Case Report Session

HERNIA SCROTALIS DEXTRA INKARSERATA

Preceptor : dr. Amran, Sp.B
Iltamaisari. G1A218012

KEPANITRAAN KLINIK SENIOR

BAGIAN KEDOKTERAN BEDAH RUMAH SAKIT UMUM DAERAH PROVINSI JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN UNIVERSITAS JAMBI
2018
LITERATURE REVIEW
Abdominal Wall Anatomy
Line:
Kraniolateral: internal inguinal ring, is
an open part of the transversalis
fascia and aponeurosis of transverse
abdominal muscle
Lower medial, above of the pubic
tubercle: external inguinal ring
Roof: Aponeurosis of the external
obliquus muscle
Floor: inguinal ligament
HERNIA

A bulge or protrusion of cavities filling

through a defect or weak part of the wall or
cavity
concerned
Epidemiology
• 75% of hernias in the inguinal and femoral
• Men > woman
• Lateral inguinal hernia (right)>>left

Etiology
• Congenital, Aquisial
• Factor:
 Open of Procesus vaginalis
 High intraabdominal pressure
 Weakness of the abdominal wall muscle
 INGUINAL HERNIA
Lateral (Indirect)
Medial (Direct)

Out of the peritoneal cavity Etiology:

1. High intraabdominal pr
Internal inguinal ring essure chronic
2. Wall muscle weakness
Inguinal canal in the Hesselbach trigo
num
External inguinal ring

If it continues until the scrotum

(Scrotalis Hernia)
Diagnosis
1. History
• Reponibel : lump in the groin. Appears when standing, coughing, sneezing,
straining. Disappear after lying down
• Inkarserata, strangulata : accompanied by nausea and vomiting
2. Physical Examination
• Inspection : there’s a lump when straining. Asymetry of groin, scrotum, labia
• Palpation :
 Empty pouch: touch on funiculus spermaticus  swipe the layer of pouch
like 2 silk surfaces
 Filled pouch: palpable intestine, omentum, ovary
 Reposition
3. Supported examination
 Finger Test :

1. Use 2nd finger or 5th finger.

2. Inserted through scrotum (external annulus to the inguinal canal).
3. Patients are told to cough
• Impulse at the fingertrip, means lateral inguinal hernia.
• Impulse beside the finger medial inguinal hernia.

Zeimen test

1. Lie down position, if there is a lump enter first (usually by the patient)
2. Right hernia is examined with the right hand.
3. Patients are told to caugh is stimulation to:
• 2nd finger : lateral inguinal hernia.
• 3rd finger : medial inguinal hernia.
• 4th finger : femoral hernia
Thumb Test Examination :
• Internal anus is pressed by thumb and the patient is told to
push
• When the lump is out, it means medial inguinal hernia
• If the lump doesn’t come out, it means lateral inguinal hernia
Management of Hernia
Conservative
• Reposition
• Buffer usage/ support
Management
2. Operative
• Herniotomy
• Hernioplasty

Baby & child  Herniotomy

Adult  Herniorrhaphy
Patient

Name : Tn. S
Age : 55 tahun
Gender : Male
Address : RT 03 Desa Muara Dedak, Kec.
Bayung Lencir
MRS : 06-08- 2018
Generalized Status

General Condition : looked sick

Awareness : Compos Mentis
GCS : 15 E4V5M6
Vital Sign :
- Pulse : 84x/minute
- RR : 18 x/minute
- Temperature : 36,5 C
- Blood Pressure : 120/80 mmHg
- SpO2 : 99%
History
Main Complaint
Bump in the right scrotum
RPS
± 1 year SMRS the patient feels the lump in the right groin, at first as
bis as a thumb, not painful, disappear when lying down or resting and
out during activities or walking. Lumps are not painful, not hot, and not
red. There’s no nausea, vomiting, bloating, and fever. BAB and BAK
no complaints.

