approach to inguinoscrotal swelling

2. Account for up to 20% of General surgical pt
Very common General practices

3. Inguinal
 Sebaceous
Cysts/Lipoma’s
 Inguinal
Lymphadenopathy
 Saphenous Varix
 Femoral Artery aneurysm
 Psoas Abscess
 Undescended testes.
 Inguinal Hernia
 Femoral Hernia
Scrotal
 Testicular tumor
 Epididymal cyst
 Spermatocoele
 Hydatid of Morgagni
 Varicocoele
 Hydrocoele
 Inguino-scrotal
Hernia

4. • Inguinal Canal
Spermatic Cord/ round ligament
• Femoral Canal and Ring
• Scrotum/testes

5.  4cm downwards , forwards, and
medially
It extends from the deep
inguinal ring to the superficial
inguinal ring
. Site of Inguinal Hernia
Transmits the Spermatic cord/Round
ligament.
Round ligament
Runs from Uterine fundus via
canal to Labia.

6.  Floor
 Inguinal Ligament
and Lacunar
ligament
 Roof
 Arching fibres of Int
Obl & Trans
abdominis and
Conjoint tendon
 Anterior Wall
 External
Oblique
aponeurosis
 Superficial Ring
 Post Wall
 Conjoint tendon
medially,
Transversalis fascia
laterally
 Deep ring

7.  The femoral canal is
located in the anterior
thigh.
Medial border – Lacunar
ligament.
Lateral border – Femoral
vein.
Anterior border –
Inguinal ligament
Posterior border –
Pectineal ligament,
superior ramus of the
pubic bone, and the
pectineus muscle

8.  Upper end of femoral canal defined
by femoral ring.
•Femoral Ring
Site of Femoral Hernia

9.  Lateral border
of rectus
muscle
 Inguinal
Ligament
 Inferior
epigastric
vessels (med
border of deep
ring)

10.  Above by
the arching fibers of the
internal oblique and
transversus abdominus
Muscles
 Medially by
the Rectus Abdominus
Muscle and its fascial
Rectus Sheath
 Inferiorly by
Coopers Ligament
 Laterally by
the Ileopsoas Muscle
 .
Deep ring
Hesselbachs triangle
Femoral canal

11.  Spermatic
cord
 Pedicle of
the testes
 Made up of
12 things

12. 3 Arteries
• Testicular
• Artery to the Vas
Deferens
• Cremasteric
3 Nerves
• Sympathetic branches
• Ilio-inguinal (on cord)
• Genital Br of Genito-femoral
nerve.
3 Important structures
 Vas Deferens
 Pampiniform Plexus
 Processus Vaginalis
3 Coverings
• External Spermatic Fascia
• Cremasteric Muscle
• Internal Spermatic Fascia

13. Spermatic cord
 Only truly forms at
the superficial ring.
 Passes through the
superficial ring
 above and medial to
the pubic tubercle.
 Descends through
S/C fat into the
scrotum.

14. Testes
 Suspended on spermatic cord,
 Enveloped within Tunica
vaginalis
 Drain via epididymis to
Vas Deferens
 Made up of
 Germinal elements-
Seminiferous tubules
 Non-Germinal elements-
Stroma, Leydig cells

15. Examination of lump

16. Lump--
 When and how was it first noticed
 Precipitant activity
 Recent illnesses
 What symptoms are present
 pain, functional impairment
 GI /GU disturbance.
 Systemic symptoms-fevers, night
sweats
 Is the lump size changing
 Does the lump come and go
 How or what is precipating factor

17. Lump
• Position, Shape and size
• Surface
• Skin changes
• Mass surface
• Temperature
• Tenderness
• Composition-Solid/Fluid/Gas
• Consistency
• Fluctuation/Fluid thrills/Resonance
• Translucency
• Pulsatility
• Reducibility/Cough impulse

18. • Both sides
• Hernia Tests
• Standing and lying
• Get above it
• Cough Impulse
• Deep ring occlusion
• Three finger zieman’s test
• Reducibility and control
• Associated structures
• testes, Lymph nodes.
• Special tests
• Transillumination

19. Investigation
 Occasional use only
 Ultrasound/duplex
 For early hernia’s-not so reliable.
 Useful for testes/vascular assessment
 CT
More for assessing deeper anatomy
 Herniagram
 Laparoscopy

20.  Discrete Scrotal Lumps or testes
Ultrasound
 Lymphadenopathy-Generalized, unexplained or
persistent
BIOPSY
 Exclude Malignancy

21. Inguinal
 Sebaceous
Cysts/Lipoma’s
 Inguinal
Lymphadenopathy
 Saphenous Varix
 Femoral Artery aneurysm
 Psoas Abscess
 Undescended testes
 Inguinal Hernia
 Femoral Hernia
Scrotal
 Testicular tumor
 Epididymal cyst
 Spermatocoele
 Hydatid of Morgagni
 Varicocoele
 Hydrocoele
 Inguino-scrotal
Hernia

22. Sebaceous cysts
 Retention cysts of sebaceous glands
 Fixed to skin-dimple if squeezed
 Can become infected-abscess.
 Incise and drain
 Management
 excise when non-inflammed.

