I have added viva notes after this proforma for quick revision of important stuff asked in exam. LINK FOR EXAMINATION VIDOES : 1. https://youtu.be/uO-w_9w5okI 2. https://youtu.be/Vc_ZH_-Oad4

1. Case Presentation
On
INGUINAL HERNIA
AYESHA HUMA
MBBS 4TH YEAR , SIMS

2. CHIEF COMPLAINTS
A 58yrs old male patient vijay ,farmer by
occupation , resident of SunCity ,
presented to the OPD with complaint of-
swelling in right groin since 1yr

3. H/O PRESENTING ILLNESS
• Patient was apparently asymptomatic 1year back, later he presented with
complaint of swelling in right groin for 1 year.
• Single swelling initially appeared in right inguinal region, above the groin crease
and then extended into the scrotum
• Initially small in size (2X2 cm as described by patient in hand gesture) gradually
increased to present size of 10*4 cm approx
• Swelling increases in size with cough, straining, lifting of weight
• Swelling disappears on lying down position.

4. • No h/o pain over swelling or pain abdomen
( seen in strangulated hernia )
• No h/o fever , vomittings or constipation
( Features of intestinal obstruction not seen )
• No h/o cough (to r/o copd as it’s a risk factor for Hernia )
• No difficulty in micturition ( to r/o BPH in elderly male & UTI )
• No h/o swelling in contralateral side, other regions of body
( To r/o bilateral or ventral hernia )

5. PAST HISTORY
• No H/O HTN/ DM/ TB/ EPILEPSY / Bronchial Asthma.
• No H/o any surgery in the past.
( Appendicectomy can lead to damage to nerves resulting in weakness of
Abdominal musculature )
• No H/o any cardiac problems.

6. PERSONAL HISTORY
• Diet-Mixed
• Appetite-Good
• Sleep- adequate
• Bowel and Bladder – regular
• No addictions
No Significant family history.
No known history of drug allergies.

7. GENERAL EXAMINATION
I have examined the patient in presence of attendant after obtaining verbal
consent in a well lit room after adequate exposure
• On examination patient is conscious, coherent, cooperative , well oriented
with time place and person.
• Moderately built and moderately nourished with BMI of 24 kg/m²
• No –pallor No –icterus, no- clubbing, no- cyanosis, no-lymphadenopathy,
no- edema
Vitals:
• Temp = 98 F
• PR-96 bpm, regular, rhythmic normovolemic.
• BP-130/80 mmHg measured on Rt arm in supine position.
Respiratory Rate 15 cycles/ min , Abdominothoracic

8. LOCAL EXAMINATION
INSPECTION
• SITE : Extending from above Groin crease down into the scrotum up to
upper pole of right testis
• SHAPE & SIZE : A single pyriform shaped swelling of size approx
10 X 4 cm
• SKIN & SURFACE : Skin over swelling is normal & there were no scar ,
redness or engorged veins. Surface is smooth.
• No visible peristalsis over the swelling
• Cough impulse – present
• Penis is in midline
• In supine position swelling reduced after manipulation by patient initially
reduces easily later it reduces with difficulty without gurgling sound.
• Left inguinal region, scrotum, testis – normal

9. PALPATION
• No local rise of temperature or tenderness overlying the swelling
. All inspectory findings are confirmed ( site , size , shape , surface ,
overlying skin )
• Swelling is above and medial to the pubic tuberclesurface
• Extends into the scrotum upto the upper pole of Rt testis
• I wasnt able to get above the swelling
• Consistency – doughy & granular
• Testes was palpable separately from the swelling
• Ring occlusion test – on occlusion of deep ring with thumb, swelling did
not appear
• Ziemans test- cough impulse felt at right index finger
• Finger invagination test – felt at tip of index finger

10. PERCUSSION
• Dull note ( omentocele)
AUSCULTATION
• No peristaltic sounds heard over the swelling ( omentocele)
Left inguinoscrotum - normal

11. EXAMINATION OF ABDOMEN
INSPECTION
• Abdomen is not distended. Umbilicus central in position
• No sinuses/scars.
• All quadrants are equally moving with respiration
PALPATION
• No organomegaly, no mass per abdomen
PERCUSSION
• Tympanic note all over the abdomen
AUSCULTATION
• Bowel sounds heard

12. PER RECTAL EXAMINATION
• No fissure,
• No external hemorhhoids ( to r/o constipation )
• Sphincter tone normal
• NO prostatomegaly

13. • Cardiovascular system :
S1 S2 heard,
no murmurs
NAD
• Respiratory system :
normal vesicular breath sounds heard
NAD

14. SUMMARY
 A 60 yr old gentleman with no comorbidities , presented with a
painless , progressive swelling which was started in the right groin &
gradually reached to the upper pole of testis. Swelling increases in
size on standing & completely reduces on lying down by
manipulation with no history of irreducibility & intestinal obstruction

15. PROVISIONAL DIAGNOSIS
Right reducible uncomplicated incomplete
indirect inguinal hernia with omentocele

16. Important VIVA QUESTIONS

17. Immediately lateral to inferior epigastric vessel

21. FEMORAL TRAINGLE

24. FEMORAL RING BOUNDARIES

25.  The increase in pressure can dilate the femoral vein, which in turn
stretches the femoral ring, allowing part of the organ to pass through the
femoral canal before exiting via the saphenous opening

26. INGUINAL vs FEMORAL HERNIA ❓

28. DIRECT VS INDIRECT INGUINAL HERNIA ❓

29. COMPLETE INCOMPLETE
COMPLETE vs INCOMPLETE INGUINAL HERNIA ❓

30. ( Mouth , neck ,
body & fundus )
Parts Of hernia ❓

31. CONTENT OF HERNIA.

32. MYOPECTINEAL ORIFICE OF FRUCHARD

33. Myopectineal orifice (MPO) is a
well defined weak area in the lower
anterior abdomen.
Direct and indirect inguinal hernia,
femoral hernia exit the abdominal
cavity traversing this MPO.
Fruchaud advanced the separate
concepts of inguinal hernias and
femoral hernias and provided a
new (for the time) concept of the
repair of these hernias. Today, with
laparoscopic herniorrhaphy, a
surgeon attempts to repair the
weak MPO instead of only the
herniated locus.

34. TRAINGLE OF DOOM
It is a triangle bound
MEDIALLY :vas deferens,
LATERALLY : testicular vessels,
BASE: the peritoneal fold.
👉The importance of this triangle is in this area you can find the external iliac artery
vessels & genital branch of genito femoral nerve
TRAINGLE OF PAIN
is bound
SUPERIORLY : the iliopubic tract
MEDIALLY : testicular vessels,
LATERALLY : and the peritoneal fold.
👉Content : Femoral nerve , lateral cutaneous nerve of thigh , anterior cutaneous nerve
of thigh , femoral branch of genito femoral nerve

35. TRAPEZOID OF DISASTER ( TRAINGLE of pain + doom )

36. COMPLICATIONS OF HERNIA ❓

37. SURGICAL MANAGEMENT OF HERNIA.

39. THANK YOU