A full coverage of Inguinal Hernia clinical case presentation for undergraduate and post graduate students.

1. Clinical Case discussion
Dr. Loveleen Garg
PG Resident, Deptt Of Surgery .

2. Case
• A 76 years old male, resident of Faridkot,
Shopkeeper by occupation, presented with
chief complaints of
1. Swelling in right lower abdomen X 1 month
2. Pain in swelling X 7 days

3. History of Present Illness
• HDBT 1 month back when patient was
apparently well and noticed swelling in right
lower abdomen,
– insidous onset,
– gradually increased in size,
– Intermittent,
– more prominent on standing/ coughing / sneezing
– Completely disappears on lying down

4. Contd…
• Swelling was initially painless,
• Now c/o pain in swelling since 7 days,
– Sudden onset,
– Non pregressive,
– Dullache,
– Mild in intensity, doesn’t impair routine activities,
– intermittent ,
– Resolves spontaneously.

5. Contd…
• No H/O nausea & vomitings.
• No H/O fever.
• No H/O constipation.
• No H/O any urinary complaints ( nocturia/
straining/ inreased frequency/ weak stream/
intermittency/ residual urine).
• No H/O heavy weight lifting.
• No H/O chronic cough.

6. Past history
• No H/O similar illness in past.
• No H/O hypertension/ diabetes mellitus/ TB/
bronchial ashthma/ CAD/ thyroid illness.
• No H/O any surgical intervention in past.

7. Personal history
• Married, 2 children
• Vegetarian by diet,
• Non alcoholic and non smoker
• No H/O any substance abuse.
• No H/O any drug allergy.

8. Family history
• No relevant family history.

9. Examination
• GPE:
– Pt was calm/ conscious/ co-operative/ oreinted to
time, place and person.
– Comfortably sitting on bed.
– Moderate built
– No pallor/ icterus/ clubbing/ cyanosis/ LAP/
edema.

10. Contd…
• Vitals:
BP- 120/80 mmHg, right arm, in supine
position.
PR- 70/min, regular, good volume, no R-R or
R-F delay.
RR- 16/ min, thoracoabdominal
Temp- 98.8’F

11. Contd…
• Head to toe examination: no significant
finding except scoliosis.
• Systemic examination:
• CNS: E4V5M6, grossly intact
• Chest: B/L NVBS present, No rhonchi/ crepts
• CVS: S1S2 normal, No murmur

12. Contd…
• Local examination:
• Inspection: (In standing position)
A swelling seen in right inguinal region,
approx 4x3 cms in size,
above the inguinal ligament,
globular in shape,
cough impulse present,
overlying skin normal,
no visible pulsations or visible peristalsis seen,
reduces completely on lying down,
external genitalia normal.

13. Contd…
• Palpation: done in standing position
A swelling seen in right inguinal region,
4x3 cms in size, above the inguinal ligament,
globular in shape,
non tender,
smooth surface, smooth margins,
soft & elastic in consistency,
upper edge not palpable,
cough impulse present,
reducible with gurgling sounds,
no local rise of temperature,

14. Contd…
• Palpation contd…
external genitalia normal, bilateral testes palpable in
scrotal sac,
Deep ring occlusion test- swelling disappeared
Zieman’s 3 finger method- s/o indirect hernia
Ring invagination test- impulse felt on tip of finger
• Percussion: resonant over the swelling.
• Auscultation: normal bowel sounds heard over
the swelling.

