguinal hernia

• Location
• Protruded region
• Passage through 2 inguinal rings
• Clinical test for differentiation

Answer 15

Inguinal hernia: protrusion of organs at inguinal region
Site of neck: above + medial to pubic tubercle

1. Indirect inguinal hernia: lateral to inferior epigastric A/V
   Reason: organ protrudes via inguinal canal
   Passes through both deep + superficial rings
   Occlusion test +ve: can be reduced by pressing on deep inguinal ring
2. Direct inguinal hernia: medial to inferior epigastric A/V
   Reason: organ protrudes via Hasselbach triangle
   Passes through only superficial ring
   Occlusion test -ve

Question 16

Ddx painful vs painless groin lump

Answer 16

Question 17

Outline history taking for groin lump

Answer 17

□ Lump: onset, duration, change in size

□ Painful vs painless

□ Reducible vs non-reducible: reducible = hernia

□ Intermittent vs constant: intermittent, esp if ↑with straining = hernia

□ Obstructive symptoms: obstructed hernia

□ Systemic illness: B symptoms, LL infections

□ RFs for hernia, eg. prev Hx, c.t. disease, chronic cough, constipation, FHx

Question 18

Inguinal hernia

• Demographics
• Which side and type are more common?

Answer 18

Demographics: M:F >10:1, peak 6th-7th (M)

2/3 of inguinal hernia is indirect
2/3 of recurrent ones are direct
60% right sided, 30% left sided, 10% bilateral

Question 19

Non-modifiable risk factors of inguinal hernia

Answer 19

FHx of hernia

Previous Hx of hernia (contralateral or ipsilateral)

Male gender

Advanced age

Abnormal collagen metabolism (A/w AAA, steroid use, smoking)

Patent processus vaginalis (indirect)

Question 20

Modifiable risk factors of inguinal hernia

Answer 20

Increase in intrabdominal pressure

• Obesity
• Chronic constipation with straining
• Chronic pulmonary disease with chronic cough
• BPH with straining
• Occupational heavy lifting

Previous pelvic surgery
- Eg. prostatectomy with damage to deep inguinal ring

Abdominal wall weakness (direct)

• Cachexia
• Ilioinguinal n. palsy (in appendicectomy)

Question 21

2 clinical classification systems for inguinal hernia

Answer 21

□ Nyhus classification: designed for posterior approach based on size of inguinal ring and integrity of posterior wall

□ EHS groin hernia classification

Question 22

Diagnostic tests for inguinal hernia

Answer 22

Clinical physical exam

Imaging:

• USG groin**
• Herniography (contrast into abdomen, rare)
• CT abdomen (rare)

Diagnostic laparoscopy

Question 23

Treatment options for inguinal hernia (interventional and watchful/ preventative measures)

Answer 23

Watchful waiting: ↓intra-abdominal pressure:
→ Lifestyle changes, eg. weight loss, change jobs, avoid heavy lifting
→ Treat predisposing conditions, eg. COPD, chronic constipation

Surgical definitive treatment:

• Herniotomy: excision of hernia sac with ligation of neck and reduction of content
• Herniorrhaphy: herniotomy + meshless repair of posterior wall of inguinal canal
• Hernioplasty: herniotomy + mesh repair of posterior wall of inguinal canal ***** GOLD STANDARD **

Question 24

Surgical repair of inguinal hernia

Compare 2 major approaches

Answer 24

Open repair: usually anterior approach, can be done under GA, SA, LA
- Lichtenstein’s tension-free mesh repair: gold standard

Laparo-endoscopic approach: always posterior approach, always done under GA:

• Total extraperitoneal repair (TEP)
• Trans-abdominal pre-peritoneal repair (TAPP)

Question 25

Advantages and disadvantages of Laparo-endoscopic approach inguinal hernia repair vs open repair

Answer 25

Advantage: ↓post-op pain and faster recovery Similar recurrence, morbidity and mortality rate Similar operative time and risk of perioperative Cx Less wound complications than Lichtenstein repair Disadvantage: - TEP a/w more Vascular injuries - TAPP a/w more VIsceral injuries

Question 26

Indicators for laparoendoscopic inguinal hernia repair

Answer 26

 Bilateral hernia (no need two incisions)  Female (r/o undiagnosed femoral hernia, a/w ↓pain)  Recurrent if prev repair is open (avoid adhesions)  High pre-operative pain (a/w ↓post-op pain)  Diagnosis in doubt

