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18 Hernia Sheet
173
Examination ofInguinal andFemoral Hernia (DD)
N.B.Examination of a hernia is different from examination of any other swelling
mentioned in the Chapter of examination of a swelling.
A Swelling at the site of a Known hernia orice “Or a scar over a cavity” which
gives an impulse on cough is a hernia till Prove otherwise.
As mentioned earlier in this chapters the examination sheet has to answer 7
questions:
1. Is it a Hernia or not?
2. Which type of the Hernia?
3. What are the contents of the hernia?
4. Is it Complicated or not?
5. Is there a cause of increased intra-abdominal pressure?
6. Is the patient t for surgery or not?
7. Is there another Hernias? And marking the side of hernia for medicolegal
purpose.
8. DD of this hernia especially in inguinal or femoral hernia?
Inspection
Examine the patient standing and ask him to take-off his clothes from the Lower
Chest to the midthigh.
• Site and impulse on cough: This will answer the First question and may answer
the fourth question putting in mind that strangulated Hernia may not show an
impulse on Cough.
• Size: In Cms or Inches.
• Shape: Direct hernia is rounded in shape and Oblique hernia is oval in shape if
purely inguinal but becomes oblong as it descends to the scrotum.
• Surface: Usually.
• Surrounding Structures “including Skin:
• Skin: Scar of previous operation, inammation “in Inamed or strangulated
hernia”.
• Pubic Tubercle: Neck of the inguinal hernia is above and medial to the pubic
tubercle “PT”, while in the Femoral Hernia it is below and lateral the PT.
• N.B.Alternatively run your index nger over the inguinal Ligament from the
ASIS to the pubic tubercle: Hernias above the Line are inguinal hernias while
femoral hernias are below this Line “Author’s Sign”.
• N.B.There is no need to do the above test If the hernia reaches the Neck of
the Scrotum “Funicular hernia”, Becomes Inguinoscrotal “Complete acquired
hernia” or Complete from the start “Congenital preformed sac”.
• Other swellings: Other Hernias
174
A. Farag et al.
Palpation
In Hernia Sheet we start by putting our hand at the neck of the scrotum “Four ngers
behind and the Thumb in Front and ask the patient to Cough. This will determine
from the very beginning of palpation if it is a hernia or not and will Classify the
swelling into three Categories which are very important in DD:
1. Inguinal “Pubonocele”: The swelling is fully above the neck of the scrotum “The
Examiner’s Hand”.
2. Pure Scrotal: The Swelling is fully below the Neck of the scrotum.
3. Inguino-Scrotal: where the Swelling Crosses between the examiners ngers at
the neck of the scrotum.
N.B.DD will be discussed for each category.
Palpation proceeds as follows:
• Temperature: Warm in Inammations which may be due to:
• Inamed Coverings “due to the wear of an ill-tting truss.
• An Inamed Content such as inamed appendix “Amyand’s hernia”, inamed
Fallopian tube, an inamed Meckel’s diverticulum “Littre’s Hernia” or an
inamed colonic diverticulitis in a hernia.
• Tenderness: in inamed hernia or strangulation “Tense, Tender and No Impulse
on cough”
• Site and Expansile Impulse on cough: Femoral, Inguinal “Pubonocele, Funicular
or Complete” according to its position in relation to the pubic tubercle “and the
Inguinal Ligament as described above”. It gives an expansile impulse on cough
“Increase in size in all directions as examined by the two index ngers of the
examiner where the distance between the tip of both ngers increases on coughing. “The only exception is strangulated hernia which may lead to confusion in
the diagnosis in cases of Femoral hernia DD inamed L.N.
• Size: in Cms or Inches.
• Shape: As by inspection.
• Surface: Smooth.
• Consistency: Doughy Sensation if it contains Omentum (Table18.1).
