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Home , Lumbar triangle, Obturator hernia, Spigelian hernia

Abdominal masses and . Objectives : The lecture had no slides So, this teamwork is from the Raslan’s Notebook

Sources : Raslan’s Notebook Color Index : Slides & Raslan’s | Textbook | Doctor’s Notes | Extra Explanation

2 Mind Map

Abdominal masses

RIGHT UPPER LEFT UPPER EPIGASTRIC RIGHT ILIAC FOSSA LEFT ILIAC FOSSA HYPOGASTRIC QUADRANT MASS QUADRANT MASS MASSES MASSES MASSES MASSES

Hernias

INGUINAL FEMORAL UMBILICAL AND INCISIONAL EPIGASTRIC RARE EXTERNAL METHODS OF PARAUMBILICAL HERNIA HERNIA HERNIA HERNIA HERNIAS HERNIA REP AIR

3 RIGHT UPPER QUADRANT MASS HEPATIC MASSES: GALLBLADDER MASSES • Congestive heart failure • Mucocele: Containing Mucus • Macronodular • Empyema: Containing pus • • Courvoisier law: • Hepatoma or secondary carcinoma If the gallbladder is palpable and the patient is jaundiced, the • Hydatid cyst obstruction of the common causing the jaundice is DDx • unlikely to be a stone because the previous inflammation will have • Riedel’s lobe: an extension of the right lobe down below made the gallbladder thick and non-distensible the costal margin along the anterior axillary line

• Can’t go above it, and moves with respiration • Moves with respiration • Dull to percussion up to the level of the 8th rib in the • Not dull because it is covered by the colon midaxillary line • It can be balloted i.e. felt bimanually • Edge: Sharp or rounded Sings

Physical • Surface: Smooth or irregular LEFT UPPER QUADRANT MASS SPLEEN ENLARGED LEFT KIDNEY • Typhoid • Myeloid and lymphatic leukemia • Tuberculosis • Spherocytosis • Syphilis • Thrombocytopenia purpura • Glandular fever • DDx • Malaria • True solitary cyst • Ka lazar • Hydatid cyst • Lymphoma • Appears from below the costal margin and enlarges towards the umbilicus 4 • Firm, smooth and has a defined notch on its upper edge • Cannot get above it, and dull on percussion Sings Physical EPIGASTRIC MASSES Cause CARCINOMA OF THE STOMACH PANCREATIC PSEUDOCUST • Abdominal pain/mass • Collection of pancreatic secretion, caused by , • on the surface of the pancreas or in part of the whole lesser • Loss of weight and appetite sac. DDx • There is history of followed by epigastric fullness, pain, and sometimes vomiting.

• When palpable it is hard and irregular and • Firm mass in the epigastric region with indistinct lower disappears below the costal margin i.e. cannot edge. get above it • The upper limit is not palpable. • Moves with respiration • Usually resonant because it is covered by the stomach • Moves very slightly with respiration Physical Sings RIGHT ILIAC FOSSAMASSES APPENDICULAR MASS APPENDICULAR ABSCESS TUBERCULOSIS • Central abdominal pain • As for with additional • Inflamed ileocecal lymph nodes, parts of shifting to the right iliac fossa symptoms of an abscess such as and the terminal and the cecum associated with nausea, fever, rigors, sweating and • Vague chronic central pain for months

DDx vomiting and loss of appetite increased local pain • General ill health and weight loss • The pain eventually becomes intense and settles in the iliac fossa

• Tender indistinct mass, dull to • A tender mass which in its late • The mass is firm, distinct and hard percussion and fixed to the stages may fluctuate and be • It is not tender and does not resolve with right iliac fossa posteriorly. associated with edema and observation reddening of the overlying skin Physical Sings 5 Continued: RIGHT ILIAC FOSSA MASSES CHRON’S DISEASE PSOAS ABSCESS OTHERS • Recurrent episodes of pain in the • General ill feeling for months, night • Cecal carcinoma right iliac fossa, malaise, loss of sweats and weight loss • Actinomycosis DDx weight and episodes of • Ruptured epigastric artery and . • Iliac lymphadenopathy • Iliac artery aneurysm • The elongated terminal ileum • Soft, tender, dull and compressible forms an elongated sausage- • There may be fullness in the lumbar shaped mass which is rubbery and region tender. • The swelling extends below the and it may be possible to Physical Sings empty the swelling. LEFT ILIAC FOSSA MASSES CARCINOMA OF THE SIGMOID COLON OTHERS • Recurrent lower abdominal pain and • General cachexia • Chron’s disease chronic for years • Lower abdominal pain associated with • Psoas abscess • The acute episodes starts suddenly with rectal bleeding

