Posts Tagged → Hernia

Abdominal Wall Hernias

Inguinal hernia CTHPI:

23M w/no known medical history presenting with abdominal “ball” x10d. Patient denies pain, and is tolerating regular diet w/o N/V. Reports lifting weights.

PMH/PSH/FHx/SHx:

None, non-contributory, no t/e/d.

Meds:

Acetaminophen, NKDA

PE:

  • VS:     T N/A      HR 86     RR 18       BP 116/64      O2 N/A
  • Gen: Well-appearing young male, no acute distress
  • HEENT: PERRL, MMM no lesions
  • CV: RRR, normal S1/S2, no murmurs
  • Lungs: CTAB, no crackles/wheezes
  • Abd: +BS, soft, NT/ND, 3cm bulge in right inguinal region with valsalva, above inguinal ligament, ~7cm lateral to symphysis, non-tender, reduces spontaneously after valsalva GU: uncircumcised penis, testes descended b/l, normal size, non-tender, no herniation through inguinal canal palpated with valsalva
  • Ext: Warm, well-perfused, 2+ peripheral pulses
  • Neuro: Alert and oriented, appropriate

Assessment/Plan:

23M ċ inguinal hernia, currently asymptomatic with no evidence of incarceration/strangulation. Recommend follow-up at city hospital for evaluation and possible surgical repair. Advised to refrain from strenuous activity, heavy lifting.

Physical Examination Techniques: 1

Physical Examination Techniques

  • Observation: Best performed with patient standing and physician seated on a stool facing the patient
  • Palpation: place hand over patient’s groin (see figure), with two fingers each superior and inferior to the inguinal ligament. Have the patient cough and feel for a palpable bulge or impulse.
  • GU: With a finger in the inguinal canal, bulges felt against the side of the examining finger are direct hernias, while those felt at the tip of the finger are indirect.

Types of Abdominal Wall Hernias: 2

Types of abdominal wall hernias

Name Location Etiology/Epidemiology
1. Umbilical Linea alba through weakened umbilical ring.Paraumbilical hernias through linea alba in the region of the umbilicus. Congenital or acquired due to increased intra-abdominal pressure (obesity, pregnancy, ascites, PD)
2. Epigastric Linea alba between umbilicus and xiphoid process Congenital weakness of linea alba (lack of decussating fibers)
3. Spigelian Semilunar line: along the lateral borders of rectus abdominus. Herniation typically occurs caudally (below arcuate line) due to absence of posterior rectus sheath.
4. Incisional Site of prior incision Poor fascial healing possibly due to: infection (increased risk in wound dehiscence), obesity, smoking, immunosuppression excess wound tension, CT disorders.
5. Inguinal Indirect: internal (deep) inguinal ring, lateral to inferior epigastric vessels.Direct: external (superficial) inguinal ring, medial to inferior epigastric vessels. Indirect > direct.
6. Femoral Inferior to the inguinal ligament, through empty space medial to femoral sheath. F > M, increased likelihood of incarceration/strangulation (40%)
7. Lumbar 3 Arise in two anatomical triangles:Superior lumbar triangle – lateral border internal oblique, medial border erector spinae, superior border 12thrib.Inferior lumbar triangle – lateral border external oblique, medial border latissimus dorsi, inferior border iliac crest. (See figure) Associated with surgery (incisional), typically urologic.
8. Obturator Protrusion of peritoneal sac through obturator foramen. Rare, occur primarily in elderly women (high predisposition for incarceration).

Locations of Abdominal Wall Hernias:

Locations of abdominal wall hernias

Layers of the Anterior Abdominal Wall:

abdominal_wall

Differential diagnosis for groin masses: 4

Category Inguinal 5 Scrotal 6 Vulvar 7 Perineal 8
Vascular Varicocele extension Varicocele Vulvar varicocity

Hemangioma
Infectious, Inflammatory Lymphadenopathy
Abscess
Inflammatory joint process (hip, related bursae)
Thrombophlebitis		 Epididymitis
Epididymo-orchitis		 Condyloma
Molluscum
Bartholin’s cyst
Neoplastic Benign (lipoma)
Lymph node metastatsis		 Testicular malignancy Malignant skin lesions Soft-tissue malignancy
Anal SCC
Rectal GIST
Metastasis (commonly anorectal, prostatic)
Congenital, Anatomic Hernia
Testis (undescended, retracted)		 Epididymal cyst
Spermatocele
Hydrocele		 Embryological remnants (mucocele)
Traumatic Hematoma
Aneurysm (complication of catheterization)		 Hematoma Hematoma

Locations of Groin Masses: 9

Locations of groin masses

References:

  1. Amerson JR. Inguinal Canal and Hernia Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 96. Available from: http://www.ncbi.nlm.nih.gov/books/NBK423/
  2. Aguirre, D. A., Casola, G., & Sirlin, C. (2004). Abdominal Wall Hernias: MDCT Findings. American Journal of Roentgenology, 183(3), 681–690. doi:10.2214/ajr.183.3.1830681
  3. Guillem, P., Czarnecki, E., Duval, G., Bounoua, F., & Fontaine, C. (2002). Lumbar hernia: anatomical route assessed by computed tomography. Surgical and radiologic anatomy : SRA, 24(1), 53–56.
  4. Roberts, J. R., & Hedges, J. R. (2010). Clinical procedures in emergency medicine. (5th ed., Vol. section 7, p. Ch. 44). W B Saunders Co. Retrieved from http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4160-3623-4.00044-4
  5. Shadbolt, C. L., Heinze, S. B., & Dietrich, R. B. (2001). Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics : a review publication of the Radiological Society of North America, Inc, 21 Spec No, S261–71.
  6. Eyre, RC. Evaluation of nonacute scrotal pathology in adult men. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2013.
  7. Foster, D. C. (2002). Vulvar disease. Obstetrics and gynecology, 100(1), 145–163.
  8. Tappouni, R. F., Sarwani, N. I., Tice, J. G., & Chamarthi, S. (2011). Imaging of unusual perineal masses. American Journal of Roentgenology, 196(4), W412–20. doi:10.2214/AJR.10.4728
  9. Collins, R. (2008). Differential diagnosis in primary care. Philadelphia: Lippincott Williams & Wilkins.