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Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
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Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
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Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
Cpd Hernia
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Cpd Hernia
Cpd Hernia
Cpd Hernia
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Cpd Hernia

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  • 1. GOOD MORNING!GOOD MORNING!
  • 2. CASE PRESENTATIONCASE PRESENTATION & DISCUSSION ON& DISCUSSION ON INGUINOSCROTALINGUINOSCROTAL MASSMASS martinjosephscabahugmdmartinjosephscabahugmd
  • 3. General DataGeneral Data C.P.C.P. 5959--yearyear--oldold malemale SampalocSampaloc, Manila, Manila
  • 4. Chief complaintChief complaint InguinoscrotalInguinoscrotal mass on the rightmass on the right
  • 5. History of Present IllnessHistory of Present Illness 2 yrs2 yrs bulging inguinal massbulging inguinal mass 5x8cm5x8cm straining, prolonged standingstraining, prolonged standing reduciblereducible ((--) pain, fever) pain, fever ((--) changes in bowel movement) changes in bowel movement ((--) urinary symptoms) urinary symptoms ((--) respiratory symptoms) respiratory symptoms
  • 6. 10 months PTA10 months PTA increase size ofincrease size of mass,mass, reaches the scrotal areareaches the scrotal area Persistence of symptomsPersistence of symptoms ConsultConsult AdmissionAdmission
  • 7. Past MedicalPast Medical HxHx:: ((--)) HypertentionHypertention ((--) Diabetes Mellitus) Diabetes Mellitus ((--) Bronchial Asthma) Bronchial Asthma ((--) Heart) Heart DisaeseDisaese
  • 8. Physical ExaminationPhysical Examination General Survey:General Survey: Conscious, coherent, ambulatoryConscious, coherent, ambulatory not innot in cardiorespiratorycardiorespiratory distressdistress BP130/90BP130/90 HR 81HR 81 RR 19RR 19 T 37.1T 37.1 C&LC&L symmetrical chest expansionsymmetrical chest expansion no retractions, clear breath soundsno retractions, clear breath sounds
  • 9. Heart:Heart: normal rate regular rhythm, (normal rate regular rhythm, (--) thrills,) thrills, murmurmurmur Abdomen:Abdomen: flat, NABS, soft, non tender,flat, NABS, soft, non tender, nono organomegalyorganomegaly
  • 10. InguinoInguino scrotal mass rightscrotal mass right Inguinal ring 4.5 cmInguinal ring 4.5 cm ReducibleReducible SoftSoft ((--) bowel sounds) bowel sounds ((--)) transilluminationtransillumination ((--)) erythemaerythema ((--) tenderness) tenderness
  • 11. Salient featuresSalient features --5959--yearyear--old Maleold Male --inguinoscrotalinguinoscrotal massmass --ReducibleReducible --Noted when patient strains &Noted when patient strains & prolonged standingprolonged standing --Soft, nonSoft, non--tendertender -- ((--) bowel sounds) bowel sounds -- ((--)) transilluminationtransillumination 4.5 cm external inguinal ring
  • 12. INGUINOSCROTAL MASS, RIGHT INFLAMMATORY NON INFLAMMATORY
  • 13. INGUINOSCROTAL MASS, RIGHT INFLAMMATORY Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy Swelling and rapidSwelling and rapid progression of painprogression of pain fever, chillsfever, chills redness, edematousredness, edematous Multiple,Multiple, tendertender
  • 14. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Malignant Non-malignant
  • 15. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Malignant Non-malignant
  • 16. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Malignant Soft tissueSoft tissue SarcomaSarcoma Large size,Large size, superficial or deepsuperficial or deep FibrosarcomaFibrosarcoma SubcutaneousSubcutaneous fatfat DisorganizedDisorganized growthgrowth LyposarcomaLyposarcoma Deep muscleDeep muscle TesticularTesticular TumorTumor Nodule, firm,Nodule, firm, nonnon--tendertender
  • 17. INGUINOSCROTAL MASS, RIGHT NON INFLAMMATORY Non-malignant Soft tissue Sebaceous cysts Lipoma Lipoma of the cord Spermatocoele Torsion of the testis
  • 18. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia Swelling and rapidSwelling and rapid progression of painprogression of pain fever, chillsfever, chills red, edematousred, edematous
  • 19. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia
  • 20. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia Multiple, tenderMultiple, tender Obvious are ofObvious are of inflammationinflammation