DDx severe pain, nausea, loss of appetite and • Change in bowel habits and sometimes (Same masses of the right constipation intestinal obstruction iliac fossa )

• Tender indistinct mass, with sings of • Hard mass, non tender general or local • May be mobile or fixed • The colon above the mass may be distended with indentable feces Physical Sings

6 HYPOGASTRIC MASSES

URINARY BLADDER FIBROIDS PREGNANT UTERUS

• Acute retention: the bladder is full and • They cause irregular and heavy • The uterus enlarges to the tender. periods, disturbed micturation, lower xiphisternum by the 36th

DDx • Chronic retention: Painless abdominal pain and backache week of pregnancy, at this • History of prostatism stage the fetus is palpable • A pregnant uterus is smooth, • Arises out of the and so it has no • Arises out of the pelvis and so the firm and dull lower edge lower edge is not palpable • Not mobile and dull to percussion • Firm or hard, moves slightly in • Direct pressure often produces a desire transverse direction and dull on to micturate. percussion Physical Sings

7 ABDOMINAL HERNIA

• DEFINITION: • COMPOSITION: • An abnormal protrusion of intra-abdominal contents through a defect in ü The sac: diverticulum of consisting the abdominal wall. of a mouth, , body and fundus • Protrusion of a viscus or part of it through an opening in the wall of its ü The body: varies in size and is not necessarily containing cavity. occupied • Abdominal hernias have a peritoneal sac, the neck of which is often ü The coverings: derived from the layers of the unyielding and constitutes a potential source of compression of the abdominal wall hernial contents ü The contents: may be omentum, bowel, ovary, • ETIOLOGY bladder... Etc • CONGENITAL DEFECTS: • COMMON CLINICAL PRESENTATION • Indirect , OF ABDOMINAL WALL HERNIA: • Patent processes vaginalis: almost always causes indirect inguinal hernia ü Swelling • ACQUIRED ü Reduction ü Site • Loss of tissue strength and elasticity, due to aging or repetitive stress: ü • ABDOMINAL WALL SITES: • Operative Trauma, in which normal tissue strength is altered surgically: ü Mid-line ü ü Umbilical area • Increased intra-abdominal pressure: ü Inguinal region ü Heavy lifting ü Femoral canal ü Coughing, asthma, and COPD ü Para-median lineObturator ü Straining at defecation or urination (e.g. Benign prostatic ü Lumber area hypertrophy, constipation, colon/rectal cancer) ü Obturator foramen ü Multiparity (Multiple pregnancies) ü Incisional or scar line ü Ascites and abdominal distension o Obesity 8 CLASSIFICATION remain constantly remain constantly IRREDUCIBLE The contents IRREDUCIBLE IRREDUCIBLE constantly The contents The contents REDUCIBLE outside remain outside outside The contents of the sac are reduced spontaneously or manually INFLAMED STRANGULATED INCARCERATED OBSTRUCTED • • • • • • • • • • • • • • • • • • Rare , due rpe r imprisoned Trapped or Blood supply remains intact obstruction presents with distention and constipation obstruction presents with pallor and vomiting intestine Contains obstructed Nausea, vomiting, and symptoms of (possible). Blood supply remains intact denote obstruction Does not spontaneously or manually). Initially it is reducible, then it becomes irreducible => cannot be reduced (either The constricting agents that compress the blood supply are: (In order of rigid surroundings The is the most liable to strangulation due to its narrow neck and its persist after reduction. Strangulation is probable if pain and tenderness of an incarcerated hernia Symptoms of an incarcerated hernia present combined with a toxic appearance. Gangrene may occur within 5 Blood supply is seriously impaired rendering the contents ischemic Likely in hernias with narrow A surgical emergency ü ü ü ü ü ü ü Absent cough impulse (non Tense and tender Signs Sudden pain over the hernia o Nausea and vomiting Adhesions with the sac (rare) Symptoms External ring in children The Neck to inflammation on the sac contents, e.g. acute appendicitis or i - 6 hours after the inset of symptoms expansile ) i Salpingitis frequency) 9 SURGICAL (Just for your information) • Superficial ring: triangular aperture in the external •In males, it contains oblique aponeurosis 1.25 cm above the pubic tubercle üThe ilioingunal nerve • Deep ring: U-shaped condensation of the transversalis üThe spermatic cord and its contents, which are fascia 1.25 cm above the inguinal ligament oGenital branch of the genitofemoral nerve • The inguinal canal: oTesticular artery üIn infants the two triangular aperture are oPampiniform plexus of veins superimposed and the canal is slightly oblique oCremasteric muscle fibers üIn adults it is 3.75-4 cm long oCremasteric vessels üIn females, it contains the round ligament of the oVas deferens uterus Contains the spermatic cord and round •Boundaries of the inguinal canal ligament of the uterus üAnteriorly: external oblique aponeurosis üPosteriorly: facia transversalis and conjoined tendon üSuperiorly: internal oblique aponeurosis üInferiorly: inguinal ligament