23. Lipomas
 Benign
 Clinically
 soft lumps
 Skin free, mobile
 Slip sign
 usually longstanding and
asymptomatic.
 Management
 excise surgically

24. • Causes
• Primary Lymphatic disease-
Lymphoma
• Secondary Lymphadenopathy
• Malignant disease
• Benign
• Physiological reaction to
inflammatory state
• Management
• Exclude Inflammatory causes
• Examine, Observe, Antibiotics
etc.
• Exclude obvious malignancy
• Biopsy-FNA/Open

25.  Prominent Varicosity of Upper
Long Saphenous Vein.
 Typical Patient
 Middle aged and older
 F>M
 Usual Risk Factors
 Pregnancy, Pelvic Mass
 Clinically
 Dragging lump over upper thigh, disappears when
lying
 Cough impulse +
 Management-surgical ligation.

26. • Abscess within Psoas fascia that
tracks to groin and presents as a
lump.
• Associated with
Retroperitoneal
infection/inflammation
• Post Surgical eg. Nephrectomy
• Pancreatitis
• Spinal TB
• Management
• Drain and treat underlying cause

27. • Rare in adults
• Usually Dx and treated as children
• In adults usually present as infertility
• A/w painless lump in Inguinal canal
• Prone to infertility and testicular cancer.
Managemant
Orchiopexy 6 to 12 month
young -orchiopexy if viable
-atrophied orchidectomy

28. Assessment
 Hx/Ex as previous
 If not obvious Hernia/Varicocoele/ Hydrocoele and
Ultrasound
- normal testes
- Lump origin
- Solid vs cystic etc.
• If still in doubt-Call plan for Surgical exploration

29. Solid lumps.
 Testicular origin
 mostly malignant
 Paratesticular origin
 mostly benign
 Cystadenoma, Adenomatoid tumor (epididymis)
 Inflammatory
Cystic lumps
Usually benign
 Epididymal cyst,
 Spermatocoele,
 Hydatid of Morgagni

30. Testicular tumors
• Usually painless lumps in 2nd to 4th decades
• Germinal-95%
• Seminoma/Embryonal Cell/ChorioCa/Teratoma
• Non-Germinal
• Stromal-Leydig Cell Tumor; Gonadoblastoma

31. Collections of fluid in Tunica Vaginalis
 Typically >40yrs except infantile.
 Classes
 Congenital-communicating
 Reactive-tumor/trauma/infection
 Idiopathic.
 Clinically
 Usually dragging scrotal mass,
 Can get above them, fluctuant, transilluminate well
 Must exclude malignancy
 Clinically normal testes or ultrasound
 Treatment
 Aspirate-tend to recur
 Surgery-Jaboulet procedure EOS
 Lord ‘s procedure plication of sac

33.  Dilatation of the Pampiniform Plexus
 Usually affects 20 to 50 yo’s
 L>R
 due to venous anatomy
 Acute varicocoele-exclude Renal maligancy
 May cause infertility
 Painless lump
 Bag of worms
 Cough impulse +ve
 May reduce on lying down
 Treatment
 Ligation at deep ring or excision.

34.  Epididymal cyst
Cyst arising from epididymis
 Spermatocoele
 Sperm filled cyst arising from the testes.
 Hydatid of Morgagni
 Small mobile cyst from top of testes
 Embryological remnant of Mullerian duct.
 Subject to torsion
 Management
 Exclude testicular Mass-Ultrasound
 Surgery if large/symptomatic.

36.  Hernia Numbers
 25% of males (2% F) will develop a groin hernia
 65% Indirect Inguinal hernia
 55% on the right
 31% Direct Inguinal Hernia
 4% Femoral Hernia
 More common in women 20 % of all groin herniae
c/w 2% male.
 Causes
 Congenital
 Chronic Stress to area
 Metabolic-Collagen-vasc Ds, Smoking

37.  Inguinal
 Direct
 Indirect
 Pantaloon
 Femoral hernia
 Sliding hernia

38.  A Hernia in which the
peritoneal wall that forms part
of the sac has an organ
naturally adherent to it.
 Eg. If an organ (usually
Bladder or colon) slides out
with its adherent peritoneum
through the hernia defect the
organ itself becomes part of
the wall of the sac.
Sliding hernia
Non sliding hernia

39.  Clinically
 Groin pain/discomfort
 Dragging, worse during the day
 Lump
 Asymmetry-inguino-scrotal swelling
 GI/GU obstruction
 Incarceration/Irreducibility

40.  Direct
 Old age
 Diffuse bulge
 Rarely into scrotum
 Controlled only at superficial ring
 Indirect
 Young pt
 Usually more defined
 May extend into scrotum
 Herniation/reduction more prominent
 Controlled at deep ring.

