Surgery Case

Mohamed Razeem

Monday, November 21, 11

Mr G, 67y, M, Retired farmer

PC - Enlarged scrotums (bilateral), discomfort HPC - Going on for 2yrs. No pain, only discomfort, no effect on coughing/ straining L side first, shortly followed by R Persistent Cough Systems review unremarkable

Monday, November 21, 11

PMHx
Ongoing bilateral inguinal hernia for past 10yrs, Increases with coughing/ straining. Been managed with a truss 2009- R eye cataracts removed 2004- Allergic asthma diagnosed 2001- Type II DM diagnosed 1964- Open appendicectomy

Monday, November 21, 11

DHx
NKDA Aspirin 75mg OD, Ramipril 10mg OD, Rosuvastatin 20mg OD Symbicort inhaler 200mg+6ug BD Glicazide 40mg OD

Monday, November 21, 11

FHx
Maternal grandfather & uncle - TII DM

SHx
Smokes 30cigs/d since 16y (76 pack years) Drinks Alcohol occasionally Lives with wife. ADL unremarkable
Monday, November 21, 11

O/E
General: Looks well & comfortable, BP 130/78, HR 64bpm, RR 16/min, Apyrexial, No clubbing, stigmata of liver disease, icterus, pallor. Abdo: Lanz scar on RF, Bilateral inguinal lumps, Soft & Non tender, no organomegaly, masses/ascites, +BS Inguinal lumps: Increases on coughing, soft & nontender, neck med. & Sup. to PT, Reducible (not maintained by pressure over DIR), +Cough impulse, +BS Bilateral scrotal lumps, Soft & non tender, not reducible, can get above it, separate from testis, +cough impulse CVS, RS, CNS & MSS unremarkable
Monday, November 21, 11

Ix
FBC & Electrolytes
Na 141 K 4.1 U 4.3 Cr 63 Hb 16.4 MCV 96 Pl 232 WCC 8.8

Monday, November 21, 11

Monday, November 21, 11

Dx & Plan
Bilateral Inguinal hernia extended to scrotum (previously diagnosed) Bilateral inguinal hernia through abdo. wall (previously diagnosed) Plan - Elective laparascopic repair of all hernias at the same time Surgery went as planned. All hernia repaired without any complications Pt discharged home after 2 days post-op
Monday, November 21, 11

Terms Quiz Inguinal Eponyms Congenital Hiatus

Monday, November 21, 11

Femoral DDx Lump in groin

Hernias
Causes

Diaphragmatic Unusual

Defining Terms

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?)

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?) likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position)

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?) likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position) 2. It was medial & superior to pubic tubercle (?)

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?) likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position) 2. It was medial & superior to pubic tubercle (?) Inguinal hernia

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?) likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position) 2. It was medial & superior to pubic tubercle (?) Inguinal hernia 3. This went on for years. Then, one day, the lump became irreducible (?)

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?) likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position) 2. It was medial & superior to pubic tubercle (?) Inguinal hernia 3. This went on for years. Then, one day, the lump became irreducible (?) Incarcerated

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?) likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position) 2. It was medial & superior to pubic tubercle (?) Inguinal hernia 3. This went on for years. Then, one day, the lump became irreducible (?) Incarcerated 4. Few days later, the lump then became painful & overlying skin reddened (?)

Monday, November 21, 11

Defining Terms
1. Mr A noticed a lump in the groin that is reducible (?) likely Inguinal/Femoral hernia (protrusion of viscous/part of viscous through the walls of its containing cavity into an abnormal position) 2. It was medial & superior to pubic tubercle (?) Inguinal hernia 3. This went on for years. Then, one day, the lump became irreducible (?) Incarcerated 4. Few days later, the lump then became painful & overlying skin reddened (?) Strangulated

Monday, November 21, 11

Defining Terms

Monday, November 21, 11

Defining Terms

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?)

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?) Obstruction

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?) Obstruction 6. Mr A was taken in to theatre and hernia sac was ligated and excised (?)

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?) Obstruction 6. Mr A was taken in to theatre and hernia sac was ligated and excised (?) Herniotomy

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?) Obstruction 6. Mr A was taken in to theatre and hernia sac was ligated and excised (?) Herniotomy 7. Mr A had a hernia arisen from an open appendisectomy scar 5 years ago (?)

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?) Obstruction 6. Mr A was taken in to theatre and hernia sac was ligated and excised (?) Herniotomy 7. Mr A had a hernia arisen from an open appendisectomy scar 5 years ago (?) Incisional hernia

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?) Obstruction 6. Mr A was taken in to theatre and hernia sac was ligated and excised (?) Herniotomy 7. Mr A had a hernia arisen from an open appendisectomy scar 5 years ago (?) Incisional hernia 8. This hernia was repaired without excision (?)

Monday, November 21, 11

Defining Terms
5. Mr A complained of abdominal pain, vomiting and constipation (?) Obstruction 6. Mr A was taken in to theatre and hernia sac was ligated and excised (?) Herniotomy 7. Mr A had a hernia arisen from an open appendisectomy scar 5 years ago (?) Incisional hernia 8. This hernia was repaired without excision (?) Herniorrhaphy

Monday, November 21, 11

Causes
Chronic cough Chronic Constipation Straining to void urine Surgery Severe muscular effort Obesity Weakening with age

Monday, November 21, 11

Inguinal Hernias

Clinically Oriented Anatomy, Sixth Edition

Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur

Monday, November 21, 11

Inguinal Hernias

Clinically Oriented Anatomy, Sixth Edition

Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur

Monday, November 21, 11

Direct Vs Indirect
Indirect Origin Cong. V Acq Control by pressure over DIR Strangulates Extends to scrotum Reduces on lying Recurrence Occurrence Pass through DIR lat. to inf. epigastric v. may be congenital yes commonly often not readily uncommon 2/3 Direct pass post. wall of canal med. to inf. epigastric v always acquired no rarely rarely spontaneously more common 1/3

Monday, November 21, 11

Femoral Hernias

Clinically Oriented Anatomy, Sixth Edition

Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur

Monday, November 21, 11

Other abdo. hernias

Incisional hernia Umbilical, paraumbilical, supraumbilical Epigastric Spigelian Recurrent inguinal

Monday, November 21, 11

Diaphragmatic Hernias

Congenital diaphragmatic Congenital hiatus

Monday, November 21, 11

Diaphragmatic Hernias

Acquired Hiatus

Monday, November 21, 11

Eponymous Hernias Terms

Richters hernia Littres hernia Maydls hernia

Monday, November 21, 11

Unusual hernias
Obturator hernia Sciatic Lumbar Gluteal

Monday, November 21, 11

DDx of a lump in the groin

Monday, November 21, 11

DDx of a lump in the groin

Monday, November 21, 11

DDx of a lump in the groin

Monday, November 21, 11

DDx of a lump in the groin

Monday, November 21, 11

DDx of a lump in the groin

Monday, November 21, 11

DDx of a lump in the groin

Monday, November 21, 11

Thank you
References:
Clinically Oriented Anatomy, Sixth Edition, Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur (ebook) General Surgery Lecture Notes, 12th edition, Ellis, Calne & Watson

Monday, November 21, 11