±6 months SMRS the patient feels a lump appear to the right scrotum,
but the lump can be disappear on its own and not painful. Lumps
appear if the patient is on the move and lost when the patient lies
down or rests.
History
± 2 days SMRS, lumps on the patient’s right scrotum return to bulge when the
patient has an activity and can’t be lost during lying down. Patients complain
about lump that can’t be re-enter. They feels pain in lumps, nausea (+),
vomiting (+) 2x, like what’s eaten and drunk, as much as ½ cup of starfruit,
stomach feels bloated (+). The last chapter 1 day before entering the hospital,
4 hours last BAK before entering the hospital, the amount is enough, clear
yellow-colour. The patient then was taken to the K.H.Daud Arif Hospital and
the referred to Raden Mattaher Hospital.
RPD
History of lifting heavy objects often since a young age
A long history of coughing is denied
History of difficulty in defecation/urination is denied
History of hypertention, DM, allergies are denied
RPK
None of the families have suffered from this disease
Physical Examination
Head : Normochepal
Eye : CA(-/-), SI (-/-), RC(+/+) isochor
Nose : discharge (-),
Ear : discharge (-)
Mouth : cianosis labial(-), dry labia (-)
Throath :T1-1, hyperemic pharynx (-)
Neck : symmetrical, trachea deviation (-),
lymphadenopathy (-)
Physical Examination
Lung
I : symmetrical
P :fremitus left = right , crepitation (-), tenderness (-)
P : sonor the entire lung field
A :vesicular (+/+), Ronki (-), wheezing (-)

Heart
I = Unseen Ictus cordis
P = Palpable Ictus cordis on left ICS V,
Midclavicular line
P = Heart border dbn
A = regular BJ I and II, murmur (-), gallop (-)

Abdomen
I:distention, darm contour (-), darm steifung (-)
P: epigastric tenderness (+), lien and hepar are
not palpable, defans musculer (-)
P:hypertimphany
A:intestinal noise (+) increase, metallic sound (-)
Physical Examination

Extremitas Superior et Inferior

•L = edema (-), cyanosis (-)
•F = warm accral, CRT < 2 second
•M = unlimited active and passive movements, ROM dbn
Locaity Status

Inguinal regio until scrotalis dextra regio:

Inspection : Visible elliptical lumps from the inguinal

region to the dextra scrotum, skin color just like other
surrounding skin, translumination (-), no abnormalities of
inguinal and left scrotum.

Palpation: Size 12 cm x 10 cm x 7 cm, the temperature

just like surrounding skin, no tenderness, elastic
consistency, fluctuations (-), testicles is palpable separate
from the lump, can’t be inserted, Abnormalities of left
scrotum and inguinal are not founded.
Supported Examinations
 Routine blood
Normal Value Result
WBC 4-10 x 109/L 11.14
RBC 3.5-5.5 1012/L 5.46
HGB 11-16 g/dL 16
HCT 35-50% 46.5
PLT 100-300 x 109/L 328

Ur : 24 mg/dl
Kr : 1.2 mg/dl
Supported Examinations
Diagnosis
Hernia skrotalis dekstra inkarserata
Management

- Pro Hernioraphy
- NGT insertion
- Catheter insertion
- IVFD RL + ketrolac 20 gtt/i
- Inj. Ranitidin 2 x 50mg
- Inj. Ceftriaxone 1 x 2 gr
Prognosis

Quo ad vitam : ad bonam

Quo ad functionam : ad bonam
Quo ad sanam : dubia ad bonam
 Date Clinical Condition Management