• Special tests:
Table 18.1 DD between omentum and bowel as a content of a hernia
Omentum Intestine
Consistency Doughy ‘Like paste” and no gurgle Soft with a gurgle especially during
reduction
Reduction Easy at the start and difcult at the
end
Percussion Dull Resonant
Auscultation No sounds Gurgle
Difcult at start and easy at the end
18 Hernia Sheet
Table 18.2 DD. between direct and indirect inguinal hernia
Direct hernia Indirect hernia
Site Inguinal Inguinal, Funicular or Inguinoscrotal
Shape Oval Oblong
Internal ring test Negative Positive
Direction of reduction Direct posterior Upwards, backwards and laterally
Direction of descend Direct anterior Downwards, forwards and medially
N.B.It is important to differentiate Direct and indirect hernia because indirect hernia is Liable to
complications mainly “Obstruction and strangulation” and surgery is highly recommended, while
Direct hernia is not liable to such serious complications
N.B. The Complete “Inguinoscrotal hernia” may be Congenital into a congenital unobliterated
Processus Vaginalis where the Hernia is complete from the start and the testis is felt as a content of
the Sac. DD.Acquired Complete hernia which starts as Pubonocele, then Funicular, then Complete
with the testis felt separate from the hernia sac and a groove is felt between them
175
Internal “Deep ring test: if hernia is reducible (Table18.2):
1. In the Supine position, reduce hernia and notice the direction of reduction,
Locate deep ring at midpoint of inguinal ligament “Halfway between ASIS and
PT” Occlude deep ring with the Index nger while hernia reduced.
2. Ask the patient to stand while the examiner rmly applying pressure with the
thumb to maintain occlusion of the internal ring.
3. Ask patient to cough, if the hernia appears with the thumb closing the internal
ring it is a direct hernia “negative internal ring test”. “Notice the direction of
descent which is directly anterior”.
4. Remove your thumb and ask the patient to cough, if the hernia appears it is an
indirect hernia “Notice the direction of descend “Downwards, forwards and
medially in the direction of the inguinal canal”.
• Surrounding structures: Skin, PT and inguinal ligament as mentioned above.
• Other swellings: Other hernia orices.
Percussion: Resonant if large and containing Bowel.
Auscultation: Gurgle if large and contains bowel.
Complications ofaHernia
Common
1. Irreducibility: The rst complication and makes the hernia more Liable to the
other more serious complications.
2. Obstruction: when the content of the hernia is whole Circumference of the bowel
and presents with acute pain and irreducibility together with cardinal manifestations of Intestinal obstruction namely “Colicky pain, Vomiting which is noisy
and explosive “Not silent and regurgitant like that of ileus”, Distension and abso-
176
A. Farag et al.
lute Constipation” in different combinations and sequence according to the level
of bowel obstruction.
• In Upper GI obstruction, Pain and Vomiting start early with minimal disten-
sion and late absolute constipation where the patient can pass one or two
motions before it becomes an absolute constipation “evacuating the stools
which passed distal to the obstruction before it happens”.
• In Lower GI obstruction Pain and absolute constipation appear early,
Distension is marked and Vomiting is late.
3. Obturation: reserved to intestinal obstruction from within. In the case of a hernia
it may be with stools or foreign material Such as bezoars, gallstone, worms, or
foreign body.
4. Strangulation: It is interference with the blood supply of the hernia which threatens with gangrene of its content:
The Hernia is severely painful and is tense and Tender “In Inammation it is tender
but not tense”.
It is accompanied by cardinal manifestations of Intestinal obstruction if it con-
tains the whole Circumference of a bowel loop.
Strangulation without cardinal manifestations of bowel obstruction can happen if
the strangulated content is Omentum, appendix, Meckel’s diverticulum, Ovary and/
or tube or if the hernia contains only a part of the circumference of the bowel
“Richter hernia”. Most commonly, it is the anti-mesenteric portion of the bowel.
These hernias often develop in small Fascial defects.
Less Common
1. Inammation: Tender, red, hot with or without signs of inammation which may
be due to inamed coverings or an inamed content as mentioned above. With
or without signs of systemic inammation “Fever, rigors and tachycardia”.
2. Rupture: Which is a rupture of the intestine inside the hernia with its immediate
retraction into the general peritoneal cavity due to direct trauma to the hernia
especially when irreducible “rare and seen once by the author”. It should be
suspected by History of direct trauma on irreducible hernia and sudden disappearance “reduction of the hernia. It is an emergency situation because.
Emergency abdominal exploration to see, repair the perforated part of the bowel
after debridement with or without simultaneous repair of the hernia according to
the degree of contamination of the peritoneal cavity especially when a mesh is
needed for Hernioplasty.
3. Hydrocele of a hernia Sac: Rare but seen more frequently in patients with mas-
sive ascites and narrow neck of the hernia sac which allows only the ascetic ood
to go in the hernia sac “No actual content”.
18 Hernia Sheet
177
Examination oftheScrotum
• Cord “Vas and Vessels “For associated Varicocele due to congenitally weak mes-
enchyme or Infantile Hydrocele “4 Layered sac hernia which may be confusing
for a surgeon in his early training”.
• Epidydmis, tunica Vaginalis, Testis and Skin of the Scrotum “Front and back” on
both sides.