10 INGUINAL HERNIA The most common form of hernia in both sexes Subdivided into direct and indirect in adult males it is most commonly indirect

• INDIRECT (OBLIQUE) INGUINAL HERNIA • Most common of all forms at all age groups • The male: female ratio is 20:1 • Travels down the inguinal canal on the outer side of the spermatic cord • Its neck lies lateral to the inferior epigastric vessels • Pantaloon (Saddlebag) hernia is the simultaneous • Can be due to a congenital lesion i.e patent processus vaginalis occurrence of a direct and an indirect hernia. • Strangulation is common, but less than in femoral hernia It causes two bulges (medial and lateral) that straddle the inferior epigastric vessels • Seen in young patients • Hasselbach’s triangle is bounded by: i • In adult males ü Inguinal ligament inferiorly ü Mostly on the right side because of delayed decent of the right ü Inferior epigastric artery laterally testicle ü Lateral border of rectus muscle medially ü 12% bilateral • DIRECT INGUINAL HERNIA • Comes out forward via the posterior wall of the inguinal canal at Hasselbach’s (i.e. inguinal) triangle due to a defect or weakness of the facia transversalis • Always acquired, never congenital • It has a wide neck and therefore there is no hazard of strangulation • The neck is medial to the inferior epigastric vessels • Does not attain a large size

11 INGUINAL HERNIA

Clinical presentation Groin pain referred to the testicle Cough impulse (Expensile) A large hernia causes dragging pain Presents as a swelling or fullness at the hernia site Aching sensation (radiates into the area of the hernia) No true pain or tenderness upon examination Enlarges with increasing intra-abdominal pressure and/or standing Differential diagnosis • Hydrocele • Saphena varix (dilation of the saphenous vein at • Encysted hydrocele of the cord its junction with the femoral vein in the groin) • Varicocele • Spermatic cord lipoma • Epididymoorchitis • Inguinal lymphadenopathy Psoas abscess • Undescended testis • Cutaneous lesions, e.g. sebaceous cyst, skin • Ectopic testis tumor. • Testicular tumor • Pseudohernia • Femoral artery aneurysm Treatment Surgical repair: open vs laproscopic

Essential steps for the Complete division of the external oblique aponeurosis and the inguinal hernia repair Differentiation between indirect and direct defects Isolation of the spermatic cord Ligation and removal of the sac at the deep inguinal ring flush with peritoneum Oblique reconstruction of the inguinal canal with an anterior and posterior wall and an internal and external ring

