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Mr. Roberts
Your patient in the office is a 28 year-old male
with a several day history of groin and
testicular pain.
History
What other points of the history
do you want to know?
Characterization of
symptoms
Temporal sequence
Alleviating /
Exacerbating factors:
Characterization of Symptoms: R
groin pain began at work after
lifting 50 lb boxes. Abrupt onset,
now constant.
Alleviating / Exacerbating factors:
Improved with lying down, worse
with standing
Associated signs/symptoms: Eating
normally, no diarrhea or
constipation
ROS: no dysuria
MEDS: Tylenol
SH: married, single partner.
Construction worker
Relevant Family Hx.
Noncontributory
Differential Diagnosis
Based on History and Presentation
Inguinal hernia
Testicular torsion
Epididymitis
Prostatitis
Muscle strain
Physical Examination
CV: RRR
Revised Differential
Inguinal hernia
Epididymitis
Laboratory
Studies
What next?
What next?
1. Immediate OR
2. Attempt at reduction
What next?
Reduction should be attempted in the patient with an
incarcerated hernia. This allows an operation to be
performed electively rather than emergently, and allows
choice of anesthesia and operative approach.
Reduction is best accomplished by elongating the neck
of the hernia sac while applying pressure to reduce the
hernia. The patient should be given adequate sedation
and analgesia, and placed in Trendelenberg position.
Management
Discussion of patient response to management
recommendations:
If reduction is unsuccessful, the patient should be
prepared for urgent operation.
Management
Although symptomatic hernias should all be repaired
operatively, it is not clear that all small, asymptomatic
hernias should be fixed.
Age, comorbid conditions, patient activity and patient
preference should be considered.
Current trials are studying the natural history of these
small hernias.
Management
Management
This woman likely has an obturator or possibly
a femoral hernia.
Obesity can make examination of the groin
difficult.
Her management is much different than the
previous case.
Management
Plain films of the abdomen
should also be obtained, as
the patient may have a bowel
obstruction due to small
bowel incarceration in the
hernia.
Discussion
The majority of hernias should be repaired when discovered, as
the mortality increases 9 to 10 fold with emergent compared to
elective repair. Elective repair done with an open approach can
be performed under local, spinal, or general anesthesia. It can
also be done laparoscopically, which requires general anesthesia.
In addition to the elective or urgent/emergent nature or the repair,
anesthetic choice, patient preference, and primary or recurrent
nature of the hernia factor into the decision regarding operative
approach. A laparoscopic approach, or an open preperitoneal
approach, is best for recurrent or bilateral hernias. For unilateral
primary groin hernias, the approaches have similar recurrence
rates, similar disability times, and similar costs.
Discussion
Indirect hernia: contents protrude through the indirect inguinal ring
through a patent processus vaginalis into the inguinal canal. In men,
they follow the spermatic cord and may present as scrotal swelling,
while in females they may present as labial swelling.
Direct hernia: contents protrude through Hesselbachs triangle medial
to the inferior epigastric vessels.
Femoral hernia: contents protrude through the femoral canal,
bounded by the inguinal ligament superiorly, the femoral vein
laterally, and the pyriformis and pubic ramus medially. Unlike
inguinal hernias, these hernias protrude below, rather than above, the
inguinal ligament.
Discussion
Obturator hernia: Herniation through the obturator canal alongside
the obturator vessels and nerves. This hernia occurs mostly in
women, particularly elderly women with a history of recent weight
loss. A mass may be palpable in the medial thigh, particularly with
the hip flexed, externally rotated and abducted (Howship-Romberg
sign).
Sliding hernia: A hernia in which one wall of the hernia is made up
of an intraabdominal organ, most commonly sigmoid colon,
ascending colon, or bladder.
Laparoscopic Repair
QUESTIONS ??????
Summary
Inguinal hernia is primarily a clinical diagnosis
Ultrasound can be helpful in diagnosing testicular
torsion; also if hernia diagnosis unclear
Surgical repair, elective or emergent
Various operative and anesthetic approaches
Obturator and occasionally femoral hernias may
present as nonspecific abdominal pain,
nausea/vomiting
Acknowledgment
The preceding educational materials were made available through the