  • 21. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia
  • 22. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia Soft tissueSoft tissue SercomaSercoma Large size, superficialLarge size, superficial or deepor deep
  • 23. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia FibrosercomaFibrosercoma Subcutaneous fatSubcutaneous fat Disorganized growthDisorganized growth
  • 24. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia LyposercomaLyposercoma Deep muscleDeep muscle
  • 25. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Lipoma of the cord •Sebaceous cysts hernia Testicular TumorTesticular Tumor Nodule, firm, nonNodule, firm, non-- tendertender
  • 26. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Sebaceous cysts •Lipoma •Lipoma of the cord •Spermatocoele •Torsion of the testis hernia No cough impulseNo cough impulse
  • 27. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Sebaceous cysts •Lipoma •Lipoma of the cord •Spermatocoele •Torsion of the testis hernia Cyst ofCyst of reterete testestestes Cystic massCystic mass + transillumination+ transillumination bilateralbilateral
  • 28. Inguinoscrotal mass right inflammatory Non-inflammatory Epididymoorchitis Inguinoscrotal abscess Lymphadenopathy malignant Non-malignant Soft tissue •Sebaceous cysts •Lipoma •Lipoma of the cord •Spermatocoele •Torsion of the testis hernia Sudden onset of painSudden onset of pain Scrotal enlargementScrotal enlargement with edemawith edema
  • 29. Hernia direct indirect History: •55M, Recurrent bulging mass, inguinosrotal area, R •Aggravated by straining, relieved by lying down PE: •inguinoscrotal mass, R •Soft, non-tender, reducible •No transillumination •+ cough impulse •No bowel sound Prevalence •Indirect, more common •Rutledge report, 1,437 patients •60% indirect •36% direct •4% femoral •Lichtenstein report • 44.4% Indirect •43.1% direct •12.5% others
  • 30. SurgicalSurgical5%5% SecondarySecondary Direct InguinalDirect Inguinal HerniaHernia SurgicalSurgical95%95% PrimaryPrimary IndirectIndirect InguinalInguinal HerniaHernia TreatmentTreatmentCertaintyCertaintyImpressionImpression
  • 31. ParaclinicalParaclinical Diagnostic ProcedureDiagnostic Procedure Do I needDo I need paraclinicalparaclinical procedure?procedure? Certain of my primary diagnosisCertain of my primary diagnosis pattern recognitionpattern recognition prevalenceprevalence NO.NO.
  • 32. Goal of TreatmentGoal of Treatment Reduce herniated organ/bowelReduce herniated organ/bowel repair defectrepair defect ≥≥4cm4cm Ligation of the sacLigation of the sac
  • 33. Treatment OptionsTreatment Options There are at present three general options forThere are at present three general options for the surgical repair of indirect inguinal hernia,the surgical repair of indirect inguinal hernia, namely:namely: open repair with mesh grafting,open repair with mesh grafting, open repair without mesh grafting,open repair without mesh grafting, laparoscopic repair with mesh graftinglaparoscopic repair with mesh grafting
  • 34. Not availableNot available P 8000P 8000-- P10000P10000 IntraIntra abdominalabdominal complicationcomplication samesame LAPAROLAPARO-- SCOPICSCOPIC Available most ofAvailable most of the timethe time P 5000P 5000Graft rejectionGraft rejection RR 0.2%RR 0.2% LowLow recurrence raterecurrence rate Less postLess post--opop painpain Easy toEasy to performperform Early back toEarly back to workwork OPEN WITHOPEN WITH MESHMESH AvailableAvailableP 2000P 2000 InfectionInfection recurrencerecurrence Repair floorRepair floor anatomicalanatomical OPENOPEN WITHOUTWITHOUT MESHMESH AVAILABILITYAVAILABILITYCOSTCOSTRISKRISKBENEFITBENEFIT 4 cm internal4 cm internal ringring
  • 35. At present, although open repair with meshAt present, although open repair with mesh and laparoscopic repair are now commonlyand laparoscopic repair are now commonly done especially in developed countries, thedone especially in developed countries, the controversy is far from being settled becausecontroversy is far from being settled because of the tendency for blanket recommendationsof the tendency for blanket recommendations and randomized controlled trials and metaand randomized controlled trials and meta-- analyses showing conflicting results, someanalyses showing conflicting results, some favoring open repair without mesh (1,5,7).favoring open repair without mesh (1,5,7).