Examination oftheAbdomen
• To Exclude an Intra-abdominal pathology which can cause an increased intra-
abdominal pressure.
• Open appendectomy scar which may be the cause of a right direct hernia due to
accidental damage of the Ilio-inguinal nerve.
Examination ofUmbilical andPara-Umbilical Hernia
Swelling at the Umbilicus which gives an Impulse on cough. It may be True
Umbilical which may be Congenital dating since birth or acquired which develop
later in Life with marked increase in intra-abdominal pressure e.g. massive ascites
“Where the Umbilical scar is seen on the summit of the Hernia sac” or ParaUmbilical “The scar is on one side of the sac and is acquired.
N.B.Congenital true Umbilical hernia usually heals by the age of 2years using
compression band and button.
Inspection of a scar tissue may indicate a recurrence or a scar or previous
Laparoscopic surgery “An Incisional Hernia”.
Examination ofIncisional Hernia
Special points to be addressed during such examination besides answering the
above mentioned questions in the Hernia sheet are:
• Is it Complicated or not? If it is reducible it is not complicated.
• The size of the defect as compared to the size of the sac: The larger the defect the
less liable are the complications “surgery is done for Cosmetic reasons and on
the patient’s request”
• If bone forms part of the edge? If bone forms part of the edge this hernia will
need a hernioplasty with a mesh “the edges cannot be approximated to each other
i.e. not amenable to Herniorrhaphy”. The Clearest examples are hernias after
Kidney incision, Open Cholecystectomy and after Pfannenstiel Incision.
178
A. Farag et al.
Rare Types ofHernia
• Abdominal wall Hernias:
• Spigelian Hernia: It is a type of hernia that occurs along the Spigelian fascia,
which is a layer of tissue located along the side of the abdominal wall. This
type of hernia typically occurs in the lower abdomen, near the waistline, and
can cause pain and discomfort. Spigelian hernias are relatively rare and may
require surgical repair to prevent complications.
• Lumbar hernia: It is a type of hernia that occurs in the lumbar region of the back,
which is the area of the lower back on either side of the spine. Lumbar hernias
are rare and can be either congenital (present at birth) or acquired (developed
later in life). They occur when abdominal contents, such as fat or intestines,
protrude through a weakness or defect in the muscles of the lower back.
• Symptoms of a lumbar hernia may include a visible bulge or lump in the
lower back, pain or discomfort in the area, and sometimes difculty with
bowel movements.
• Pelvic Hernias:
• An obturator hernia is a rare type of hernia that occurs when abdominal contents, such as the small intestine, protrude through the obturator foramen,
which is a small opening in the pelvic bone. Obturator hernias are more common in elderly, thin women and are often associated with conditions that
cause thinning of the abdominal wall, such as weight loss or chronic illness.
Symptoms of an obturator hernia can be nonspecic and may include pain in
the inner thigh or groin that worsens with movement, nausea, vomiting, and
bowel obstruction. Obturator hernias can be challenging to diagnose because
they do not typically cause a visible bulge or lump.
• Perineal hernia is a type of hernia that occurs in the perineal region, which is
the area between the anus and the external genitalia. Perineal hernias involve
the protrusion of abdominal contents through a defect in the pelvic oor muscles and connective tissue in the perineal region. These hernias are more common in dogs than in humans, but they can occur in both.
• Symptoms of a perineal hernia may include a visible or palpable bulge near
the anus, difculty defecating, constipation, straining during bowel movements, pain or discomfort in the perineal area, and in severe cases, urinary or
fecal incontinence.
• Sciatic hernia is a rare type of hernia that occurs through the sciatic foramen,
which is a small opening in the pelvis through which the sciatic nerve passes.
The sciatic foramen is located in the lower part of the pelvis, near the hip
joint. A sciatic hernia involves the protrusion of abdominal contents, such as
fat or intestines, through this opening, causing a bulge in the buttock or thigh
area. Symptoms of a sciatic hernia may include a visible or palpable mass in
the buttock or thigh, pain or discomfort in the affected area, and in some
cases, symptoms of bowel obstruction if the hernia compresses the intestines.
Chapter 19
D.D. ofInguinoscrotal Swelling
AhmedFarag, AsifMehraj, andPatrickJordan
Abstract Oblique inguinal Hernia: Commonest, Varicocele: It is a condition char-
acterized by the enlargement of the veins within the scrotum, which is the pouch of
skin that holds the testicles. Varicocele are similar to varicose veins that occur in the
legs, and they are most commonly found on the left side of the scrotum. Varicocele
can cause pain, discomfort, and swelling in the scrotum, and they may also affect
fertility in some cases.
