Inguino-Scrotal Lumps

Inguino-Scrotal Lumps

Why?

Because they’re common.

Because they’re really common.

Because the anatomy is fun to quiz people on.

Because they’re common.

Account for up to 20% of General surgical referrals.

Pathologies

Inguinal

Sebaceous Cysts/Lipoma’s

Inguinal Lymphadenopathy

Saphenous Varix

Femoral Artery aneurysm

Psoas Abscess

Undescended testes.

Inguinal Hernia

Femoral Hernia

Scrotal

Testicular tumor

Epididymal cyst

Spermatocoele

Hydatid of Morgagni

Varicocoele

Hydrocoele

Inguino-scrotal Hernia

Assessment-History

Lump When was it first noticed?

How was it noticed?

Precipitant activity

Recent illnesses

What symptoms are present? ?pain, functional impairment

GI/GU disturbance.

Systemic symptoms-fevers, night sweats etc.

Is the lump changing?

Does the lump come and go How or when?

Assessment-Exam

Lump Position, Shape and size

Surface Skin

Mass surface

Temperature

Tenderness

Composition-Solid/Fluid/Gas Consistency

Fluctuation/Fluid thrills/Resonance

Translucency

Pulsatility

Reducibility/Cough impulse

Relations to surrounding structures

Regional Lymph nodes

Assessment-Exam

Both sides

Hernia Tests Standing and lying

?Get above it

Cough Impulse

Reducibility and control

Associated structures Pulses, testes, Lymph nodes.

Special tests Transillumination

Assessment

Investigation Occasional use only

Ultrasound/duplex For early hernia’s-not so reliable.

Useful for testes/vascular assessment

CT More for assessing deeper anatomy

Herniagram

Laparoscopy

Assessment

How Not to Kill people, Don’t miss tumors

Exclude Malignancy Lymphadenopathy-Generalized, unexplained or persistent

BIOPSY!

Discrete Scrotal Lumps or unexaminable testes

Ultrasound and/or Refer

No Part time Vascular Surgery

Anatomy

Inguinal region

Inguinal Canal

Spermatic Cord

Femoral Canal and Ring

Scrotum/testes

Anatomy

Inguinal region Includes

Lower abdominal wall

Femoral Triangle Sartorius/Add Longus/

Inguinal Lig

Contains Femoral Pedicle

Lymph Nodes

Skin/fat/muscle

Anatomy

Inguinal Canal An oblique series of

defects in the layers of the abdominal wall.

Site of Inguinal Herniae

Transmits the Spermatic cord/Round ligament.

Round ligament

Runs from Uterine fundus via canal to Labia.

Anatomy

Inguinal Canal Floor

Inguinal Ligament and Lacunar ligament

Roof Arching fibres of Int Obl

& Trans abdominis and Conjoint tendon

Anterior Wall External Oblique

aponeurosis

Superficial Ring

Post Wall Conjoint tendon medially,

Transversalis fascia laterally

Deep ring

Anatomy

Femoral Canal Beneath the inguinal

ligament Iliacus muscle

Femoral Nerve

Femoral Sheath containing…

Femoral vessels

Femoral Canal

Femoral Canal Space for venous

expansion

Lymphatics.

Upper end defined by femoral ring.

Anatomy

Femoral Canal Beneath the inguinal

ligament Iliacus muscle

Femoral Nerve

Femoral Sheath containing…

Femoral vessels

Femoral Canal

Femoral Canal Space for venous

expansion

Lymphatics.

Upper end defined by femoral ring.

•Femoral Ring

•Site of Femoral Herniae

Anatomy

Eponyms Hesselbachs Triangle

Lateral border of rectus muscle

Inguinal Ligament

Inferior epigastric vessels (med border of deep ring)

Fruchauds Myopectineal Orofice Hesselbachs triangle

Deep ring

Femoral sheath/canal.

Anatomy

Spermatic cord

Pedicle of the testes

Made up of 12 things

Anatomy

Spermatic cord

Pedicle of the testes

Made up of 12 things You’re not getting

away with that!

Anatomy

3 Arteries

3 Nerves

3 Important structures

3 Coverings

Anatomy

3 Arteries Testicular

Artery to the Vas Deferens

Cremasteric

3 Nerves Sympathetic branches

Ilio-inguinal (on cord)

Genital Br of Genito-femoral nerve.

3 Important structures Vas Deferens

Pampiniform Plexus

Processus Vaginalis

3 Coverings External Spermatic Fascia

Cremasteric Muscle

Internal Spermatic Fascia

Anatomy

Spermatic cord

Only truly forms at the superficial ring.

