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Inguino-scrotal lumps
 

Inguino-scrotal lumps

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Inguino-scrotal lumps

Inguino-scrotal lumps
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    Inguino-scrotal lumps Inguino-scrotal lumps Presentation Transcript

    • Inguino-Scrotal Lumps
    • Inguino-Scrotal Lumps Why?  Because they’re common.  Because they’re really common.  Because the anatomy is fun to quiz people on.  Because they’re common.  Account for up to 20% of General surgical referrals.
    • Pathologies Inguinal  Scrotal  Sebaceous  Testicular tumor Cysts/Lipoma’s  Inguinal  Epididymal cyst Lymphadenopathy  Spermatocoele  Saphenous Varix  Hydatid of Morgagni  Femoral Artery aneurysm  Varicocoele  Psoas Abscess  Undescended testes.  Hydrocoele  Inguinal Hernia  Inguino-scrotal  Femoral Hernia Hernia
    • Assessment-History Lump  When was it first noticed?  How was it noticed?  Precipitant activity  Recent illnesses  What symptoms are present?  ?pain, functional impairment  GI/GU disturbance.  Systemic symptoms-fevers, night sweats etc.  Is the lump changing?  Does the lump come and go  How or when?
    • Assessment-Exam Lump  Position, Shape and size  Surface  Skin  Mass surface  Temperature  Tenderness  Composition-Solid/Fluid/Gas  Consistency  Fluctuation/Fluid thrills/Resonance  Translucency  Pulsatility  Reducibility/Cough impulse  Relations to surrounding structures  Regional Lymph nodes
    • Assessment-Exam Both sides Hernia Tests  Standing and lying  ?Get above it  Cough Impulse  Reducibility and control Associated structures  Pulses, testes, Lymph nodes. Special tests  Transillumination
    • Assessment 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
    • Assessment How Not to Kill people,  Don’t miss tumors  Exclude Malignancy  Lymphadenopathy-Generalized, unexplained or persistent  BIOPSY!  Discrete Scrotal Lumps or unexaminable testes  Ultrasound and/or Refer  No Part time Vascular Surgery
    • Anatomy Inguinal region Inguinal Canal  Spermatic Cord  Femoral Canal and Ring Scrotum/testes
    • Anatomy Inguinal region  Includes  Lower abdominal wall  Femoral Triangle  Sartorius/Add Longus/ Inguinal Lig  Contains  Femoral Pedicle  Lymph Nodes  Skin/fat/muscle
    • Anatomy Inguinal Canal  An oblique series of defects in the layers of the abdominal wall.  Site of Inguinal Herniae  Transmits the Spermatic cord/Round ligament.  Round ligament  Runs from Uterine fundus via canal to Labia.
    • Anatomy Inguinal Canal  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
    • Anatomy Femoral Canal  Beneath the inguinal ligament  Iliacus muscle  Femoral Nerve  Femoral Sheath containing…  Femoral vessels  Femoral Canal  Femoral Canal  Space for venous expansion  Lymphatics.  Upper end defined by femoral ring.
    • Anatomy Femoral Canal  Beneath the inguinal ligament  Iliacus muscle  Femoral Nerve  Femoral Sheath containing…  Femoral vessels  Femoral Canal  Femoral Canal  Space for venous expansion  Lymphatics.  Upper end defined by •Femoral Ring femoral ring. •Site of Femoral Herniae
    • Anatomy Eponyms  Hesselbachs Triangle  Lateral border of rectus muscle  Inguinal Ligament  Inferior epigastric vessels (med border of deep ring)  Fruchauds Myopectineal Orofice  Hesselbachs triangle  Deep ring  Femoral sheath/canal.
    • Anatomy Spermatic cord  Pedicle of the testes  Made up of 12 things
    • Anatomy Spermatic cord  Pedicle of the testes  Made up of 12 things You’re not getting away with that!
    • Anatomy 3 Arteries  3 Important structures 3 Nerves  3 Coverings
    • Anatomy 3 Arteries  3 Important structures  Testicular  Vas Deferens  Artery to the Vas Deferens  Pampiniform Plexus  Cremasteric  Processus Vaginalis 3 Nerves  3 Coverings  Sympathetic branches  External Spermatic Fascia  Ilio-inguinal (on cord)  Cremasteric Muscle  Genital Br of Genito-femoral  Internal Spermatic Fascia nerve.
    • Anatomy 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.
    • Anatomy 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
    • Pathologies Inguinal  Scrotal  Sebaceous  Testicular tumor Cysts/Lipoma’s  Inguinal  Epididymal cyst Lymphadenopathy  Spermatocoele  Saphenous Varix  Hydatid of Morgagni  Femoral Artery aneurysm  Varicocoele  Psoas Abscess  Undescended testes  Hydrocoele  Inguinal Hernia  Inguino-scrotal  Femoral Hernia Hernia
    • Skin stuff 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.
    • Skin stuff Lipomas  Benign Fatty lumps  Clinically  fixed (skin and fat)  soft lumps,  usually longstanding and asymptomatic.  Management  excise surgically
    • Inguinal Lymphadenopathy 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
    • Saphenous Varix 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 +  Thrill down vein when percussing.  Management-surgical ligation.
    • Femoral Artery Aneurysm. True aneurysms  Pulsatile lump in groin  Associated with other aneurysmal disease  Mx-Vascular surgical repair if >2-3cm False aneurysm  Secondary to puncture  Dx on duplex  Mx-Call a vascular surgeon- thrombose or repair.
