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.
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 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 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 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
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
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.
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.
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
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 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.
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.
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.
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