Question 27

Indicators for open inguinal hernia repair

Answer 27

 High GA risk (perform under LA, lap usu need GA)  Bleeding risk (easier haemostasis)  Recurrent if prev repair is laparoscopic  Previous lower abdominal wall surgery  Large scrotal or irreducible hernia  Complicated hernia

Question 28

Immediate and early complications of inguinal hernia repair

Answer 28

□ GA risks: acute MI, CVA □ Immediate to early: → AROU → Bleeding: bruising, bleeding/scrotal haematoma → Iatrogenic injury to surrounding structures: paraesthesia, impotence ``` □ Early: → Infection of wound/mesh → Haematoma → Wound dehiscence → Pain: discharge patient with adequate analgesia ```

Question 29

Late complications of inguinal hernia repair

Answer 29

→ Chronic post-operative inguinal pain (CPIP) → Recurrence (<0.5%) from inadequate ring and posterior wall closure → Sexual dysfunction (~5-7%): nerve damage, ischaemic orchitis and testicular atrophy (testicular A/V damage)

Question 30

Femoral hernia - Demographics - Risk of untreated hernia

Answer 30

Demographics: 70% is female, mostly in elderly F Multiparity is a RF → loosening of pelvic ligaments Clinical significance: most liable to strangulation

Question 31

Femoral canal - Course - Content - Boundaries

Answer 31

Course: septum crurale (closed superiorly) → femoral ring→ cribriform fascia (inferiorly) Content: LN of Cloquet, lymphatics, adipose tissues Boundaries: inguinal ligament (anteriorly), Cooper’s ligament/pectineus (posteriorly), lacunar ligament (medially), femoral v (laterally)

Question 32

Femoral hernia - Presentation

Answer 32

□ Groin bulge: usually Rt-sided but 20% bilateral → Neck is located below + lateral to pubic tubercle → Often irreducible due to narrow neck □ Strangulation: initial presentation in up to 40%

Question 33

D/dx femoral hernia

Answer 33

□ Inguinal hernia: neck medial and above inguinal ligament, usually reducible with expansile cough impulse □ Saphena varix: cough impulse +, fluid thrill when patient coughs or when saphenous vein below varix is tapped, ± venous hum □ Femoral lymphadenopathy: Hx of LL infection/malignancy □ Skin lumps: sebaceous cyst, lipoma □ Femoral artery aneurysm: expansile pulsation □ Others: psoas bursa (disappear when hip flexed), obturator hernia, ectopic testis

Question 34

Femoral hernia Treatment options

Answer 34

Early elective repair due to higher risk of complications 1. Open techniques - Lockwood’s infrainguinal approach - Lotheissen’s transinguinal approach - McEvedy’s high approach 2. Laparoscopic techniques: → Total extraperitoneal approach (TEP) → Transabdominal preperitoneal approach (TAPP)

Question 35

True umbilical and paraumbilical hernia Compare the structures protruded through in these 2 hernias

Answer 35

True umbilical hernias: herniation through umbilical scar → Usually occurs in infants secondary to a congenitally weak umbilicus Paraumbilical hernias: herniation through linea alba just above or below the umbilicus → Usually occurs in adulthood due to weakened linea alba

Question 36

Infantile umbilical hernia - Cause - S/S - Mx

Answer 36

□ Cause: congenitally weak umbilicus (no true fascial defect) □ S/S: asymptomatic, conical bump at umbilicus, rarely strangulates □ Mx: conservative if <5y + asymptomatic (95% resolve spontaneously), or herniorrhaphy

Question 37

Adult umbilical hernia - Cause - S/S

Answer 37

Cause: ↑abd pressure with weakened linea alba, eg. obesity, multiparity, ascites S/S: → Paraumbilical lump (can be very large) → GI symptoms (traction on stomach/transverse colon) → Transient colics due to partial obstruction → Often strangulates (narrow neck compared to large sac) with risk of enterocutaneous fistula if ruptured

Question 38

Management options for adult umbilical hernia

Answer 38

surgical repair usually indicated (high risk of strangulation) → Umbilical herniorrhaphy:surgical repair usually indicated (high risk of strangulation)

