2.Hernia - SURGERY AUDIO case presentation for Final MBBS by Dr Ghanashyam Vaidya 2/8

[0:00]a case of inguinal scrotal swelling. This case presentation is the second in the series of cassette clinics of general surgery prepared by Dr. Ghanashyam Vaidya from Karnataka Health Institute, Ghataprabha, an ex-student of Seth GS Medical College and KEM Hospital, Mumbai. A 45 years old Hindu male patient, Dhanji, a manual labourer, staying at Lalbaug, comes with complaints of a swelling in the left groin since 10 months. The patient was apparently alright 10 months back, when he accidentally noticed a swelling in the left groin, which appeared on straining and disappeared on lying down. It was painless, and it gradually increased in size and extended into the scrotum over the last 10 months. So, it appears on straining and disappears on compressing. Yes, sir. So, what is your diagnosis? A hernia, sir. inguinal or femoral? Sir, more likely to be inguinal, because femoral hernias are usually not so easily expansile or reducible, due to their narrow neck and adherent omentum. And secondly, femoral hernias do not descend into the scrotum. But why do you say that it is a hernia? From the history that it appears on straining and disappears on lying down or compressing it. Does that happen with a varicocele? Yes, sir. With a lymph vericose? Yes, sir. Sorry, sir. It could be any of the three. Don't make this mistake. Do not take the diagnosis for granted even in straightforward cases like this. Examiners know that you know the diagnosis. They are interested in the differential diagnosis, whether you have thought of and ruled out all other possible causes. So, until all other causes of inguinal scrotal swellings are ruled out by your history and then examination, mention a differential diagnosis. Of course, you have already mentioned a point with which you could have argued that this is nothing but a hernia. Can you now tell me what it is? Sir, it was first noticed in the groin. Right. It was first seen in the groin and then descended into the scrotum. The varicocele and the lymph vericose, the other reducible swellings, would have been first noticed in the scrotum. Proceed. At present, it does not reduce automatically on lying down, but with manipulation the patient can reduce it. Any significance? Yes, that it is in a reducible stage, and since manipulation is required to reduce it, it is more likely to be an indirect hernia than a direct one. Right. Regarding complications, no history of attack of irreducibility with severe pain, distension of abdomen, vomiting and constipation. What is the significance? For any past incident of irreducibility and intestinal obstruction. History of such an attack stresses the need for surgery as early as possible. There is no history of similar swellings in the opposite groin, or anywhere else over the abdomen. Where else over the abdomen do you get external hernias? Firstly, over the anterior abdominal wall in the midline, epigastric hernia through the linea alba above the umbilicus, umbilical and paraumbilical hernias at the umbilicus, divertication of recti and incisional hernia through midline incisions. Laterally, Spigelian hernia at the lateral border of the rectus muscle at the level of the arcuate line, interparital hernia and incisional hernia. Secondly, in the inguinal region, inguinal and femoral hernias through inguinal canal and femoral ring respectively and obturator hernia through the obturator canal. Thirdly, on the back, superior and inferior lumbar hernias through the superior and inferior lumbar triangles respectively. Where are these triangles situated? Sir, superior lumbar triangle is bounded by 12th rib above, lateral border of sacro spinalis medially and free posterior border of the internal oblique laterally. The inferior lumbar triangle of Petit is based on the superior crest of ilium, bounded by latissimus dorsi medially and external oblique laterally. Lastly, gluteal and sciatic hernias inside the abdomen through greater and lesser sciatic foramina respectively. Is a fat person like this one more prone to develop hernia? Yes, sir, fat as it collects tends to separate the muscle bundles and fibres and weakens the abdominal wall musculature. So, these people are more prone to develop paraumbilical hernia, direct inguinal hernia and hiatus hernia. Regarding aetiology of the hernia, there is history of strenuous work, patient is a manual labourer. No history of chronic cough, though he is a chronic smoker. No history of chronic constipation or straining at stools. No history of difficulty in micturation, night frequency, poor stream or terminal dribbling. Why did you ask that? For enlargement of prostate. All these straining factors raise the intra-abdominal pressure repeatedly to a very high level, and some potentially weak point in the abdominal wall gives way and gives rise to an external hernia. Yes, to find out the aetiology of hernia, you must ask the history of strenuous work, chronic cough, constipation and straining at micturition. Anything else in aetiology? No history of massive distension of abdomen, no history of operation on the affected side of the abdomen, McBurney's incision, kidney incision. Right, if the incision of a previous abdominal operation is placed laterally as in