August 7, S : bloating, vomiting (+) 2x, epigastric R/

2018 pain (+) - Pro Hernioraphy
O : Blood Pressure : 120/80mmHg - NGT insertion
HR : 84x/menit - Catheter insertion
RR : 18x/menit - infus Rl +ketrolac 20
T : 36.5 tpm
skin : enough turgor - inj. ceftriakson 1x2 gr
eye: palpebral conjungtiva anemis -/-, - inj. ranitidin 2x50 mg
sunken eyes -/- - Puasa operasi
Abdominal : distension, hypertympani, BU
(+) ↑
Locality status: inguinal region until
scrotalis dex
I : oval shaped lump, skin color = around
Pa : 12x10x7 cm size, temperature= around
 Date Clinical Condition Management
August 8, complaint: nausea vomiting (-), operation R/
2018 regio pain (+), flatus (+) - Bed rest
KU : komposmentis - IVFD Rl + ketrolac 20
VS : Blood Pressure : 120/90 mmHg tpm
N : 82x/menit - inj. ceftriakson 1x2 gr
RR : 20x/menit - inj. metronidazol 3x500
t : 36,6°C mg
eye :palpebral conjungtiva anemis -/-, - inj. ranitidin 2x50 mg
sunken eyes -/- - Soft diet
Abdominal : visible wound sutures dextra
inguinal regio covered with gauze, seepage
gauze (-), blood (-), edema (-), tenderness (+),
skin temperature around the wound = around
Flat, flexible, BU (+) ↓
Minimal Drainage
Ass: Post hernioraphy + mesh H+1
 Date Clinical Condition Management
August 9, Complaint: operation regio pain (+) R/
2018 decrease, flatus (+) - IVFD Rl + ketrolac 20
KU : komposmentis tpm
VS: Blood Pressure : 120/90 mmHg - inj. ceftriakson 1x2 gr
N : 80x/menit - inj. metronidazol 3x500
RR : 20x/menit mg
t : 36,6°C - inj. ranitidin 2x50 mg
eye :palpebral conjungtiva anemis -/-, - Aff NGT dan chateter
sunken eyes -/- - Usual Diet
Abdominal : visible wound sutures dextra - Gradual mobilization
inguinal regio covered with gauze,
tenderness (+) ↓, temperature around the
wound = around
Flat, flexible, BU (+) N
Minimal Drainage Ass: Post hernioraphy
+ mesh H+2
 Date Cinical Condition Management
August 10, Complaint: operation regio pain (+) R/
2018 decrease, flatus (+) - IVFD Rl + ketrolac 20
KU : komposmentis tpm
VS : Blood pressure: 120/90 mmHg - inj. ceftriakson 1x2 gr
N : 78x/menit - inj. metronidazol
RR : 20x/menit 3x500 mg
t : 36,6°C - inj. ranitidin 2x50 mg
eye :palpebral conjungtiva anemis -/-, - Aktive mobilization
sunken eyes -/- - Aff drainage
Abdominal : visible wound sutures
dextra inguinal regio covered with
gauze, tenderness (+) ↓, temperature
around the wound = around
Flat, flexible, BU (+) N
Drainage (-)
Ass: Post hernioraphy + mesh H+3
 Case Analysis
± 1 year SMRS the patient feels the
lump in the right groin, at first as
bis as a thumb, not painful,
disappear when lying down or • Ireponibel Inguinal Hernia
resting and out during activities or
walking. Lumps are not painful, not
hot, and not red.

• Inguinal hernia continues to

±6 months SMRS the patient feels
a lump appear to the right scrotum, scrotum through inguinal ring
but the lump can be disappear on
its own (scrotal hernia) is reponible
 ± 2 days SMRS, lumps on the
patient’s right scrotum return to • Ireponibel scrotalis hernia
bulge when the patient has an
activity and can’t be lost during
lying down.

nausea (+), vomiting (+) 2x, like • Intestinal passage dissorders

what’s eaten and drunk, as much as
½ cup of starfruit, stomach feels occur(hernia inkarserata)
bloated (+)

History of lifting heavy objects often

• Risk factors for abdominal wall
since a young age weakness
 Physical Examination
Case theory
Abdominal : gangguan pasase usus akibat
I:distention, darm contour (-), darm steifung (-) obstruksi
P: epigastric tenderness (+), lien and hepar are not palpable,
defans musculer (-)
P:hypertimphany
A:intestinal noise (+) increase
Inguinal regio until scrotalis dextra regio: •Oval shape, seen from the inguinal to scrotum:
lateral inguinal hernia/ indirect
I: Visible elliptical lumps from the inguinal region to the •Translumination (-)  remove dd from
dextra scrotum, skin color just like other surrounding skin, hydrocele
translumination (-), no abnormalities of inguinal and left
scrotum.

P: Size 12 cm x 10 cm x 7 cm, the temperature just like
surrounding skin, no tenderness, elastic consistency,
fluctuations (-), testicles is palpable separate from the lump,
can’t be inserted, Abnormalities of left scrotum and inguinal
are not founded.
• Temperature just like surrounding skin, no
tenderness, remove signs of strangular hernia
•Testicles are palpable apart from the lump,
can’t be inserted: Ireponibel hernia
Supported Examinations

In a three-position abdominal plain image,

hearing bone appearance and step ladder
appearance are seen → indicates signs
of obstruction
Management
• Do it immediately because initial intrakarta sign is
Pro hernioraphy
present, to prevent complication
• To decrease abdominal distension
NGT Insertion

• To monitor fluid balance

Chateter insertion

IVFD RL + ketrolac 20 • Avoid dehydration due to intestinal obstruction and

gtt/i ketrolac dripas analgesic
• Prophylaxis to reduce excessive acid production
Inj. Ranitidin 2 x 50mg

• Infection prophylaxis
Inj. Ceftriaxone 1 x 2 gr