41.  Inguinal
 Lie in/above groin crease
 Appear above and medial to pubic tubercle.
 Extend into scrotum
 Femoral
 Lie below crease
 Appear below and lateral to tubercle
 Extend into thigh

42.  Incarceration
 Obstruction
 Strangulation
 Risk-Indirect and Femoral>>>Direct
 Surgical emergency
 Call the surgeon-don’t try and reduce.
 Herniated Viscera is entrapped and infarcted.
 Acute, tender, painful lump +/- SBO
 Richters Hernia
 Reduction en-mass.

43.  Eliminates pain
 Eliminates Lump
 Avoids hernia growth
 Avoids risk of strangulation
 Esp in indirect hernia
 Straightforward surgery.

44. Watchful Waiting Surgical TT
May be appropriate for pt with
asymptomatic hernia or elderly pt with
minimal symptoms or easily reduced
inguinal hernia.
Routine F/U with health care professional
A Randomized trial concluded that this is an acceptable option for men with minimally symptomatic
inguinal hernia and that delaying repair until symptoms increase is safe due to low rate of incarceration.
23% of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms
(most often hernia-related pain) , only 1 pt (0.3%) experienced acute hernia incarceration without
strangulation within 2years, a second had acute incarceration with
Bowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA
2006,295:285)

45.  TAXIS –TRIAL REDUCTION
Flexes thigh
Adduct the thigh
Internally rotated
 TRUSS: A RAT TAILED SPRUNG TRUSS WITH A
PERINEAL BAND TO PREVENT THE TRUSS FROM
SLIPPING AWAY Hernia truss.

47.  Method of
reconstruction of
the inguinal floor is
necessary in all
adult hernia repairs
to prevent
recurrence.
Inguinal
Floor
Reconstruction
Primary tissue
repair
Open tension
free
repair
Laproscopic &
preperitoneal
repairs

48.  Bassini repair: inferior arch of transversalis
fascia (TF) or conjoint tendon is
approximated to shelving portion of inguinal
ligament.
 McVay: TF / IPT is sutured to cooper
ligament.
 Shouldice: TF is incised and reapproximated.

49.  The conjoined
tendon of the
transversus
abdominis and the
internal oblique
muscles is sutured
to the inguinal
ligament

50.  Lichtenstein repair &Patch and Plug
technique: Mesh is used to reconstruct
inguinal floor
• Mesh plug technique : place mesh in the
hernial defect

51.  Originally done as OPD procedure under LA
It Involves-
 Dissecting Inguinal canal and mobilising cord
 Inverting/removing hernia sac
 Reinforcing posterior inguinal wall with prolene
mesh.

52.  Lichtenstein tension free mesh
repair
 All can be done under LA
 Widely adopted
 Recurrence rate 1-2%-Lichtenstein

53.  TAPP
 Trans abdominal Pre-peritoneal Patch
 TEPP
 Totally Extraperitoneal Pre-peritoneal Patch
 Both place a Mesh patch over the hernial defect
inside the abdominal muscle layer, outside the
peritoneum.

54. TAPP (transabdominal prepeitoneal
procedure):
peritoneal space entered by conventional lap at
umbilicus and peritoneum overlaying inguinal floor is
dissected away as flap.
TEP (Total extraperitoneal repair):
preperitoneal space is developed with a balloon
inserted between posterior rectus sheath and
peritoneum  balloon inflated to dissect the
peritoneal flaps awau from posterior abdomianl wall
and the direct and indirect spaces, other ports
inserted into this preperitoneal space without entering
peritoneal cavity.
After lap. Dissection and reduction of hernia sac , a large piece of
mesh is placed over inguinal floor

55.  Lap repairs vs Open repair
 Multiple RCT’s C/W open repair.
 Results equivalent for
 Recurrence rate
 Better for
 Post -op pain
 Return to work
 Chronic Groin pain
 Worse for
 OP time, long learning curve
 Cost

56.  Infection ~1.5%
 Incl Mesh infection
 Bleeding~1%
 Hernia recurrence
 Varies with technique, should be <2%
 Nerve injury/Chronic groin discomfort 5-10%
 Ischaemic orchitis/atrophy ~1-2%
 Urinary retention 1-10%

57. • Reduction of hernia sac
• Obliteration of defect in femoral canal by
approximation of iliopubic tract to cooper
ligament
Three approaches have been described for open
surgery :
1. Infra-inguinal approach (Lookwood)
2. Supra-inguinal approach ( McEvedy)
3. Trans-inguinal approach ( Lotheissen lacement of
mesh to close defect

58.  The sac is dissected out below the inguinal
ligament via groin crease incision.
 Then the sac is opened and the contents are
inspected and reduced into the abdomen.
 Then the neck of the sac is pulled down ,
ligated and allowed to retract through
femoral canal.
 Then close the femoral canal by mesh plug or
non absorbable sutures.

59.  Vertical incision is made over the femoral
canal and continued upwards above the
inguinal ligament.
 This incision provides good access to the
preperitoneal space and then to the
peritoneum itself.
 Use finger dissection to sweep peritoneum
from anterior abdominal wall , so the neck of
the sac can be identified.
 Dissect the sac , reduce the contents and
repair the defect by mesh or sutures.

60. The incision is made superior and parallel to
inguinal ligament extending from pubic
tubercle to mid inguinal point.

61. Thanks