Keywords Inguinal · Scrotal · Inguinoscrotal · Swelling · Examination · Sheet ·
Hernia · Varicocele · Hydrocele
1. Oblique inguinal Hernia “Commonest”: AS above.
2. Varicocele:
It is a condition characterized by the enlargement of the veins within the scro-
tum, which is the pouch of skin that holds the testicles. Varicocele are similar to
varicose veins that occur in the legs, and they are most commonly found on the
left side of the scrotum. Varicocele can cause pain, discomfort, and swelling in
the scrotum, and they may also affect fertility in some cases.
Symptoms of Varicocele may include a dull ache or pain in the scrotum,
swelling or enlargement of the scrotum, and a feeling of heaviness or dragging
sensation in the scrotum. Some men with Varicocele may also experience fertility issues, as the increased blood ow and higher temperature in the scrotum can
affect sperm production and quality.
A. Farag (*)
Kasr Alainy Hospital, Cairo University, Cairo, Egypt
A. Mehraj
Apollo Health City, Hyderabad, India
e-mail: Asifdr80@yahoo.com.in
P. Jordan
SPr SVUH, Dublin, Ireland
e-mail: jordanpr@tcd.ie
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_19
179© The Author(s), under exclusive license to Springer Nature
180
A. Farag et al.
On Examination as in case of a Hernia where the hand of the examiner exam-
ines the Neck of the Scrotum with the thumb anterior to the neck of the scrotum
and the rest 4 Fingers behind it. Try to roll the Cord between your ngers and the
thumb gently without hurting the patient. Normally you can feel the Vas difference as a tough robe and the veins few and soft vertical structures. In Varicocele
they are many tortuous and engorged which give the classic sensation of a “bag
of Worms” used for shing. They are normally compressible, gives a thrill on
cough and decrease in size or disappear on Lying down “Primary varicose veins”.
DD. is Secondary Varicocele which is due to obstruction of those veins at the
Level of their drainage into the left renal vein or into the IVC on the right side
due to Tumor thrombus from a Hypernephroma. Characteristically they are
always engorged and does not disappear or decrease on Lying down and no thrill
on Cough.
3. Funiculitis: It is a medical term that refers to inammation of the spermatic cord,
which is the cord-like structure that contains blood vessels, nerves, and the vas
deferens that connects the testicles to the rest of the reproductive system.
Funiculitis can be caused by various factors, including infections and trauma.
Symptoms of funiculitis may include pain or discomfort in the scrotum or
groin area, swelling or redness in the scrotum, and sometimes fever or other
signs of infection. In some cases, funiculitis may be associated with conditions
such as epididymitis. Infection may be non-specic with reux of the infected
Urine into the Vas Deference or specic “Now rare” Characterized by matting of
the Cord in Filariasis or Beaded Cord in T.B.
4. Encysted hydrocele: It is a specic type of hydrocele that involves the presence
of a cyst or sac-like structure within the spermatic cord. This condition is characterized by the accumulation of uid within a localized area of the spermatic
cord, leading to a cystic swelling.
Encysted hydrocele of the cord typically presents as a painless, rm, and
sometimes palpable mass along the spermatic cord. The cystic structure may
contain clear uid and can vary in size. It is important to differentiate encysted
hydrocele of the cord from other scrotal masses, such as hernias or tumors,
through physical examination. A Characteristic sign is that the Cyst moves up
and down freely except with pulling down of the testis “Which makes the Cord
tense “the cyst can be moved side—side with the cord but not vertically across
the cord”.
5. Diffuse Hydrocele of the Cord: It is like the encysted hydrocele of the Cord but
longer and oblong in shape.
6. Congenital Hydrocele: It is a common condition in newborns and infants char-
acterized by the accumulation of uid around the testicle within the scrotum. It
is often referred to as a “communicating hydrocele” because it is typically associated with a persistent connection between the abdominal cavity and the scrotum, known as the Processus Vaginalis.
In infants, the processus vaginalis is a normal structure that allows the testi-
cles to descend into the scrotum during fetal development. In some cases, this
19 D.D. ofInguinoscrotal Swelling
connection remains open after birth, leading to the accumulation of uid and the
formation of a hydrocele.
Infantile hydroceles are usually painless and may present as a soft, uid-lled
swelling in the scrotum. They are typically non-tender and may change in size
throughout the day. In most cases, infantile hydroceles are harmless and tend to
resolve on their own within the rst year of life as the processus vaginalis
closes off.