12 • FEMORAL HERNIA • UMBILICAL AND PARAUMBILICAL HERNIA • Commonly affecting females i • Umbilical hernia is seen in infants and children • Most liable to strangulationi • The female: male ratio is 20:1 • • The hernia descends vertically to the saphenous opening Paraumbilical hernia (PUH) affects adults. • The defect is either supra or infraumbilical through the linea • Surgical anatomy alba Boundaries of the femoral sheath • When enlarged, it becomes rounded or oval shaped • May contain omentum, small intestine or transverse colon ü Anteriorly: inguinal ligament ü Posteriorly: Iliopectineal ligament, pubic bone and pectineus • Etiology muscle fascia ü Obesity ü Medially: lacunar ligament ü Flabbiness of the abdominal muscles ü Laterally: femoral nerve ü Multiparity • The femoral canal • Clinical Features The most medial compartment of the femoral sheath ü Irreducibility in PUH is due to omental adhesions within the sac Extends from the femoral ring to the saphenous opening • Pain may be colicky due to parital or complete intestinal 1.25 cm long and 1.25 cm wide at the base obstruction Contains fat, lymphatic vessels and the lymph node of Cloquet • Treatment: Open (Mayo’s repair) or laproscopic repair (if • Differential diagnosis o femoral hernia the defect is more than 4 cm) ü Inguinal hernias are located above and medial to the ü inguinal ligament and pubic tubercle, whereas femoral hernias are located below and lateral to the inguinal ligament and •EPIGASTRIC HERNIA pubic tubercle i • Due to a defect in the linea alba between the xiphoid process and the umbilicus ü Saphena varix • Starts as a protrusion of the extraperitoneal fat at the site where a ü Femoral lymphadenopathy small blood vessel pierces the linea alba ü Femoral artery aneurysm o Psoas abscess • If the protrusion enlarges, it drags a pouch of peritoneum after it • Complications: •· Clinical features Strangulation due to a narrow unyielding femoral ring ü May be asymptomatic or painful, either locally or simulates peptic ulcer pain Treatment: Surgical repair • Treatment: Mayo’s repair 13 INCISIONAL HERNIA •Occurs in surgical scars and it has no actual neck (or its neck is • Occurs at the space between the semilunar line and the lateral adge of wide), so it does not lead to complications the rectus muscle (Inferior to the arcuate line) Causes • The posterior recuts sheath is lacking which contributes to the inherent • Mechanical factors (increase in weakness in this ares • Preoperative diagnosis is correct in only 50% of patients intraabdominal pressure postoperatively) • US and CT scan are helpful to confirm the diagnosis ü Prolonged § ü Chronic cough • Approximation of the tissues adjacent to the defect with interrupted ü Repeated vomiting sutures is curative. ü Lifting heavy objects in the immediate postoperative • If the defect is large, it can be covered with mesh period • Patient factors LUMBAR HERNIAS ü Infection • Broad bulging hernias ü Malnutrition • Usually don’t get incarcerated ü Diabetes and chronic illness ü Steroid treatment • Petit’s hernia • Technical factors Occurs in the inferior lumbar triangle which has the following boundaries ü Too much tension on closure, or closure with ü Laterally: external oblique muscle § عdorsi latissimus ü Medially: sutures absorbable ü Ischemia ü Inferiorly: ü Clinical features: swelling at the scar associated • Grynfeltt’s hernia Less common sometimes with pain • Occurs in the superior lumbar triangle which is bounded: § ü Treatment: Open or laparoscopic repair ü Superiorly: inferior margin of the 12th rib ü Medially: sacrospinalis muscle • The obturator canal is covered by a membrane pierced by the ü Laterally: internal oblique muscle obturator nerve and vessels. Weakening of the obturator •SLIDING HERNIA membrane and enlargement of the canal may result in the • formation of a hernia sac. Which can lead to intestinal It is a hernia in which part of the posterior wall of the sac is formed by a herniation and obstruction viscus (intraabdominal organ), e.g. sigmoid colon, cecum, ovary or portion of • Presentation could be with evidence of compression of the the bladder • obturator nerve leading to pain in the medial aspect of the thigh The wall of the hernial sac, rather than being formed completely by peritoneum, is in part formed by a retroperitoneal structure • Treated by surgery 14 • Bladder slides posterio-medially (PM) and the colon posterio-lateral (PL) RARE EXTERNAL HERNIAS

LUMBAR HERNIAS • Broad bulging hernias • Usually don’t get incarcerated •SLIDING HERNIA • Petit’s hernia •It is a hernia in which part of the posterior wall of the sac is Occurs in the inferior lumbar triangle which has the following boundaries formed by a viscus (intraabdominal organ), e.g. sigmoid ü Laterally: external oblique muscle colon, cecum, ovary or portion of the bladder ü Medially: latissimus dorsi • The wall of the hernial sac, rather than being formed completely by peritoneum, is in part formed by a ü Inferiorly: iliac crest retroperitoneal structure • Grynfeltt’s hernia Less common • Bladder slides posterio-medially (PM) and the colon • Occurs in the superior lumbar triangle which is bounded by: § posterio-lateral (PL) ü Superiorly: inferior margin of the 12th rib ü Medially: sacrospinalis muscle ü Laterally: internal oblique muscle

