Lump in the Groin – PBL 28
Definition & Types
A hernia is the protrusion of an organ or
the fascia of an organ through the wall of the
cavity that normally contains it.
• Types
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Inguinal
Femoral
Umbilical
Incisional
Diaphragmatic
Degrees of hernia
• A reducible hernia- occurs when a hernia can be
pushed back into the abdomen, either spontaneously
or with manipulation.
• An irreducible hernia- occurs when a femoral hernia
becomes stuck hernial orifice.
• An obstructed hernia- occurs when a part of the
intestine becomes intertwined with the hernia, causing
an intestinal obstruction. The obstruction may grow
and the hernia can become increasingly painful.
• A strangulated hernia- occurs when the blood supply to
the herniated bowel gets blocked causing it to get
ischemic.
Inguinal Hernias
• The inguinal canal is a fascial tunnel leading
from the abdomen to the scrotum/labia. This
is a weak point in the bowel wall.
• Inguinal hernias occur above the inguinal
ligament
Indirect
Direct
Travel through both the deep and
Usually Occur in a Hesselbach’s triangle
superficial inguinal rings and are often due
(defined by the edge of the rectus
to the deep inguinal ring not closing
abdominis muscle, the inguinal ligament
properly. They can extend into the
and the inferior epigastric artery). They
scrotum/labia.
can exit through the superficial ring but
cannot extend into the scrotum.
Gerry Ahern: “Hernias occuring lateral to the inferior epigastric
artery are indirect and those that occur medially are direct.”
Femoral Hernias
• Occur just below the inguinal ligament in the
femoral triangle. They often get strangulated.
Para-umbilical
• A protrusion of the intestines or gut into
the abdomen through a weak point of
the muscles or ligaments near the navel.
Incisional
• Abdominal contents can herniate through
surgical scars as they represent weakpoints in
the abdominal wall.
Diaphragmatic
• A defect in the diaphragm allows abdominal
contents to enter the thorax.
• E.g. Hiatus hernia- When the stomach or part of it
enters the thorax through the eosophageal
hiatus.
– Sliding- the gastro-oesophagual junction enters the
thorax
– Rolling- the gastric fundus enters the thorax
Examination of a lump part 1
•
Exposure
– Area of the lump should be adequately exposed. This should include area of lymphatic
drainage for that part of the body
•
Diagnosis of a lump
– Depends on 3 main things:
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•
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Determining which layer of the body in which the lump lies, i.e. skin, subcutaneous tissue, fat or deep
organ
Knowledge of the anatomy of that part of the body
Knowledge of pathological abnormalities affecting the anatomical structures in that area
Layer
– First determine if the lump is mobile or attached to skin
– Then determine if lump is deep or superficial to the muscle or tethered to the muscle
– Ask the patient to tense the muscle in that area
•
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If lump disappears it is deep to the muscle
If lump becomes fixed this indicates the lump is attached to the muscle
Is the lump inflammatory or due to infection?
– If it is hot or tender or if there is inflammation or redness of the overlying skin this indicates
that it is inflammatory
Examination of a lump – part 2
•
Is the lump benign or malignant
– Signs of malignancy include a hard fixed lump with an irregular outline. It may be invading or
ulcerating the overlying skin
– A benign lump is normally smooth and well defined with a distinct edge. If the lump is cystic
then it may be trans illuminable. A soft spongy lump is more likely to be benign.
•
Is the lump a hernia
– The lump should be tested for a cough impulse or reducibility. This indicates a hernia.
•
Is the lump vascular
– The lump should be palpated and if it is pulsatile this would indicate it is arterial in nature
– If the lump is expansile this suggests an aneurysm
– Auscultate the lump for a bruit, which would indicate underlying stenosis
•
Examination of the field of lymphatic drainage and regional lymph nodes
– Check for surrounding lymphadenopathy. This may be a sign of infection of metastatic cancer
•
General Examination
– Examine the whole patient for other similar lumps or relevant abnormalities
Case Study
• Mr X – 45 yo construction worker
• Presented to ED with a gradual onset pain
beginning one week prior
• Pain is in the epigastric and umbilical area
• Has spent week prior building a house
• No past history of any major illnesses or
surgeries
O/E
• There is a small hard lump above the umbilicus approx
1-2 cm in diameter.
• The lump is just below the skin and is hard.
• The lump is not reducible but increases in size on
coughing.
• The lump is not warm but there is redness in the
overlying skin.
• The lump has quite a marked outline on palpation.
• The lump is not pulsatile on palpation and no
surrounding lymphadenopathy.
Diagnosis
• The lump is a small hernia through rectus
abdominis defect of the omental fat.
• The hardness of the lump is most likely due to
inflammation of the omental fat.
Treatment
• The patient will have surgery to remove the
hernia as it is not reducible and can’t be
manoeuvred back to its normal position.
• http://www.youtube.com/watch?v=R6pwlIVQ
PVA
• http://www.youtube.com/watch?v=lFC0AWkY
1p0&feature=related
Complications of hernias
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Inflammation of the herniated viscera
Irreducibility – causing a permanent lump
Obstruction – bowel obstruction
Strangulation – constriction of blood vessels
blocking blood flow to the organ causing
ischaemia
• Hydrocele of the hernial sac – serous fluid
accumulation in the cavity
• Haemorrhage