7. Infantile Hydrocele: is like congenital hydrocele but its connection to the abdom-
inal cavity is closed “DD.It does not change in size over the day. When encountered during hernia repair it is called 4 layered sac hernia “The 2 walls of the
Hydrocele overlapping the 2 walls of the hernia sac. And hernia is called infantile hernia “see above’.
8. Tumors of the Cord are usually benign “Lipoma or diffuse lipomatosis of the
Cord but rarely malignant.
181
D.D. ofPure Inguinal Swelling
1. Swellings n the femoral triangle. See in the relevant Chapter.
2. Swellings in the right Iliac fossa. “See in the Abdominal Sheet”
D.D. ofScrotal Swelling
1. Vaginal hydrocele “Commonest”: including the variants e.g. Haematocele,
Pyocele or Chylocele. Vaginal hydrocele can be primary or secondary. Primary
Vaginal hydrocele usually presents with heaviness, and enlargement in size. On
inspection and palpation it is a purely scrotal swelling “Below the examining
hand at the neck of the scrotum. It shows a bipolar uctuation test positive.
Alternating squeeze of the hydrocele between the examiner’s hands on at the
neck of the scrotum and the other at the lower pole of the testis the other hands
and ngers will receive and expansile pulsation on the negative “Receiving
hand”. Characteristically we cannot feel the other contents of the scrotum “Testis
and epidydmis” due to tense uid inside the Tunica. It shows a positive transillumination test.
On the other hand the Secondary hydrocele can develop after trauma includ-
ing hernia surgery, inammation or tumors. Secondary hydrocele is usually Lax,
we can palpate the Testis and Epidydmis well and the tunica vaginalis can be felt
by gentle rolling of the skin of the scrotum below the lower pole of the testis
where it is felt like a shirt under the jacket ‘i.e. 2 layers under the skin of the
scrotum.
182
A. Farag et al.
Pyocele and Haematocele may be felt as severe pain, tense tunica V. which is
tender with or without Systemic manifestations of inammation. Negative transillumination test.
N.B.Trans-Illumination test: By holding an electric Torch light externally to
the scrotum “e.g. from behind, one can easily determine whether the mass is
cystic (light shines through and can locate the position of the testis and epidydmis in order to avoid injuries to the testis if anteriorly located during an operation
for primary hydrocele) or solid (light blocked by the mass, Pyocele or
Haematocele).
Chylocele is another variant which can only be diagnosed with aspiration.
The Milky uid drained has a very low Specic gravity and becomes clear by
adding ether “As a fat solvent”.
2. Epidydmo-orchitis “Second most common”: DD.Torsion testis”. It presents as
in Funiculitis above but infection extends into the epidydmis and testis. Torsion
testis is an emergency operation which should be done before gangrene of the
testis by xation of the testis to the bottom of the scrotum and exploration of the
other side is important to avoid torsion of the other side”
In Torsion testis the testis Lie high at the neck of the scrotum “due to shorten-
ing of the cord by torsion” and pain increases with elevation. In Epidydmoorchitis, the testis Lie down and hanging lower than the normal side and elevation
relives pain. If in doubt US and duplex are very helpful, if not available explore
as torsion testis.
3. Spermatocele: typically arise from the head of the epididymis, which is located
on the superior aspect of the testicle. During trans-illumination it is Cystic with
septae inside “Chinese Lantern appearance”.
4. Tumors of the Testis: of different types and stages usually the testis is heavier
than the normal side and characteristically there is loss of testicular sensation
when touched by the Examiners hand “This should be done very carefully
because when done with reluctance or frequently, it can lead to spread of
the tumor.
5. Chronic Epidydmo-orchitis: Nonspecic, Syphilis, TB or Bilaharzial: As men-
tioned in Funiculitis but the Symptoms of inammation are milder than acute
inammation in Non-specic infections. In T.B. the cord and head are beaded
and the epidydmis “Which is normally behind the scrotum can invade the skin of
the scrotum and cause a T.B. sinus at the back of the Scrotum In Syphilis a
Gumma of the testes may be mistaken for malignancy but it can cause interstitial
orchitis without Gumma. Bilaharzial infection being a venous disease it may
affect the head of the epidydmis causing a Mass “Bilaharzial granuloma”
6. Tumors of the epidydmis and Cord specially Lipomas and Fibromas.
D.D. ofSwelling intheSkin oftheScrotum
• Localized swelling: