2. 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.
4. 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?
6. 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
7. 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
8. 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
10. Anatomy
Inguinal region
Includes
Lower abdominal wall
Femoral Triangle
Sartorius/Add Longus/
Inguinal Lig
Contains
Femoral Pedicle
Lymph Nodes
Skin/fat/muscle
11. 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.
12. 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
13. 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.
14. 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
15. 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.
19. 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.
20. 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.
21. 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
23. 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.
24. Skin stuff
Lipomas
Benign Fatty lumps
Clinically
fixed (skin and fat)
soft lumps,
usually longstanding and
asymptomatic.
Management
excise surgically
26. 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.
27. 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.
28. 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
29. 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.
30. 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
35. 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.
36. 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.
38. 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
40. 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
41. Inguinal herniae
Clinically
Groin pain/discomfort
Dragging, worse during the day
Lump
Asymmetry-inguino-scrotal swelling
GI/GU obstruction
Incarceration/Irreducibility
43. 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.
44. 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
45. 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.
48. 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.
50. Hernia operations
Lichtenstein tension free mesh repair.
Results
All can be done under LA
Widely adopted
Recurrence rate 1-2%-Lichtenstein
51. 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.
53. 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.
55. 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
56. 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