Question 39

Management options for adult umbilical hernia

Answer 39

Umbilical herniorrhaphy: surgical repair usually indicated (high risk of strangulation) Mayo’s operation for defect <4cm Mesh repair preferred after herniorrhaphy if defect >4cm

Question 40

Incisional hernia Risk factors

Answer 40

Patient RF: - Poor wound healing - Chronic high intra-abdominal pressure Surgical RF: - Wound complications - Poor fascial closure (e.g. tension, broken sutures...etc) - Large incision on abdomen (e.g. AAA repair)

Question 41

Incisional hernia Diagnostic Ix D/dx

Answer 41

Imaging: CT abdomen for pre-op planning D/dx: → Rectus diastasis: similar bulge when tensing RA but NOT a/w fascial defect → Others: rectus haematoma, abdominal wall tumours

Question 42

Incisional hernia Management options Prevention of recurrence

Answer 42

□ Conservative: truss wearing, RF control □ Surgical: herniorrhaphy ± mesh repair → Open: onlay (commonest, easiest), sublay or inlay mesh → Laparoscopic with intraperitoneal onlay mesh (IPOM) Prevention: □ Choose off-midline incision □ Close abdominal incisions properly with abdorbable monofilament sutures □ Prophylactic mesh replacement for high-risk (optional)

Question 43

Ddx painful scrotal swelling

Answer 43

- Common causes Testicular torsion (surgical emergency) Acute epididymitis/epididymo-orchitis Torsion of appendix testis ``` - Uncommon causes Incarcerated inguinal hernia Torsion of appendix epididymis Trauma and acute haematocele Orchitis, eg. mumps Infection, eg. Fournier’s gangrene Referred pain, eg. from renal stone ```

Question 44

Ddx painless scrotal swelling

Answer 44

Scrotal edema Hernia Hydrocele Haematocele Varicocele Testicular tumour / leukaemia Epididymal cyst (spermatocele) TB epididymitis

Question 45

History taking for scrotal swelling

Answer 45

□ Pain: onset, severity, any precipitating factors (eg. trauma, exercise) □ Swelling: onset, progression, any variation with posture or Valsalva (hydrocele, varicocele, hernia) □ Torsion: referred abdominal pain, ↓appetite, nausea/vomiting □ Fever: epididymitis, orchitis □ Urinary symptoms: flank pain/haematuria (stones), dysuria (UTI), AROU (pelvic mass) □ Sexual Hx: may be related to epididymitis

Question 46

Outline P/E for scrotal swelling

Answer 46

Abdominal and groin examination ``` Examination of scrotum: Any tenderness? Can get above it? Separable from testis? Transluminate? ``` Testicular lie: high-lying testis with bell-clapper deformity suggestive of torsion Cremasteric reflex: absent in testicular torsion Phren’s test: ↓pain with elevation of testis in acute epididymitis

Question 47

Diagnostic Ix for scrotal swelling

Answer 47

USG scrotum Doppler USG for testicular torsion (whirlpool sign)

Question 48

Hydrocele - Definition - Etilogies

Answer 48

Hydrocele: collection of peritoneal fluid between two layers of tunica vaginalis Causes: - Congenital (spontaneous resolution) - Primary idiopathic (middle age, poor fluid reabsorption in tunica vaginalis) - Secondary reactive (old age, due to testicular diseases)

Question 49

Differentiate communicating and non-communicating hydrocele

Answer 49

Communicating (congenital) due to patent processus vaginalis Non-communicating due to other causes → Infantile hydrocele → Vaginal hydrocele → Hydrocele of cord

Question 50

Symptoms and signs of hydrocele

Answer 50

Unilateral scrotal swelling ± pain, pressure sensation, scrotal skin irritation transilluminable Can get above the mass Testis not well-defined

Question 51

Hydrocele Diagnostic Ix Tx

Answer 51

Diagnosis: usu clinical ± Doppler USG to r/o 2o cause Options: - Simple aspiration +/- sclerrotherapy - Herniotomy for congenital hydroceles - Simple excision of sac (thick sac) - Lord’s plication of sac/ Jaboulay’s procedure for thin-walled sac