  • 36. others favoring open repair with mesh (9others favoring open repair with mesh (9--10)10) and still others, laparoscopic approach (11and still others, laparoscopic approach (11-- 13).13).
  • 37. Protocol on HerniaProtocol on Hernia A departmental consensus was made usingA departmental consensus was made using the diameter of the external inguinal ring (>4the diameter of the external inguinal ring (>4 centimeters) as predictor for preoperativecentimeters) as predictor for preoperative preparation of mesh in patients for indirectpreparation of mesh in patients for indirect inguinal hernia repair.inguinal hernia repair.
  • 38. Protocol on HerniaProtocol on Hernia The protocol was then prospectively validatedThe protocol was then prospectively validated on adult patients with unilateral indirect inguinalon adult patients with unilateral indirect inguinal hernia from January to August, 2003 using intrahernia from January to August, 2003 using intra-- operative measurement of the external andoperative measurement of the external and internal inguinal ring as the indicator for meshinternal inguinal ring as the indicator for mesh grafting.grafting.
  • 39. The department believes that there areThe department believes that there are indications for the use of mesh in theindications for the use of mesh in the treatment of indirect inguinal hernia.treatment of indirect inguinal hernia. Recurrence and large size of hernia defect areRecurrence and large size of hernia defect are the basic indicationsthe basic indications favoring open repair without mesh (1,5,7)favoring open repair without mesh (1,5,7) open repair with mesh (4, 13) and still others,open repair with mesh (4, 13) and still others, laparoscopic approach (3, 6, 11).laparoscopic approach (3, 6, 11).
  • 40. PrePre--op preparationop preparation Psychological supportPsychological support Screen for previous medical problemScreen for previous medical problem HypertensionHypertension MetoprololMetoprolol 50mg BID x 2 weeks50mg BID x 2 weeks Optimize patientOptimize patient’’s conditions condition ConsentConsent Preparation of materialsPreparation of materials
  • 41. Operative TechniqueOperative Technique Oblique incision over LangerOblique incision over Langer’’s lines line External oblique aponeurosis openedExternal oblique aponeurosis opened
  • 42. IntraIntra--op findingsop findings HernialHernial sac locatedsac located anteromediallyanteromedially to theto the cord containingcord containing omentumomentum Internal ring measures 4Internal ring measures 4 cm in widest diametercm in widest diameter
  • 43. Operative TechniqueOperative Technique •Spermatic cord identified •Hernial sac identified and opened •Hernial contents reduced •Ligation of the hernial sac
  • 44. Operative TechniqueOperative Technique •Mesh approximated over the defect •Medial corner of the mesh overlaps the pubic bone •And sutured with interrupted prolene 3-0
  • 45. Operative TechniqueOperative Technique Spermatic cord placed between the two tails of the mesh
  • 46. Operative TechniqueOperative Technique Two tails crossed –over and sutured together
  • 47. Operative TechniqueOperative Technique •Hemostasis •Instrument and sponge checked •Fascial closure with vicryl 0 •Subcuticular skin closure with vicryl 4-0 •Dry sterile dressing
  • 48. Final DiagnosisFinal Diagnosis Indirect Inguinal Hernia, RightIndirect Inguinal Hernia, Right Grade IIIGrade III--BB
  • 49. PostPost--op supportop support AnalgesiaAnalgesia KetoprofenKetoprofen 100mg TIV q6 x 3 doses100mg TIV q6 x 3 doses shifted to oral Paracetamol 500mg q4shifted to oral Paracetamol 500mg q4 Early ambulationEarly ambulation Diet as toleratedDiet as tolerated Daily wound careDaily wound care Discharged on the 2nd PODDischarged on the 2nd POD
  • 50. Prevention and HealthPrevention and Health Anticipate complicationsAnticipate complications AdequateAdequate hemostasishemostasis Avoid vascular compromiseAvoid vascular compromise Avoid infectionAvoid infection Avoid dehiscenceAvoid dehiscence
  • 51. Prevention and HealthPrevention and Health Alive patientAlive patient PatientPatient’’s health problem resolveds health problem resolved No complaintNo complaint No disabilityNo disability No medical suitNo medical suit Satisfied patientSatisfied patient
