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Groin Hernias and Masses, and Abdominal Hernias

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Groin Hernias and Masses, and Abdominal Hernias 27 Groin Hernias and Masses, and Abdominal Hernias James J. Chandler Objectives 1. To be able to discuss the differential diagnosis of inguinal pain and the diagnosis and management of groin masses and hernias. 2. To develop an understanding of the anatomy, loca- tion, and treatment of different types of hernias; this includes the frequency, indications, surgi- cal options, and normal postoperative course for inguinal, femoral, and umbilical hernia repairs. 3. To understand the definition and clarification of the clinical significance of incarcerated, strangu- lated, reducible, and Richter’s hernias. 4. To develop an awareness of the urgency of surgi- cal referral, the urgency of treating some hernias. 5. To develop an understanding of the differential diagnosis of an abdominal wall apparent hernia or mass, including adenopathy, desmoid tumors, rectus sheath hematoma, true hernia, and neoplasm. Cases Case 1 A 74-year-old woman has noted an intermittent small lump in the right groin for 8 months. This has seemed to go away when she lies down, but it is present when she showers in the morning. Two nights ago, she could feel the lump when supine. It was slightly tender. Yesterday, she began feeling a steady ache in the groin and had poor appetite. The discomfort became worse, and she slept fitfully last night. This morning she felt awful, had a lemon-sized tender right groin mass, and had nausea and some diarrhea. You found her moaning, holding her distended abdomen, and trying to vomit. On examination, there were intermittent 479 480 J.J. Chandler gurgles heard in the abdomen, and a slightly pink, skin-covered, very tender lump was present in the right groin. Abdominal x-ray: dilated intestinal loops with air-fluid levels. Laboratory studies: hemoglobin, 14.6; BUN, 24; electrolytes normal; urine specific gravity, 1.028. Case 2 A male college student, age 20, presents with a 4-year history of inter- mittent soft mass in his groin and a large lump in the right side of the scrotum, which is now uncomfortable. He does not notice any groin mass on awakening, but he becomes aware of the groin and scrotal masses later in the morning, toward noon. Definitions A hernia is present when an object goes through an opening and is now in any unexpected location. There may be a covering of the object; this covering, called the sac, usually is the peritoneum. An organ, a portion of omentum, or part of the intestine, bladder, or stomach may herniate through an opening in the abdominal wall or diaphragm. This has occurred in both Case 1 and Case 2. A femoral hernia, much more common in women, presents through the femoral canal, and an indirect inguinal hernia protrudes through the abdominal wall in the spermatic cord or alongside the round liga- ment. Pediatric inguinal hernias are indirect. Direct inguinal hernias are rare in females and in males younger than 35 years of age. An internal hernia occurs when the intestine goes through an opening inside the abdominal cavity. In a Richter’s hernia (Case 1), only a part of the intestinal wall, covered by a sac formed by the overlying peritoneum, protrudes through an opening (usually in the femoral canal), and the intestinal lumen remains open. In Case 1, the woman has both a lump in the groin and not complete intestinal obstruction, meaning that she could have a knuckle of bowel wall caught in an opening but with an open lumen, as in a Richter’s hernia. This patient is dehydrated and seriously ill! (See Algorithms 27.1 and 27.2.) If an organ or a portion of the intestine uncovered by peritoneum protrudes through and forms part of the hernia sac, this is called a sliding hernia. When an intestinal loop comes out through an opening and this hernia does not go back by itself or cannot be gently pushed back, the hernia cannot be reduced. The hernia is incarcerated. When part of the intestine (or stomach) is incarcerated, there can be a shut- ting off of the venous drainage and/or the arterial circulation; this is now a strangulated hernia. Gangrenous changes develop, leading to possible perforation and possible death. Groin Masses: Differential Diagnosis These are the differential diagnoses for groin masses. • Inguinal hernia: Protrudes through the internal ring, at the level of the public tubercle; exits via the external ring (see Algorithm 27.1). 