40 years old lady complaining of Para umbilical hernia,examine her abdomen?

1
40 years old lady complaining of Para umbilical
hernia,examine her abdomen?
Station 1
2

• 1)Position .
• 2)Shape and size.
• 3)Surface and edge.
• The surface is smooth and edge easy to define,
  except when the patients abdominal wall is very
  fat. try to feel the upper border of the mass (to
  get above it)scrotal neck test
• 4)Composition.
• The lump is firm as it usually contains omentum
  . If it contains bowel, it is soft and resonant
  to percussion.it will be reducible unless the
  contents are adherent to the sac or the defect is
  very narrow. also auscultate for bowel sounds.
• 5)Cough impulse.
• 2 times ex the cough impulsive first time with
  inspection ,and second with palpation

3

• 6)Relations to skin (overlying skinred.)
• 7)Ask patient to reduce the mass herself
• 8)Perform deep ring test to differentiate
  indirect from direct.
• 9)General examination ( respiratory ,
  cardiovascular, abdominal masses, ascites, PR
  for BPH)

4

• Scrotal neck test
• thumb ant, index and middle post to scrotal
  base, try to feel the cord. If palpablegtgtits a
  scrotal mass, not palpablegtgtits an
  inguinoscrotal mass
• Deep ring test
• ask pnt to b supine and reduce mass him/herself,
  put ur finger 2cm above mid ing. ligament
  point(point between ant. Sup. Ileac spine
  pubic tubercle), keeping ur finger in place, ask
  pnt to stand up and cough.. If the mass did not
  appear (also ull feel cough impulse)gtgt its
  indirect.. If it appearsgtgt its direct..

5
Station 2
(the pic is not the same pic in the exam but this
one shows Strangulated Hernia with
Evisceration Strangulated hernia with
eviscerated small bowel seen in center )
What is your diagnosis and the management ?
6

• Diagnosis
• Strangulated hernia is incarcerated hernia with
  resulting ischemia
• management
• emergent surgery (to check whether the
  intestinal tissue has died and to repair the
  hernia.)

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NBdifference between types of hernia

• femoral hernia( the most type liable to be
  strangulated)
• indirect inguinal hernia commonest overall
• Direct inguinal hernia
• Umbilical hernia
• Para umbilical hernia
• Incision hernia
• Epigastric hernia

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Features Indirect Inguinal Hernia Direct Inguinal Hernia Femoral hernia
Typical patient Young male Older male Old female
Proportion of groin hernias 60 25 15
Anatomy Commence at deep ring, lateral to the inferior epigastric artery, and pass within the coverings of the spermatic cord. Bulges medial to the inferior epigastric artery Emerges from the femoral canal.
Relationship to the Tubercle Start lateral to and above the tubercle,but passes superomedial to the tubercle into the scrotum. Lies above the tubercle Pass inferolateral to the tubercle
Descent In to the scrotum Yes No No
Obstructs or strangulate Yes Rarely yes
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The different between hernia hydrocele

• hernia (indirect inguinal)
  Hydrocele ( non- communicating type)
• cough impulse
  no cough impulse
• reducible
  Irreducible
• cannot get above it
  Can get above
• testis palpable
  Testis not palpable
• opaque
  translucent
• Contain bowel and fluid
  only fluid

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DDXInguinal hernia
Station 3
It is not the same pic but was Picture of
swelling in inguinal region scrotum
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Station 4

• 34 years old man has a mass in the left loin,
  mention 5 important DDx

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• DDx
• LF renal tumours
• LF Pheochromocytoma
• massively enlarged spleen
• LF adrenal tumours
• LF Hydronephrosis
• LF adult polycystic kidney disease
• LF renal vein thrombosis
• LF acute tubular necrosis

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N.B. DDx of groin ( inguinal) swelling

• Hernia inguinal, femoral.
• Lymphadenopathy
• Psoas abscess/cyst
• Femoral artery aneurysm
• Saphena varix
• Testis ectopic/undescended
• Cord lipoma/hydrocele

NB Hydrocele of the cord is a groin
mass Non-communicating hydrocele is a scrotal
mass Communicating hydrocele is an inguinoscrotal
mass.