Question 52

Testicular torsion Demographics Pathogenesis

Answer 52

Demographics: two peaks at neonatal and adolescence Pathogenesis: - Bell-clapper deformity (12% M): tunica vaginalis does not anchor the testis as usual but attaches high at the spermatic cord - Separation of epididymis from body of testis - Narrow/absent fixation of lower pole of testis to tunica vaginalis Torsion event is often related to abdominal contraction → When there is abdominal straining (eg. straining, weight-lifting, coitus), cremaster contracts together w/ abdominal muscles → twisting force at testis

Question 53

Testicular torsion S/S

Answer 53

- Sudden persistent agonizing scrotal pain ± radiation to groin and lower abdomen - Gross scrotal erythematous swelling - Nausea and vomiting - Oedematous erythematous tender swelling - High-riding testis with horizontal lie - Tender, twisted cord - Absent cremasteric reflex (may be normally absent if <6y) and -ve Prehn’s sign

Question 54

Diagnostic Ix and Tx of testicular torsion

Answer 54

Diagnosis: clinical ± Doppler USG Urgent exploration indicated regardless of duration of torsion Emergency scrotal exploration - Orchiectomy for non-viable gonads - Orchidopexy for all viable gonads

Question 55

Varicocele Pathogenesis

Answer 55

Varicocele: varicose dilatation of pampiniform plexus of spermatic veins Primary varicocele: Lt renal vein is compressed between aorta and SMA Secondary varicocele: Lt renal mass or Lt Renal vein obstruction or IVC obstruction

Question 56

Describe venous drainage of testicles Why is left varicocele more common

Answer 56

Testicular venous drainage: → Multiple veins drain testis forming the pampiniform plexus → These veins join together to form testicular vein at deep inguinal ring (often lacks valve to prevent backflow) → Lt testicular vein drains into Lt renal vein → Rt testicular vein drains into IVC directly Lt varicocele is more common because → Lt testicular v. drains into Lt renal vein at perpendicular angle → Lt renal vein is compressed between aorta and SMA

Question 57

S/S of varicocele

Answer 57

Asymptomatic in majority Dull, dragging discomfort, worsen with standing Poor fertility Soft scrotal mass, Bag of worms on palpation Cough impulse Primary varicocele disappear in supine Testicular atrophy

Question 58

Diagnostic Ix and Tx of Varicocele

Answer 58

CT abdomen for isolated Rt varicocele and non-diminishing varicocele No treatment if asymptomatic + normal semen analysis - scrotal support + NSAID - Repeat semen analysis monitoring Q1-2y Surgical treatment if testicular atrophy/abnormal semen analysis or symptomatic - Surgical testicular vein ligation - Percutaneous gonadal vein embolization ± sclerotherapy

Question 59

Testicular tumors List histological types

Answer 59

Germ cell: - Seminoma (spermatocytes) - Teratoma (totipotent sperm cells) - Mixed seminoma-teratoma - Other GCTs: embryonal carcinoma, yolk sac tumours, choriocarcinoma Sex cord-stromal tumors: - Leydig cell tumours - Sertoli cell tumours Paratesticular tumors - Lymphoma - Leukaemia and plasmacytoma - Mesothelioma

Question 60

Presentation of testicular tumor

Answer 60

Painless testicular nodule/swelling: Smooth, firm, fixed enlargement ± spread to epididymis/cord ± heaviness/dull ache ± a/w reactive hydrocele S/S of metastasis Endocrine S/S: → Feminizing: gynaecomastia (5%), impotence, loss of libido, paraneoplastic hyperT (hCG) → Virilizing: precocious puberty

Question 61

Diagnostic Ix and Tx for testicular tumor

Answer 61

Blood: ↑β-hCG, AFP in non-germinomatous GCTs USG scrotum Radical inguinal orchidectomy CT A+P + CXR for regional/systemic staging Tx: Additional to orchidectomy □ Retroperitoneal LN dissection (RPLND) for high-risk early (stage I) NSGCTs □ Adjuvant RT for stage II seminomas (exquisitely radiosensitive) □ Cisplatin-based chemotherapy for other more advanced tumours

Question 62

TAPP or TEP for inguinal hernia repair?

Answer 62

Both have comparable outcomes TEP has longer learning curve/ more difficult TEP has more vascular injury TAPP has more visceral injuries

Question 63

Outline the Nyhus Classification for inguinal hernia

Answer 63