  • 52. PathophysiologyPathophysiology Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 53. Inguinal Hernia genetic •Autosomal dominant •Preferential paternal factor •Multiple, familial or part of connective tissue disorder Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 54. Inguinal Hernia metabolic •Decrease hydroxyprolene •Altered collagen precipitability and impaired hydroxylation •Increase elastase, decrease anti-proteolytic inhibitor capacity (emphysema) Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 55. Inguinal Hernia Muscle Deficiency •Congenital or acquired insufficiency of internal oblique expose the deep ring and inguinal floor t Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 56. Inguinal Hernia Physical exertion •Increase in intraabdominal pressure Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 57. Inguinal Hernia Physical exertion •Increase in intraabdominal pressure Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 58. Inguinal Hernia Patent Processus Vaginalis •Evagination of the peritoneum •60% at two months, 40% at two years, 30% adult Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 59. Inguinal Hernia Fascial factor •Myopectineal Orifice Fruchaud •Boundaries: superior, internal oblique + transverse abd muscle; lateral, iliopsoas; medial, rectus; inferior, pecten •Transversalis fascia Inguinal Hernia genetic Physical exertion metabolic Muscle deficiency Fascial factor Processus vaginalis
  • 60. Myopectineal orifice of Fruchaud Internal oblique and transverse abdominis Ileopsoas m. Pecten pubis
  • 61. NyhusNyhus ClassificationClassification Type IType I Indirect, smallIndirect, small Type IIType II Indirect, mediumIndirect, medium Type IIIType III A. DirectA. Direct B. Indirect, largeB. Indirect, large C. FemoralC. Femoral Type IVType IV RecurrentRecurrent
  • 62. Type 1Type 1 Indirect, smallIndirect, small
  • 63. Type IIType II Indirect, mediumIndirect, medium
  • 64. Type IIIType III A. DirectA. Direct
  • 65. B. Indirect, largeB. Indirect, large
  • 66. Type III CType III C
  • 67. Unified ClassificationUnified Classification
  • 68. Unified ClassificationUnified Classification
  • 69. Recurrent herniaRecurrent herniaType 4Type 4 Femoral herniaFemoral herniaCC Indirect inguinal hernia. Internal ring dilated. PosteriorIndirect inguinal hernia. Internal ring dilated. Posterior wall defectivewall defective BB Direct inguinal herniaDirect inguinal herniaAA Posterior wall defectPosterior wall defectType 3Type 3 Indirect hernia with dilated internal ring. Posterior wallIndirect hernia with dilated internal ring. Posterior wall intactintact Type 2Type 2 Indirect hernia with normal internal ringIndirect hernia with normal internal ringType 1Type 1 NyhusNyhus Classification of InguinalClassification of Inguinal Hernias.Hernias.
  • 70. GilbertGilbert’’s Classification of Inguinals Classification of Inguinal Hernias.Hernias. Femoral herniaFemoral herniaType VIIType VII Pantaloon herniaPantaloon herniaType VIType VI DirectDirect diverticulardiverticular defect 1defect 1--2 cm2 cm suprapubicsuprapubic, but anywhere, but anywhere along flooralong floor Type VType V Defective canal floor, ring is soundDefective canal floor, ring is soundType IVType IV Ring > 4 cm, sliding component, displaces inferiorRing > 4 cm, sliding component, displaces inferior epigastricepigastric vesselsvessels Type IIIType III Indirect, ring < 4 cmIndirect, ring < 4 cmType IIType II Indirect, tight ring, sac any size, reducibleIndirect, tight ring, sac any size, reducibleType IType I DescriptionDescriptionTypeType
  • 71. ReferencesReferences 1.1. BarthBarth R J,R J, BurchardBurchard K W,K W, TostesonTosteson A et al. ShortA et al. Short-- term outcome after mesh orterm outcome after mesh or ShouldiceShouldice herniorrhaphyherniorrhaphy: A: A randomisedrandomised, prospective study., prospective study. Surgery. 1998; 123: 121Surgery. 1998; 123: 121--126.126. 2.2. Cameron J. Current Surgical Therapy. VII Ed. 2001;Cameron J. Current Surgical Therapy. VII Ed. 2001; 600600--616.616. 3.3. Chung RS, RowlandChung RS, Rowland DY.MetaDY.Meta--analyses ofanalyses of randomized controlled trials of laparoscopicrandomized controlled trials of laparoscopic vsvs conventional inguinal hernia repairs.conventional inguinal hernia repairs. SurgSurg EndoscEndosc.. 1999; 13(7):6891999; 13(7):689--94.94. 4.4. Fitzgibbons R. et al.Fitzgibbons R. et al. HyhusHyhus and Condonand Condon’’s Hernia. Vs Hernia. V Ed. 2002;, 3Ed. 2002;, 3--7; 717; 71--79; 14979; 149--156.156.