    • Psoas Abscess Abscess within Psoas fascia that tracks to groin and presents as a lump. Associated with Retroperitoneal infection/inflammation  Post Surgical eg. Nephrectomy  Colonic  Pancreatitis  Spinal TB Management  Drain and treat underlying cause
    • Undescended Testes Rare in adults  Usually Dx and treated as children In adults usually present as infertility  Alt painless lump in Inguinal canal Prone to infertility and testicular cancer. Managemant  Refer to Urologist.
    • Scrotal Lumps Assessment  Hx/Ex as previous  If not obvious Hernia/Varicocoele/ Hydrocoele and normal testes Ultrasound  Lump origin  Solid vs cystic etc.  If still in doubt-Call a Urologist.  Surgical exploration
    • Scrotal Lumps Solid lumps.  Testicular origin  mostly malignant  Paratesticular origin  mostly benign  Cystadenoma, Adenomatoid tumor (epididymis)  Inflammatory pseudotumor Cystic lumps  Usually benign  Epididymal cyst,  Spermatocoele,  Hydatid of Morgagni
    • Testicular Lumps Testicular tumors  Usually painless lumps in 2nd to 4th decades  Germinal-95%  Seminoma/Embryonal Cell/ChorioCa/Teratoma  Non-Germinal  Stromal-Leydig Cell Tumor; Gonadoblastoma Management  Call a Urologist  Usually multimodal Therapy
    • Hydrocoele 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.
    • Hydrocoele
    • Varicocoele Dilatation of the Pampiniform Plexus Usually affects 20 to 50 yo’s L>R  due to venous anatomy.  Acute varicocoele-exclude RP infiltration May cause infertility Painless lump  Bag of worms  Cough impulse +ve  May reduce on lying down Treatment  Ligation at deep ring or excision.
    • Other Scrotal Lumps 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.
    • Hernias
    • Inguinal herniae Hernia Numbers  25% of males (2% F) will develop a groin hernia  65% Indirect Inguinal herniae  55% on the right  31% Direct Inguinal Herniae  Although represent 80% of bilateral herniae  4% Femoral Herniae  More common in women 20 % of all groin herniae c/w 2% male. Causes  Congenital  Chronic Stress to area  Metabolic-Collagen-vasc Ds, Smoking
    • Hernia types Inguinal  Direct  Indirect  Pantaloon Femoral Also  Sliding herniae
    • Sliding Hernia A Hernia in which the peritoneal wall that forms part of the sac has an organ naturally adherent to it.  Eg. If an extraperitoneal 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. Non sliding hernia Must look out for this at the time of surgery because the organ is easily injured upon opening the sac. Can be direct or indirect. Sliding hernia
    • Inguinal herniae Clinically  Groin pain/discomfort  Dragging, worse during the day  Lump  Asymmetry-inguino-scrotal swelling  GI/GU obstruction  Incarceration/Irreducibility
    • Hernia examination
    • Direct vs indirect Direct  Diffuse bulge  Rarely into scrotum  Controlled only at superficial ring Indirect  Usually more defined  May extend into scrotum  Herniation/reduction more prominent  Controlled at deep ring.
    • Femoral vs inguinal 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
    • Hernia Complications Incarceration 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-masse Progressive growth=Natural Hx of herniae.
    • Hernia Management Fix it!  Eliminates pain  Eliminates Lump  Avoids hernia growth  Avoids risk of strangulation  Esp in indirect hernia  Straightforward surgery.
    • Inguinal Operations Previous  Bassini, McVay, Shouldice  Forget them Now  Lichtenstein tension free mesh repair.  Laproscopic repair.
    • Hernia operations Lichtenstein tension free mesh repair.  Developed in NY at the Lichtenstein Hernia clinic  Originally done as OP procedure under LA  Involves  Dissecting Inguinal canal and mobilising cord  Inverting/removing hernia sac  Reinforcing posterior inguinal wall with prolene mesh.
    • Open Hernia Repair
    • Hernia operations Lichtenstein tension free mesh repair.  Results  All can be done under LA  Widely adopted  Recurrence rate 1-2%-Lichtenstein
    • Hernia Operations Laparoscopic  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.
    • Lap Hernia Repair
    • Hernia Operations Lap repairs  Multiple RCT’s C/W open repair.  Results equivalent for  Recurrence rate (? Better)  LoS  Better for  Post -op pain  Return to work  ?Chronic Groin pain  Worse for  OP time  Cost  Tend to be reserved for Recurrent or Bilateral repairs.
    • Hernia Operations Complications  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%
    • Femoral Herniae 3 ways  High Approach  McEvedy-via the abdomen  Best for difficult or strangulated Herniae  Middle  Lothieson-via the Inguinal canal  Used occasionally for indeterminate herniae.  Low  Lockwood-via the upper thigh/groin  Best for small hernia and elective repairs
    • Summary Remember the anatomy  Lumps can arise from any tissue.  Understand the Hernia anatomy and the clinical management is easy Don’t kill anyone  Don’t miss Malignancy-Ing LN and scrotal lumps. Fix the hernias