McBurney's incision or kidney incision. What is the mechanism of hernia formation in such a case? Sir, the ilioinguinal nerve may be damaged in these incisions, producing weakness of the lowermost fibres of internal oblique and transversus abdominis, that is the conjoint tendon. Thus weakening the posterior wall and the shutter-like action of the conjoint tendon during straining, which normally protects the posterior wall of the inguinal canal. This makes it prone to develop direct inguinal hernia. There is no history of trauma, no history of fever with chills, with simultaneous pain and enlargement of the swelling. Why? For filarial funiculitis. No history of use of truss or any operation in relation to the swelling. Family history and personal history are not contributory. Why do you want to know whether the patient has used a truss? Because prolonged use of truss may cause atrophy and weakening of the underlying muscles and also cause adhesions within the sac, making it prone to develop obstruction. On examination, on general examination, the patient is averagely built, fairly nourished. There is no pallor, cyanosis, icterus or clubbing, no significant lymphadenopathy, pulse is 80 per minute, regular, good volume. Blood pressure is 130 by 80 mm. of mercury, in right upper arm in supine position. Respiratory rate is 20 per minute, regular. RS and CVS are normal. On local examination, on inspection in standing position, a single swelling situated above the medial half of the inguinal ligament, extending into the scrotum, but not reaching its base. Why standing position? Firstly, to look for presence of a swelling, because small direct hernias and varicoceles are seen only in standing position and may be totally missed in lying down position, even with coughing. Secondly, to look for any enlargement in a pre-existing swelling on standing and thirdly, to look for the extent of an existing hernia, that is how far does it extend into the scrotum when at its maximum size, which is reached only in standing position. What is a hernia? Sir, hernia is the protrusion of viscus or a part of the viscus through a normal or abnormal opening in the wall that contains it. In this case, the abdominal wall. Proceed. On inspection in standing position, a single swelling situated above the medial half of the inguinal ligament, extending into the scrotum, but not reaching its base. What does that tell you? That it is likely to be an indirect hernia, because a direct hernia has very little tendency to descend into the scrotum. Also, it stops just above the testes as it is an acquired hernia. A congenital hernia may touch the bottom of the scrotum as it is continuous with the tunica vaginalis and testis is within the sac. Proceed. The swelling is pyriform in shape, 8 by 3 by 2 cm in size, pushing the penis to the opposite side. Why is it pyriform in shape? Because indirect hernia is narrow at the top in the inguinal canal, and expands into the scrotum below which is a loose sac. Hence, the pyriform shape. Direct inguinal hernia are more globular. Also it is pushing the penis to the opposite side, which does not happen in other inguinoscrotal swellings like varicocele. The skin over the swelling shows no redness, edema, dilated veins, no scar of any surgery or infection, no hypo- or hyperpigmentation. What does hypopigmentation signify? Sir, hypopigmentation is associated with prolonged use of truss. And hyperpigmentation in this area is usually due to tinea infections. And what is the significance of a scar? A scar of previous hernia repair means that the hernia is recurrent. A ragged broad scar will indicate post-operative infection as the possible cause for recurrence. Otherwise, we will have to look for other possible causes of recurrence and plan the surgery accordingly. What care will you take while treating a recurrent hernia? Sir, recurrent hernia will definitely need a proline mesh repair. Secondly, surgery can be difficult due to adhesions. Also, I will explain to the patient that sometimes orchidectomy may be needed for a proper repair. Good, proceed. There are no visible peristalsis, there is a distinct visible wait, come here. Can't you see the peristalsis here? No, sir. That is the movement of the scrotal skin due to the contraction of dartos muscle. Yes, don't mistake this movement of the scrotal skin for peristalsis. By the way, which hernias will show visible peristalsis? An early obstructed hernia, and a hernia with a thin covering as in a child or in recurrent hernias. Right, proceed. There is a distinct, visible expansile impulse on coughing. What does it mean? It means an uncomplicated inguinal hernia. Right, but what I want to know is what is an impulse on coughing? An abrupt increase in the size of the swelling or a momentary expansile bulge synchronous with the cough is termed as an impulse on coughing. The impulse should be looked for over the inguinal canal, over the external ring, and if a swelling be present over the swelling. When do you get no impulse on coughing in spite of the presence of an inguinal hernia? An obstructed hernia and sometimes in an omentocele due to adhesions of the omentum to the sac. On palpation, there is no local rise of temperature, no tenderness. It is not possible to reach the top of the swelling within the