27. Groin Hernias and Masses, and Abdominal Hernias 481 Immediate surgical Groin mass Painful referral Not reducible Reducible: it is a hernia Tender, looks Not tender Pulsatile like hernia Patient stands and strains Hard Soft ? Cancer Bulge near level of pubic Bulge next to femoral tubercle—inguinal artery—femoral Vascular— surgical referral now Surgical Surgical referral now Tender: referral looks like lymph node Surgical referral Algorithm 27.1. Algorithm for the evaluation of groin masses. There may be a sausage-shaped mass going all the way down into the scrotum, as in Case 2. • Femoral hernia: Bulge/mass appears medial to the femoral vein (see Algorithm 27.1), can rise higher, and can be difficult to distinguish from an inguinal hernia. • Lymph node mass: This does not disappear with pressure on it. This usually is a nontender mass that is firm, overlying the femoral artery. Lymph nodes may be inflamed and tender from infection or enlarged and firm because of cancer, a lymphoma, or metastatic cancer (see Algorithm 27.1). Femoral History and physical Possible femoral hernia Reduces spontaneously Does not reduce Surgical referral soon Immediate referral Algorithm 27.2. Algorithm for the evaluation of likely femoral hernia. 482 J.J. Chandler • Varicocele: Irregular, nontender type lump palpable in the spermatic cord superior to the left testicle. If diagnosis is uncertain, order duplex color-coded ultrasonography. • Hydrocele: “Water sac.” A fluid-filled membrane, around or above the testicle, which may extend up into the inguinal canal and may communicate with a hernia sac. A hydrocele can be transilluminated by holding a flashlight behind it. • Femoral artery aneurysm: Pulsatile, expansile mass. Refer for vas- cular surgery, now! • Psoas muscle abscess: Rare. Formerly more common when due to tuberculosis. Pus in the muscle sheath dissects inferiorly and bulges into the groin. If due to staphylococcus, patient is very ill and febrile, and the mass is acutely tender. • Tumor (benign) of spermatic cord: A fibroma is firm, nontender, and can be moved a little to the side, in the inguinal canal. • Seroma: Collection of serum in the groin. Edges are poorly defined. These generally follow a groin-area surgical procedure, such as groin dissection or arterial surgery. Hematomas are fairly common after hernia repair, but large ones are rare. • Abscess: This would be unlikely unless following a surgical proce- dure. Tender, warm skin overlying. • Cryptorchid: An undescended testicle. Duplex ultrasonography diagnosis it. See Algorithm 27.3 for a general workup for an abdominal or groin lump/mass. Anatomy of the Groin The layers of tissue found in the lower abdomen are the external oblique muscle, internal oblique, transversus abdomen, transversalis fascia, preperitoneal fat, and peritoneum (Fig. 27.1). History of abdominal of groin lump/mass Physical exam Groin Abdominal Consider CTs See Algorithm 27.2 Intraabdominal Abdominal wall? Surgical referral Surgical referral Algorithm 27.3. Algorithm for general workup for abdominal or groin lump/mass. 27. Groin Hernias and Masses, and Abdominal Hernias 483 External oblique m. Ant. rectus sheath Internal oblique m. Rectus abd. m. Peritoneum Post. rectus sheath Transversus abd. m. Transversalis fascia A Anterior rectus sheath Rectus abdominis m. B Figure 27.1. Abdominal wall layers: (A) above the semilunar line of Douglas; (B) below the semilunar line. (Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.) The inguinal canal courses obliquely from the internal ring opening in the transversalis fascia to the pubic bone and the external ring opening in the external oblique. The spermatic cord in the male comes through the internal ring; the external ring is where the spermatic cord exits to head down into the scrotum. Included in this “cord” are super- ficial and external spermatic fascial layers, cremaster muscle, external spermatic artery (in the cremaster), internal spermatic fascia, vas def- erens, testicular artery, pampiniform plexus of little veins, and some sympathetic fibers. The genital branch of the genital femoral nerve, often said to be in the spermatic cord, actually courses through the internal ring in the edge of posterior cremaster fibers and easily is sep- arated from the cord. This nerve lies posterior to the cord with its accompanying vessels in the inguinal canal. The boundaries of the inguinal canal are the transversalis fascia posterior, external oblique 484 J.J. Chandler anterior, internal oblique muscle and rectus sheath superior, inguinal ligament inferior, pubic bone medial, and internal ring lateral. See Figure 27.2 for the relationships of the inguinal canal. A hernia going through the internal ring, outside the inferior epi- gastric artery, and inside the spermatic cord courses obliquely with the cord and is termed an indirect inguinal hernia (Case 2). A protrusion through thinned-out transversalis fascia comes straight out through the abdominal wall and is called a direct inguinal hernia, which is medial to the inferior epigastric artery. These hernias bulge through Hesselbach’s triangle, which is bounded by the rectus sheath, inguinal ligament, pubis, and inferior epigastric artery (Fig. 27.3). A hernia pre- senting through both the internal ring and Hesselbach’s triangle is termed a pantaloon hernia, with a “leg” of the hernia coming out on both sides of the inferior epigastric artery.
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