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Melanoma
Sebastian G. De La Fuente
Timothy W. Mccardle
Vernon K. Sondak
Chapter 99
Melanoma Presenting with Regional
Lymph Node Involvement
Michael S. Sabel
Chapter 100
Merkel Cell Carcinoma
Michael S. Sabel
Chapter 101
Nonmelanoma Skin Cancer
Anastasia Dimick
Chapter 102
Necrotizing Soft Tissue Infections
Michelle K. Mcnutt
Lillian S. Kao
Chapter 103
Extremity Mass (Sarcoma)
Timothy L. Frankel
Alfred E. Chang
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Chapter 104
Retroperitoneal Sarcoma
Chandu Vemuri
Sandra L. Wong
Chapter 105
Penetrating Chest Injury
Albert Chi
Adil H. Haider
Chapter 106
Stab Wound to the Neck
Gina M.S. Howell
Jason L. Sperry
Chapter 107
Burns
Jeffrey S. Guy
Chapter 108
Blunt Abdominal Trauma from Motor
Vehicle Crash
Carla Kohoyda-Inglis
Stewart C. Wang
Chapter 109
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Duodenal Injury
Filip Bednar
Mark R. Hemmila
Chapter 110
Pelvic Fracture
Avi Bhavaraju
Oliver L. Gunter
Chapter 111
Airway Emergency
Derek T. Woodrum
David W. Healy
Chapter 112
Acute Renal Failure
April E. Mendoza
Anthony G. Charles
Chapter 113
Adrenal Insufficiency
Steven R. Allen
Heidi L. Frankel
Chapter 114
Acute Respiratory Distress Syndrome
(ARDS)
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Pauline K. Park
Krishnan Raghavendran
Lena M. Napolitano
Chapter 115
Ventilator-associated Pneumonia
Krishnan Raghavendran
Chapter 116
Septic Shock
Pamela A. Lipsett
Chapter 117
Abdominal Compartment Syndrome
Rebecca Plevin
Heather L. Evans
Chapter 118
Nutritional Support in the Critically Ill
Surgery Patient
Kyle J. Van Arendonk
Elliott R. Haut
Chapter 119
Acute Liver Failure
Bernard J. Dubray
Christopher D. Anderson
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Chapter 120
Variceal Bleeding and Portal
Hypertension
Brendan J. Boland
Andrew S. Klein
Chapter 121
End-Stage Renal Disease (Renal
Transplantation)
Leigh Anne Redhage
Derek Moore
Chapter 122
Melanoma of the Head and Neck
Andrew Kroeker
Andrew Shuman
Erin Mckean
Chapter 123
Head and Neck Cancer
Matthew Spector
Erin Mckean
Index
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1
Symptomatic Primary Inguinal
Hernia
EVANGELOS MESSARIS
Presentation
A 55-year-old male patient with a history of
hypertension and diabetes presents with right groin
discomfort. He reports having right groin discomfort for
the last 3 months. He also noticed a bulge in his right
groin several months ago. He has no fever, chills,
nausea, vomiting or dysuria. His vitals are normal. On
exam it is noted that he has a mass in the right groin
that extends into his scrotum. The mass is reducible,
but it immediately recurs after reduction.
Differential Diagnosis
Groin discomfort usually is associated with an inguinal or
femoral hernia or a process involving the spermatic cord or
round ligament structures. Although, inguinal hernias are
common, there are other medical conditions that can have
similar presentation. Femoral hernias, enlarged inguinal
nodes, hydroceles, testicular torsion, epididymitis,
varicocele, spermatocele, epididymal cyst, and testicular
tumors are less frequent but should be included in the
differential diagnosis of a patient presenting with a
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differential diagnosis of a patient presenting with a
symptomatic groin mass or groin discomfort.
Workup
The patient undergoes more extensive physical exam of his
abdomen, in the standing and supine position,
demonstrating a reducible inguinal mass at the level of the
external ring of the inguinal canal with minimal overlying
tenderness, suggestive of a right inguinal hernia.
The diagnosis of an inguinal hernia is based on
physical examination. Reported sensitivity and specificity of
physical examination for the diagnosis of inguinal hernia
are 75% and 96%, respectively. In males, the index finger
of the examiner should invaginate the scrotum in an attempt
to find the external opening of the inguinal canal. The
patient should then be asked to cough or perform a
Valsalva maneuver. The examiner should then feel the
hernia sac with all its contents at the tip of his index finger.
Similarly, in female patients the examiner can feel for the
hernia sac by palpating the inguinal area just laterally of the
pubic tubercle. It should be noted that the exam is
performed above the inguinal ligament, because if the
protruding mass is below the inguinal ligament, then it is a
femoral hernia. This distinction is not often easy, especially
in obese patients. In all cases both sides should be
examined (not only the symptomatic side) to rule out
bilateral inguinal hernias. No laboratory studies can help
with the diagnosis of an inguinal hernia.
Rarely the use of imaging studies is helpful in moving
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from the differential diagnosis to a single working
diagnosis. Imaging studies are mostly used in obese
patients where physical exam has limitations (Figure 1).
An ultrasound can demonstrate or rule out enlarged inguinal
nodes, hydroceles, testicular torsion, varicocele,
spermatocele, epididymal cyst, and testicular tumors.
Furthermore, an experienced ultra-sonographer can
demonstrate an inguinal hernia sac and identify its
contents. Computed tomography is mostly used on cases
of very large inguinal hernias, to depict the contents of the
sac and to identify aberrant anatomy in the inguinal canal
(Figure 2).
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FIGURE 1 • Axial cut of a CT demonstrating a moderate-size right inguinal
hernia with omentum in the hernia sac in an obese patient where physical
exam findings would be limited.
FIGURE 2 • Axial cut of a CT, demonstrating a left inguinal hernia with
sigmoid colon in the hernia sac.
Diagnosis and Treatment
Ascertaining whether patients have symptoms from their
hernia is important for decision making. For truly
asymptomatic hernias, a watchful waiting strategy can be
followed. Younger patients are almost always symptomatic
because they are invariably active. However, older patients
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because they are invariably active. However, older patients
who are not physically active may not be bothered by their
hernia and repair can be deferred indefinitely.
Inguinal hernias can present with many different
symptoms. A reducible hernia will often present with groin
discomfort that is exacerbated with activity. Patients with
incarceration or strangulation will present with more severe
pain and, potentially overlying skin erythema. The treatment
of all symptomatic inguinal hernias is surgical repair. The
goals of the repair are to relieve the symptoms and prevent
any future incarceration or strangulation of the hernia. The
timing for symptomatic hernia repairs depends on whether
the hernia is reducible, incarcerated, or strangulated.
Reducible hernias can be repaired in an elective outpatient
fashion, incarcerated hernias warrant urgent repair within
12 hours of presentation, and strangulated hernias need to
go to the operating room emergently, since the viability of
an organ in the hernia sac is compromised.
Surgical Approach
The surgical approach for a symptomatic inguinal hernia
could be open or laparoscopic, with local, spinal, or general
anesthesia. In the open procedures the repair can be
suture based (Bassini, McVay, Shouldice) or using mesh
(e.g., Lichtenstein). Mesh is also used in all the
laparoscopic cases that can be further divided in total
extraperitoneal (TEP) and transabdominal preperitoneal
(TAPP), depending on whether the peritoneal cavity is used
for access to the inguinal region or not. Although many
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