15. Differential diagnosis
1.Inguinal hernia (clinical diagnosis)
2.Undescended testis
• Clinical- Groin mass, children, underdeveloped
hemiscrotum with absent testis on the affected
side
• Tests- USG, CT, MRI
3. Lymphadenopathy
• Clinical- enlarged mass which is firm tender and
non reducible (d/d femoral hernia), associated
H/O trauma, infection or malignancy
• Tests- USG

16. Differential diagnosis
4.Femoral hernia
• Clinical- common in slender, older female, more prone
to strangulation, located below the inguinal ligament,
neck below and lateral to pubic tubercle (inguinal
hernia- above and medial to pubic tubercle)
• Tests- USG, CT
5.Femoral aneurysm
• Clinical- Pulsatile mass
• Tests- Duplex ultrasound scan
6.Psoas abscess
• Clinical- back pain and fever, chronic cough, weight
loss and night sweats, h/o contact, fixed flexion
deformity
• Tests- MRI, CT scan

17. Differential diagnosis
7.Saphena varix
• Clinical- Dilated great saphenous veins close to
saphenofemoral junction because of incompetent
saphenofemoral valve. There are signs of varicosity
elsewhere. It is soft, compressible and disappears on
lying down. Trendelenberg test +ve
• Test- Duplex ultrasound scan
8.Hydrocele
• Clinical- Transillumination, can reach above the
swelling and testis not separately felt
• Test- USG
9. Encysted hydrocele of the spermatic cord
• Clinical- Traction test
• Test- USG

18. Differential diagnosis
10. Lipoma of the spermatic cord
• Clinical- no cough impulse
• Test- USG -echogenic mass, CT- fat in
inguinal canal
11. Spermatocele
• Clinical- cyst attached to the head of the
epididymis, can get above the swelling,
transillumination, testis separately felt
12. Hydrocele of canal of nuck

28. DD scrotal swelling
• Skin- boil, sebaceous cyst, papillomas, warts
• Subcut tissues - Filariasis lymphscrotum
• Tunica vaginalis- Hydrocele, hematocele,
pyocele
• Testis- orchitis, torsion, neoplasm
• Epididymis- cyst, infection
• Spermatic cord- Varicocele, lymph varix

29. DD Inguinal swelling
• Inguinal hernia
• Lymph nodes
• Encysted hydrocele of cord
• Undescended testis

30. DD of inguinoscrotal swelling
• Inguinal hernia
• Hydrocele- infantile, congenital, hydrocele of
hernia sac
• Spermatic cord- Varicocele, lipoma of the cord,
• Testis- Undescended testis, ectopic

31. DD of femoral swelling
• Femoral hernia
• Lymph nodes
• Saphena varix
• Ectopic testis
• Psoas abscess

32. DD of inguinofemoral swelling
• Inguinal lymph nodes
• Distended psoas bursa
• Effusion in the hip joint

41. Approach algorithm
• Groin mass- reducible, cough impulse, can’t reach
above the swelling- Groin hernia( Inguinal, femoral)
• Check right, left or bilateral
• Zieman’s test, relation of hernia sac to pubic
tubercle
- Ring finger, Below and lateral to pubic tubercle,
below inguinal ligament, (elderly, slender
female),commonly strangulated - Femoral hernia
- Index or middle finger, above and medial to pubic
tubercle, above inguinal ligament- Inguinal hernia

42. Approach algorithm
• Inguinal hernia- Finger invagination test, ring
occlusion test - Direct / Indirect inguinal hernia
• Reducible / irreducible / complicated
• Incomplete or complete
• Content
- Enterocele: Soft, with gurgling sensation, resonant
on percussion, auscultation- bowel sound, first part
is difficult for reduction
- Omentocele: Doughy, last part is difficult for
reduction due to adhesion of sac with omentum

43. Approach algorithm
• Can reach above the swelling, transillumination +
- Testis not separately felt: Hydrocele (Vaginal)
- Testis felt separately: Spermatocele
• Scrotum not developed and testis absent -
undescended testis
• Scrotum developed and testis absent -
Ectopic/Retractile testis
• Pulsatile( expansile) and compressible - Femoral
aneurysm
• Evidence of varicose vein- Saphena varix

44. Final Diagnosis:
• 76 years old male with right sided reducible,
incomplete, indirect inguinal hernia with
enterocele.