scrotum. What do you mean by getting above the swelling? It is the ability to reach the upper end of the swelling within the scrotum, that is ability to palpate only the cord structures between the thumb in front and index finger behind below the external ring. Inability to reach above the swelling means that this swelling is inguinoscrotal. The top of the swelling lies entirely above medial half of the inguinal ligament and pubic tubercle is palpable lateral to it. Thus ruling out. Femoral hernia which lies lateral to the pubic tubercle. If you had not done this test, would you have mistaken this swelling for a femoral hernia? No, sir, because this swelling is descending into the scrotum, which will never happen in a femoral hernia. If the swelling was not descending into the scrotum, then palpation of the pubic tubercle and its relation to the swelling would have been very significant. The swelling stops just above the testis, which can be felt separate from the swelling. Is it separate from the cord structures also? No, sir. It appears to be within the cord structures. Why do you say so? Because the cord structures are thickened even after reduction of the swelling. Any special tests to demonstrate the fixity to cord structures? No, sir. Traction test? Sir, traction test does not apply here as the swelling is reducible. What is the traction test? In a swelling closely related to the cord structures, when downward traction is applied to the testis, the swelling comes down and becomes fixed if it is attached to the cord. This is typically demonstrated in an encysted hydrocele of the cord. Right. The swelling is soft and elastic, no bag of worms feel. It is reducible with a What does the consistency of an inguinoscrotal swelling tell? Sir, soft and elastic in an enterocele, doey and granular or knotty in omentocele, bag of worms feel in a varicocele and cystic in lymph varices, hydrocele of the cord and bilocular hydrocele. Continue. It is reducible with a gurgling sound, reduction being difficult in the initial part and easy thereafter. Which is diagnostic of? Enterocele. In an omentocele, reduction gives no gurgling sound and the reduction of the last part is difficult. Why? Sir, the gurgling sound is due to displacement of gas in the intestines through the fluid contents of the ilium through the narrow neck of the hernia. In the enterocele, initial reduction is difficult as the intestines in the hernial sac are distended. But once the air and fluid is displaced into the abdominal coils, the collapsed bowel reduces quickly. While an omentocele tends to form adhesions within the sac, making reduction of its terminal adherent portion difficult. Which other inguinoscrotal swellings are reducible? Sir, varicocele and rarely lymph varices. But if after reduction, pressure is maintained over the external ring and patient is made to stand, these swellings are seen to fill up slowly from below, unlike the hernia which descends from above. There is a palpable expansile impulse on coughing over the external ring. Internal ring occlusion test is positive. How did you do the internal ring occlusion test? First, I reduced the swelling. How did you reduce the swelling? I kept the thigh flexed and internally rotated, so as to relax the pillars of the external ring. Then I placed one hand behind the scrotum and applied even pressure to the lower part of the swelling with the other hand anteriorly directed towards the external ring. After reducing the swelling, I kept my thumb over the midinguinal point, 1.25 cm above the inguinal ligament. Thus occluding the internal ring and then asked the patient to cough. Where is the mid-inguinal point? It is the point midway between symphysis pubis and anterior superior iliac spine. And how does it differ from the midpoint of the inguinal ligament? Sir, midpoint of the inguinal ligament is midpoint between pubic tubercle and anterior superior iliac spine, so it is situated below and lateral to the midinguinal point. Now, what is positive occlusion test? In an indirect inguinal hernia, which cannot come out when the internal ring is occluded, the test is considered as positive. In a direct hernia where the defect is in the posterior wall of the inguinal canal medial to the ring, the internal ring occlusion cannot control the hernia and the test is negative. What are the fallacies of this test? Firstly, when the internal ring has been stretched excessively by a large indirect hernia, the thumb cannot occlude the ring completely. So the hernia will come out by the side of the thumb and test will be falsely negative. Secondly, in a double hernia, that is a hernia with both direct and indirect components, the test will be negative in spite of presence of an indirect hernia. And lastly, if the pressure exerted by the finger is not sufficient, then the test again will be false negative. On invagination test, the external ring admits two fingertips, the finger goes upwards, backwards and outwards, superior ramus of os pubis is not bare. And on coughing, an expansile impulse is felt by the tip of the finger and sphincter strength of the conjoint tendon is good. How did you do this test? I first reduced the swelling, then I invaginated the skin of the scrotum over my index finger, starting at the bottom of the scrotum. First, I