  • 72. 5.5. FriisFriis E,E, LindahlLindahl F. The tensionF. The tension--freefree hernioplastyhernioplasty in a randomized trial. Am Lin a randomized trial. Am L SurgSurg. 1996; 172 (4):. 1996; 172 (4): 315315--99 6.6. Go PM. Overview of randomized trials inGo PM. Overview of randomized trials in laparoscopic inguinal hernia repair.laparoscopic inguinal hernia repair. SeminSemin LaparoscLaparosc SurgSurg. 1998; 5(4): 238. 1998; 5(4): 238--41.41. 7.7. PavlidisPavlidis TE,TE, AtmatzidisAtmatzidis KS,KS, LazardisLazardis CN,CN, PapaziogasPapaziogas BT,BT, MakrisMakris JG. Comparison betweenJG. Comparison between modern mesh and conventional nonmodern mesh and conventional non--meshmesh methods of inguinal hernia repair. Minervamethods of inguinal hernia repair. Minerva ChirChir.. 2002; 57(1): 72002; 57(1): 7--1212 8.8. PingulPingul J. et al. Health Process Evidence basedJ. et al. Health Process Evidence based Clinical Practice Guidelines in Patient withClinical Practice Guidelines in Patient with Inguinal HerniaInguinal Hernia 9.9. ScottScott--ConnConn, C., C. ChassinChassin’’ss Operative Strategy inOperative Strategy in General Surgery. III Ed. 747General Surgery. III Ed. 747
  • 73. 10.10. Schwartz, S. et al. Principles of Surgery. VII Ed.Schwartz, S. et al. Principles of Surgery. VII Ed. 1999; 15851999; 1585-- 1609.1609. 11.11. The EU HerniaThe EU Hernia TrialistsTrialists Collaboration. Repair ofCollaboration. Repair of groin hernia with synthetic mesh: metagroin hernia with synthetic mesh: meta--analysis ofanalysis of randomized controlled trials. Annrandomized controlled trials. Ann SurgSurg. 2002;. 2002; 235(3):322235(3):322--32.32. 12.12. VrijlandVrijland W W, van denW W, van den TolTol M P,M P, LuijendijkLuijendijk R WR W et al.et al. RandomisedRandomised clinical trial of nonclinical trial of non--mesh versusmesh versus mesh repair of primary inguinal hernia. Br Jmesh repair of primary inguinal hernia. Br J SurgSurg.. 2002; 89: 2932002; 89: 293--297.297. 13.13. WantzWantz GE. Experience with the tensionGE. Experience with the tension--freefree hernioplastyhernioplasty for primary inguinal hernias in men. Jfor primary inguinal hernias in men. J AmAm CollColl SurgSurg. 1996; 183(4): 351. 1996; 183(4): 351--6.6.
  • 74. BassiniBassini RepairRepair Uses interupted sutures
  • 75. ShouldiceShouldice RepairRepair Uses continuous, imbricated sutures
  • 76. McVayMcVay’’ss RepairRepair Approximates the transversus abdominis and the tranversalis fascia
  • 77. ParaclinicalParaclinical Diagnostic ProcessDiagnostic Process AvailabilityAvailabilityCostCostRiskRiskBenefitBenefitDiagnosticDiagnostic ProcedureProcedure Not availableNot availableP500.00P500.00PeritonitisPeritonitis HypersensitiviHypersensitivi tyty WillWill differentiate adifferentiate a direct from andirect from an indirect herniaindirect hernia herniographyherniography Not readilyNot readily availableavailable P3000.00P3000.00Exposure toExposure to radiationradiation WillWill r/or/o otherother causes ofcauses of groin massesgroin masses CTCT--scanscan AvailableAvailableP150.00P150.00Exposure toExposure to radiationradiation WillWill r/or/o intestinalintestinal obstructionobstruction xx--rayray Not readilyNot readily availableavailable P300.00P300.00AcceptableAcceptableWillWill r/or/o otherother causes ofcauses of groin massesgroin masses ultrasoundultrasound
  • 78. THANK YOU!THANK YOU!

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