Passes through the superficial ring

above and medial to the pubic tubercle.

Descends through S/C fat into the scrotum.

Anatomy

Testes

Suspended on spermatic cord,

Enveloped within Tunica vaginalis

Drain via epididymis to Vas Deferens

Made up of

Germinal elements-Seminiferous tubules

Non-Germinal elements-Stroma, Leydig cells

Pathologies

Inguinal

Sebaceous Cysts/Lipoma’s

Inguinal Lymphadenopathy

Saphenous Varix

Femoral Artery aneurysm

Psoas Abscess

Undescended testes

Inguinal Hernia

Femoral Hernia

Scrotal

Testicular tumor

Epididymal cyst

Spermatocoele

Hydatid of Morgagni

Varicocoele

Hydrocoele

Inguino-scrotal Hernia

Skin stuff

Sebaceous cysts

Retention cysts of sebaceous glands

Fixed to skin-dimple if squeezed

Can become infected-abscess.

Incise and drain

Management

excise when non-inflammed.

Skin stuff

Lipomas Benign Fatty lumps

Clinically fixed (skin and fat)

soft lumps,

usually longstanding and asymptomatic.

Management excise surgically

Inguinal Lymphadenopathy

Causes Primary Lymphatic disease-Lymphoma

Secondary Lymphadenopathy Malignant disease

Benign Physiological reaction to inflammatory

state

Management Exclude Inflammatory causes

Examine, Observe, Antibiotics etc.

Exclude obvious malignancy

Biopsy-FNA/Open

Saphenous Varix

Prominent Varicosity of Upper Long Saphenous Vein. Typical Patient

Middle aged and older

F>M

Usual Risk Factors Pregnancy, Pelvic Mass

Clinically Dragging lump over upper thigh, disappears when lying

Cough impulse +

Thrill down vein when percussing.

Management-surgical ligation.

Femoral Artery Aneurysm.

True aneurysms

Pulsatile lump in groin

Associated with other aneurysmal disease

Mx-Vascular surgical repair if >2-3cm

False aneurysm

Secondary to puncture

Dx on duplex

Mx-Call a vascular surgeon-thrombose or repair.

Psoas Abscess

Abscess within Psoas fascia that tracks to groin and presents as a lump.

Associated with Retroperitoneal infection/inflammation

Post Surgical eg. Nephrectomy

Colonic

Pancreatitis

Spinal TB

Management Drain and treat underlying cause

Undescended Testes

Rare in adults

Usually Dx and treated as children

In adults usually present as infertility

Alt painless lump in Inguinal canal

Prone to infertility and testicular cancer.

Managemant

Refer to Urologist.

Scrotal Lumps

Assessment Hx/Ex as previous

If not obvious Hernia/Varicocoele/ Hydrocoele and normal testes Ultrasound Lump origin

Solid vs cystic etc.

If still in doubt-Call a Urologist.

Surgical exploration

Scrotal Lumps

Solid lumps. Testicular origin

mostly malignant

Paratesticular origin mostly benign

Cystadenoma, Adenomatoid tumor (epididymis)

Inflammatory pseudotumor

Cystic lumps Usually benign

Epididymal cyst,

Spermatocoele,

Hydatid of Morgagni

Testicular Lumps

Testicular tumors

Usually painless lumps in 2nd to 4th decades

Germinal-95%

Seminoma/Embryonal Cell/ChorioCa/Teratoma

Non-Germinal

Stromal-Leydig Cell Tumor; Gonadoblastoma

Management

Call a Urologist

Usually multimodal Therapy

Hydrocoele

Collections of fluid in Tunica Vaginalis Typically >40yrs except infantile.

Classes Congenital-communicating

Reactive-tumor/trauma/infection

Idiopathic.

Clinically Usually dragging scrotal mass,

Can get above them, fluctuant, transilluminate well

Must exclude malignancy Clinically normal testes or ultrasound

Treatment Aspirate-tend to recur

Surgery-Jaboulet procedure.

Hydrocoele

Varicocoele

Dilatation of the Pampiniform Plexus

Usually affects 20 to 50 yo’s

L>R due to venous anatomy.

Acute varicocoele-exclude RP infiltration

May cause infertility

Painless lump Bag of worms

Cough impulse +ve

May reduce on lying down

Treatment Ligation at deep ring or excision.

Other Scrotal Lumps

Epididymal cyst Cyst arising from epididymis

Spermatocoele Sperm filled cyst arising from the testes.

