A patient presents with a 2-year history of a reducible right-sided inguinal hernia that has progressively grown and extends into the scrotum, without associated pain or other gastrointestinal symptoms. Examination confirms a reducible, soft, expansile swelling in the right inguinoscrotal region, with findings consistent with a right-sided indirect complete inguinal hernia. The recommended treatment is Lichtenstein's tension-free open hernioplasty.

1. MITHRAAZ 2013 BATCH,
KILPAUK MEDICAL COLLEGE,
CHENNAI.

2. HISTORY OF PRESENTING
COMPLAINTS
Swelling in the right groin-2 years,
 insidious in onset,
 initially small in size and gradually progresses to
attain current size,
 extending into scrotum,
 aggravated on coughing,standing and
straining,fully reducible by patient manually,not
associated with pain

3.  No h/o abdominal distension/abdominal
pain/vomiting/constipation
 No h/o chronic cough/difficulty in
micturition/difficulty in defaecation
 H/o weight lifting present
 No h/o trauma, no h/o loss of appetite/weight
 No h/o sudden increase in size of swelling
 No h/o discolouration of skin over the swelling
 No h/o irreducibility
 No h/o swelling elsewhere in the body

4. PAST HISTORY
 No h/o similar complaints in the past
 No h/o previous hospitalisation/surgeries
 No h/o Diabetes
Mellitus,Hypertension,Tuberculosis Bronchial
Asthma,Epilepsy,Jaundice,Ischemic Heart Disease
 No h/o drug allergy

5. PERSONAL HISTORY
 Consumes mixed diet
 Normal bowel and bladder habits
 Smoker for the past 10 years: consumes 1 pack per
day
 Not an alcoholic
FAMILY HISTORY: Not relevant

6. GENERAL EXAMINATION
 Conscious,oriented,moderately built and
moderately nourished
 No pallor/icterus/cyanosis/clubbing/pedal
edema/generalised lymphadenopathy

7. VITAL SIGNS
 Pulse Rate- 68/min,regular in rhythm,no specific
character,felt equally in all peripheral palpable
vessels,no radioradial delay and radiofemoral delay
 Blood Pressure: 120/80 mm Hg measured in right
upper limb in sitting posture
 Respiratory Rate: 16/min,regular in
rhythm,abdominothoracic
 Afebrile

8. LOCAL EXAMINATION
 EXAMINATION OF RIGHT INGUINOSCROTAL
REGION:
 INSPECTION:
- 15 x 8 cm swelling in right inguinoscrotal region
which is pyriform in shape, extending 9 cm from ASIS
to bottom of scrotum
- surface smooth, margins well defined

9. - Skin over the swelling appears normal
- No redness/dilated veins/scars/sinuses
- No visible pulsations and peristalsis
- Visible cough impulse is seen
- Urethral meatus normal
External Genitalia:
-Scrotum appears normal,rugosities present
-Penis appears to be pushed to left side
Inspection in supine position:
- Swelling does not disappear

10.  PALPATION:
-Not warm, not tender
- Inspectory findings of site,size,shape and extent of
the swelling are confirmed: Extent-9cm from ASIS and
1 cm from pubic tubercle
- Expansile cough impulse felt
- Cannot get above the swelling
- Consistency: soft
- Swelling is reducible manually, with initial difficulty
and reduces with gurgling

11.  RING
OCCLUSION
TEST:
After reducing the
swelling in standing
position,deep ring was
occluded with left
thumb:-
 swelling does not
appear on coughing

12.  RING INVAGINATION TEST :
After reducing the content, in
recumbent position, fold of
scrotum invaginated into right
external ring using right little
finger:-
 Impulse is felt on tip of finger
 Direction of finger is upwards,
backwards and outwards

13.  ZIEMAN’S TECHNIQUE:
- After reducing the
swelling, in standing
position, right index finger
is placed over the right
deep ring, middle finger
over the superficial ring
and ring finger over the
saphenous opening:
 Impulse is felt on index
finger on coughing

14.  PERCUSSION:
-Resonant note heard on
percussion over the swelling
 AUSCULTATION:
-Normal bowel sounds heard
- Bowel sounds heard over the
swelling

15.  EXAMINATION OF LEFT INGUINOSCROTAL
REGION: Normal
 EXAMINATION OF REGIONAL LYMPH NODES:
Not enlarged
 EXAMINATION OF TESTIS,SCROTUM,PENIS:
Normal

16.  EXAMINATION OF ABDOMEN:
 Abdomen is normal in shape, not distended,umbilicus
in midline
 No dilated veins/scars/sinuses
 No palpable mass
 On head raising test,no Malgaigne’s bulge
 No divarication of recti
 Abdominal muscle tone is normal
 Other hernial orifices free
 Per-rectal examination- to be done

17.  SYSTEMIC EXAMINATION:
 EXAMINATION OF RESPIRATORY SYSTEM:
- Normal vesicular breath sounds heard, no added
sounds
 EXAMINATION OF CARDIOVASCULAR SYSTEM:
-S1,S2 heard, no murmurs
 EXAMINATION OF CENTRAL SYSTEM:
- No focal neurological deficit
 EXAMINATION OF SPINE AND CRANIUM:
-Normal

18. DIAGNOSIS:
Right sided reducible, indirect complete
inguinal hernia with bowel as content without
any complications
European Hernia Society Classification : PL2

19. INVESTIGATIONS
 BASELINE:
-Complete haemogram, BT, CT
-Urine routine
- Chest X ray
- ECG,ECHO
- Renal Function test
- Liver Function test
 SPECIFIC:
- USG –Abdomen and Pelvis

20. TREATMENT
Lichtenstein’s tension free
open hernioplasty on right
inguinal region

21. THANK YOU