SPIGELIAN HERNIA OBTURATOR HERNIA • Occurs at the space between the semilunar line and the lateral edge of • The obturator canal is covered by a membrane pierced by the rectus muscle (Inferior to the arcuate line) the obturator nerve and vessels. Weakening of the obturator • The posterior recuts sheath is lacking which contributes to the inherent membrane and enlargement of the canal may result in the weakness in this area. formation of a hernia sac. Which can lead to intestinal • Preoperative diagnosis is correct in only 50% of patients herniation and obstruction • US and CT scan are helpful to confirm the diagnosis • Presentation could be with evidence of compression of the obturator nerve leading to pain in the medial aspect of the • Approximation of the tissues adjacent to the defect with interrupted sutures is curative. thigh • Treated by surgery • If the defect is large, it can be covered with mesh

15 Other Hernias

1.Richter’s hernia 3. Divarication (Separation) of the recti A. It is a hernia at ant site in which only part of the abdominis (Diastasis recti) circumference of the A. Only a facial weakness, not a true hernia B. bowel (usually ) is involved B. Seen more in elderly multiparous patients C. Only one side of the bowel wall is trapped in the C. A gap in the linea alba (medial margin of the recti) seen on hernia, rather than straining through which the abdominal contents bulge. D. the entire loop of bowel. D. No treatment is necessary E. Does not usually obstruct but can strangulate or become F. incarcerated 4. Perineal Hernias G. This is especially dangerous because the Occur in the usually after surgical procedures such as an incarcerated portion of abdominoperineal resection. H. bowel can necrose and perforate in the absence of obstructive symptoms. 5. Peri- or para-stomal Hernia Hernia adjacent to an ostomy “e.g. colostomy”. 2.Littre’s Hernia A. Any groin hernia that contains a Meckel’s 6. Amyand’s Hernia Diverticulum, Hernia sac containing a ruptured . B. Rare. C. Usually incarcerated or strangulated 7. Hesselbach’s Hernia D. If the diverticulum is symptomatic or Hernia under the inguinal ligament lateral to femoral vessels. strangulated, it is mandatory to excise it at the time of repair. 8. Cooper’s Hernia Hernia through the femoral canal & tracking into the scrotum or labia majus.

16 METHODS OF HERNIA REP AIR PHYSICAL EXAM •Examine the patient in the standing and supine positions. OPEN TECHNIQUE (HERNIOTOMY AND •Examine the patient from the front REPAIR) Inspection • Bassini repair •lump: site shape • Draning •scrotum: does it extend to the scrotum • Shouldice Palpation • McVay (Cooper’s ligament repair) •Ask the patient about pain before you palpate • Mesh (i.e. hernioplasty) •Can you go above it •Can you palpate the testis LAPAROSCOPIC REPAIT •If it is a hernia type • Two types •Define pubic tubercle 1. TAPP (transabdominalpreperitoneal)repair Feel from the sides 2. TEP (totallyextraperitoneal)repair •Aim to examine the lump. •Tenderness, temperature, size ,shape, site, composition • Indicated in only two conditions: •Reducible. Ask the pts if you couldn’t v Bilateral hernia •Controlled when you pressure over deep inguinal ring. v Recurrent hernia •Expensile cough impulse. HISTORY •Direction of reappearance. Investigations LUMP CBC • duration, first symptoms, associated symptoms, Leukocytosis may occur with strangulation. progression, persistent ,other sites ,cause Assess the hydration status of the patient with nausea and vomiting. • Does it reduce on lying down? Urinalysis: narrowing the differential diagnosis of genitourinary causes • Has there been an episode of pain in the swelling? of groin pain • Has there been an episode of abdominal pain? Imaging studies: • Does the patient have any febrile symptoms? maging studies are not required in the normal workup of a hernia. Ultrasonography.(obese) HISTORY OF RECTAL BLEEDING If an incarcerated or strangulated hernia is suspected: • Causes of increase of intrabdominal pressure. Flat and upright abdominal films to diagnose a small bowel obstruction. • Previous surgeries? 17 MCQs From 432 team..

Answer Key 1:D 2:D 3:E 4:D 5:A 6:C 7:B 8:E 9:B 10:C 11:A Thank You.. Done By : Felwa Al-Harthi Nada Dammas Revised By: Mohammed Al-Nafisah

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