Hydatid of Morgagni Small mobile cyst from top of testes

Embryological remnant of Mullerian duct.

Subject to torsion

Management Exclude testicular Mass-Ultrasound

Surgery if large/symptomatic.

Hernias

Inguinal herniae

Hernia Numbers 25% of males (2% F) will develop a groin hernia

65% Indirect Inguinal herniae 55% on the right

31% Direct Inguinal Herniae Although represent 80% of bilateral herniae

4% Femoral Herniae More common in women 20 % of all groin herniae c/w 2%

male.

Causes Congenital

Chronic Stress to area

Metabolic-Collagen-vasc Ds, Smoking

Hernia types

Inguinal

Direct

Indirect Pantaloon

Femoral

Also

Sliding herniae

Sliding Hernia

A Hernia in which the peritoneal wall that forms part of the sac has an organ naturally adherent to it.

Eg. If an extraperitoneal organ (usually Bladder or colon) slides out with its adherent peritoneum through the hernia defect the organ itself becomes part of the wall of the sac.

Must look out for this at the time of surgery because the organ is easily injured upon opening the sac.

Can be direct or indirect.

Sliding hernia

Non sliding hernia

Inguinal herniae

Clinically Groin pain/discomfort

Dragging, worse during the day

Lump Asymmetry-inguino-scrotal swelling

GI/GU obstruction

Incarceration/Irreducibility

Hernia examination

Direct vs indirect

Direct Diffuse bulge

Rarely into scrotum

Controlled only at superficial ring

Indirect Usually more defined

May extend into scrotum

Herniation/reduction more prominent

Controlled at deep ring.

Femoral vs inguinal

Inguinal Lie in/above groin crease

Appear above and medial to pubic tubercle.

Extend into scrotum

Femoral Lie below crease

Appear below and lateral to tubercle

Extend into thigh

Hernia Complications

Incarceration

Strangulation Risk-Indirect and Femoral>>>Direct

Surgical emergency

Call the surgeon-don’t try and reduce.

Herniated Viscera is entrapped and infarcted.

Acute, tender, painful lump +/- SBO

Richters Hernia

Reduction en-masse

Progressive growth=Natural Hx of herniae.

Hernia Management

Fix it!

Eliminates pain

Eliminates Lump

Avoids hernia growth

Avoids risk of strangulation

Esp in indirect hernia

Straightforward surgery.

Inguinal Operations

Previous

Bassini, McVay, Shouldice

Forget them

Now

Lichtenstein tension free mesh repair.

Laproscopic repair.

Hernia operations

Lichtenstein tension free mesh repair. Developed in NY at the Lichtenstein Hernia

clinic

Originally done as OP procedure under LA

Involves

Dissecting Inguinal canal and mobilising cord

Inverting/removing hernia sac

Reinforcing posterior inguinal wall with prolene mesh.

Open Hernia Repair

Hernia operations

Lichtenstein tension free mesh repair.

Results

All can be done under LA

Widely adopted

Recurrence rate 1-2%-Lichtenstein

Hernia Operations

Laparoscopic TAPP

Trans abdominal Pre-peritoneal Patch

TEPP

Totally Extraperitoneal Pre-peritoneal Patch

Both place a Mesh patch over the hernial defect inside the abdominal muscle layer, outside the peritoneum.

Lap Hernia Repair

Hernia Operations

Lap repairs Multiple RCT’s C/W open repair.

Results equivalent for Recurrence rate (? Better)

LoS

Better for Post -op pain

Return to work

?Chronic Groin pain

Worse for OP time

Cost

Tend to be reserved for Recurrent or Bilateral repairs.

Hernia Operations

Complications

Infection ~1.5%

Incl Mesh infection

Bleeding~1%

Hernia recurrence

Varies with technique, should be <2%

Nerve injury/Chronic groin discomfort 5-10%

Ischaemic orchitis/atrophy ~1-2%

Urinary retention 1-10%

Femoral Herniae

3 ways

High Approach

McEvedy-via the abdomen

Best for difficult or strangulated Herniae

Middle

Lothieson-via the Inguinal canal

Used occasionally for indeterminate herniae.

Low

Lockwood-via the upper thigh/groin

Best for small hernia and elective repairs

Summary

Remember the anatomy

Lumps can arise from any tissue.

Understand the Hernia anatomy and the clinical management is easy

Don’t kill anyone Don’t miss Malignancy-Ing LN and scrotal

lumps.

Fix the hernias