identified the pubic tubercle. Then I assessed the size of the external ring. External ring is dilated in any hernia that comes out of the inguinal canal. Then I entered the inguinal canal and noticed the direction in which the finger goes. It went upwards, backwards and outwards, that is along the inguinal canal. In a direct hernia, it passes directly backwards through the defect in the transversalis fascia in the posterior wall. Then I tried to palpate the superior ramus of pubis, which is difficult to palpate in an indirect hernia due to a strong transversalis fascia intervening. Lastly, I asked the patient to cough with my finger in the inguinal canal and notice two points. One, an expansile impulse which is felt by the tip of the finger, which in a direct hernia would have hit the pulp of the finger, and I noted the sphincter strength of the conjoint tendon contracting over my finger which was good. Yes, but this test should be done only if the patient is comfortable with it. If it is causing pain, then avoid it. On percussion, the swelling is resonant. On auscultation, no sounds were heard. The testis, epididymis and spermatic cord are normal. No evidence of hernia on the opposite side. No meatal stenosis or palpable stricture of urethra. The tone of the abdominal wall muscles is good. No undue protrusion of lower abdominal wall on standing. No Molgaigne's bulgings on Valsalva's maneuver or on raising the neck. Sphincteric strength of the conjoint tendon on invagination test is normal. What are Molgaigne's bulgings and what is their significance? Molgaigne's bulgings are longitudinal bulgings above the lateral part of the inguinal ligaments and the iliac crest on raising the neck from a lying down supine position or on Valsalva's maneuver, that is blowing against closed vocal cords. Their presence indicates that the obliques, the lower part of the obliques are weak. If the obliques have good tone, then abdominal wall is seen to be retracted and flat over the flanks. Significance? Sir, poor muscle tone is an indication for hernioplasty. On examination of the abdomen, there is no scar, no palpable lump, no distension, no evidence of free fluid. Genitalia are normal, no evidence of meatal stenosis or palpable stricture. On examination of chest, no evidence of chronic bronchitis. I would like to do per rectal examination for enlarged prostate. My diagnosis is left, uncomplicated, acquired, reducible, indirect, incomplete, inguinal enterocele with good abdominal muscle tone, and with strenuous work as the possible etiological factor. Yes, the diagnosis should be mentioned as right or left, uncomplicated or complicated, acquired or congenital, reducible or irreducible, direct or indirect, complete funicular or bubonocele, inguinal or femoral, enterocele or omentocele with good or poor abdominal muscle tone, and with straining factor if any. Now, what will you do for this patient? Sir, I would like to investigate, treat the straining factor if any and then operate. My investigations will be complete blood count, blood sugar, blood urea creatinine, X-ray of the chest and ECG. In an elderly patient, I will ask for ultrasound of the abdomen for enlarged prostate and then if needed, cystoscopy to rule out bladder outflow obstruction. If there is bladder neck obstruction, say enlarged prostate. Then I will advise the patient to get operated for the prostatic obstruction first and then subsequently for the hernia. And if the patient refuses operation for the prostate? I will refuse to operate on the hernia and convince him that the hernia will recur if straining factor is not removed. You don't operate, and if the hernia gets obstructed? Sir, obstructed hernia is an emergency and it has to be operated irrespective of any other factor or risk. Okay, if all these conditions are satisfied, and patient is fit for surgery, what operation are you going to do? Sir, this is an indirect hernia. So my plan for operation will be high ligation of the sac, narrowing of the internal ring, and posterior wall repair. The final choice of the type of repair will be decided on the operation table after the posterior wall and the defect are assessed. Currently, polypropylene, that is Proline mesh repair is usually preferred. And if the hernia is direct? Then I will push the bulging sac down and double breast the transversalis fascia in front of it. The operation of choice will be polypropylene mesh hernioplasty. Where else will you prefer a polypropylene mesh hernioplasty? In a recurrent hernia, in presence of very weak and thin wall muscles, and if the defect is very large. Do you know of any hernioplasty repairs which do not use polypropylene mesh? Sir, Mayor's Hernioplasty where an elliptical piece of skin over the incision is used like a mesh. Shouldice repair where transversalis fascia is dissected on both sides and double breasted using fine 20 Proline sutures. And Desarda's repair where a strip of the external oblique aponeurosis is sutured behind the cord to cover the posterior wall. Right. In an indirect hernia, the key step was high ligation of the sac and narrowing of the internal ring. Whereas, in a direct hernia, the key step is the repair and reinforcement of the transversalis fascia, that is the weakened posterior wall. Good. Thank you, sir.