How to Treat – |
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from page 22 gery for a small lipoma and other superficial lumps in the office under local anaesthesia but, if there is any doubt, theatre is preferred.
Indications for surgery Previous studies suggested small asymptomatic hernias could be safely left alone without surgical treatment, and the results at
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three years confirmed this suggestion. 18 However, a seven-year follow-up revealed hernias in these patients were growing and becoming symptomatic, and surgery was then performed in well over half of the patients. 18 It might thus be concluded that surgery should be performed on most inguinal hernias.
Table 3 summarises the treatment of groin conditions.
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The future THERE are regular innovations in hernia surgery, including a vast array of meshes and the use of glue or absorbable staples to fix the mesh into position. These are all aimed at reducing the risk of acute and chronic pain following surgery, reducing infection, time in hospital and recurrence rate.
Key points
• An ordered history and examination will produce an appropriate plan of action for a diverse group of groin and scrotal conditions. With any groin problem, always examine both groins and, in males, both scrotums.
• Always consider malignant nodes, malignant testis, strangulated hernia, undescended testis or torsion of the testis. Rapid intervention may be required.
• With any acute abdominal problem always consider the possibility of a strangulated femoral hernia.
• Consider the early use of taxis to reduce early strangulated hernias. If this is successful, you must still observe the patient.
• Remember that ultrasound does not replace clinical assessment and judgement when diagnosing or managing hernias, occult hernias and sportsman’ s groin.
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Case study |
MARGE, 78, presents with a swelling in her left groin and a hernia is diagnosed.
After considering her age, medical condition, the easy reducibility of the hernia and her lack of other symptoms, her surgeon recommends conservative management and observation.
Three months later, Marge presents to the emergency department. Her surgeon notes Marge is in severe pain and is pointing at her left groin.
On examination, the hernia is larger but reducible, and the area is tender. There is no rash noted. The surgeon is puzzled but organises
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surgery and performs a repair with mesh reinforcement under local anaesthesia and light sedation. There is no evidence of strangulation during surgery, which only deepens the puzzle.
Marge has significant postoperative pain requiring narcotics. Two days later she develops a rash, which is diagnosed as shingles. She has a history of chicken pox as a child. Her recovery is then uneventful and the hernia repair is a success.
Shingles can often be diagnosed by the unilateral location of the pain, in a band distribution following the nerve.
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Figure 16. A lymphocele that developed after groin dissection for a melanoma. |
Shingles in the left groin. |
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1. Which THREE conditions occur commonly in the groin? a) Inguinal hernia b) Abscess c) Spigelian hernia d) Enlarged lymph nodes
2. Which THREE statements are correct? a) A saphena varix has fluid thrill on coughing and is compressible when standing. b) A neuroma is fusiform and mobile in at least two directions. c) Myositis ossificans results in a bony hard lesion following repeated injury. d) A sebaceous cyst has a punctum and is attached to the skin.
3. Which TWO are differential diagnoses of a groin lump? a) Femoral artery aneurysm b) Lipoma c) Varicocele d) Hydrocele
4. Which THREE statements regarding hernias are correct? a) Examine the patient supine, with their knees
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bent and feet on the couch, to allow for relaxation of the abdominal muscles. b) The irreducible hernia must be differentiated from other groin lumps, such as nodes or an abscess. c) A femoral hernia is lateral to the pubic tubercle and below the inguinal ligament. d) It can be difficult to distinguish a femoral hernia from an enlarged inguinal lymph node, or an abscess.
5. Which TWO statements regarding conditions of the scrotum and testis are correct? a) The testis is oval and situated posterior to the epididymis, with its long axis vertical. b) A varicocele is an abnormally dilated plexus of veins, which may cause aching. c) Cysts transilluminate except where the contained fluid is opaque. d) The terms hydrocele and epididymal cyst are interchangeable.
6. Which TWO statements regarding conditions of the testis are correct? a) Any hard lump or thickening in or on the surface of the testis should be considered a
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carcinoma until proven otherwise. b) The risk of malignancy is increased with an undescended testis even when the testis has been placed into its correct position. c) Surgical exploration for a suspected torsion of the testis should be delayed while waiting for an ultrasound or tests. d) Epididymo-orchitis is generally asymptomatic and is an incidental finding.
7. Which TWO statements regarding groin pain are correct? a) Sportsman’ s groin or sports hernia is common in soccer players, footballers and athletes. b) There are no algorithms or guidelines for investigation and management of groin pain. c) Femoral head conditions such as femoral acetabular impingement may present with groin pain. d) Ultrasound does not reveal any abnormalities.
8. Which THREE roles does ultrasound play in the investigation of groin pain and groin lumps? a) To make a diagnosis of hernia in the
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absence of other clinical features. b) Differentiating inguinal from femoral hernias or from other groin lumps such as nodes or abscess. c) Differentiating solid masses from cystic. d) Identifying whether there is blood flow in the testis.
9. Which TWO conditions are treated with aspiration or excision? a) Torsion of hydatid cyst of Morgagni. b) Epididymal cyst. c) Hydrocele. d) Epididymo-orchitis.
10. Which THREE statements regarding the management of groin lumps and pain are correct? a) Local lymph node excision may be complicated by a lymphocele. b) Torsion of the testis requires emergency orchidectomy. c) Varicoceles may be treated with either ligation or embolisation. d) A team approach using radiotherapy and chemotherapy has produced gratifying results in malignancy of the testis.
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CPD POINTS |