56-year-old (Male) with Inguinal Pain and Swelling

00:01 Okay, guys we have a critical question here.

00:05 You will see this question on your boards.

00:07 You will see this situation on the wards. It is important. Let's buckle down.

00:13 A 56-year-old male is admitted to the emergency department with sudden onset of pain, left sided scrotal swelling, and nausea.

00:24 The patient states that his symptoms started three hours ago after he lifted up a heavy pack.

00:30 He says that the swelling had been intermittent, present for several years, but most prominent when physically straining or coughing but he had never had it be painful.

00:42 The past medical history is unremarkable.

00:46 The patient reports a 26-pack-year smoking history.

00:50 The vital signs are as follows: blood pressure is 150/90, heart rate is 85, respiratory rate is 14, and his temperature is 37.8 degrees Celsius.

01:02 His BMI is 32.9. The patient's respiratory and cardiovascular exams are within normal limits.

01:10 The abdomen is moderately distended.

01:13 There is a tender erythematous scrotal swelling on the left, which cannot be manually reduced.

01:21 Which of the following tests should be performed to confirm the diagnosis in this patient? Answer choice A: Ultrasonography; Answer choice B: No further tests are needed; Answer choice C: Fine needle biopsy; Answer choice D: Laparoscopy; or Answer choice E: CT scan Now, take a moment to come to the answer by yourself before we go through it together.

01:52 Okay guys, like I said, this is a very important question.

01:55 The diagnosis and workup we're going to talk about here is something you will see you on the boards and you will also see on the wards.

02:03 Alright so, let's go to the question characteristics.

02:07 Now, this is actually a surgery question.

02:09 The diagnosis we're gonna talk about is bread and butter surgery.

02:13 It's a two-step question.

02:15 We first gotta figure out the diagnosis and then figure out how can we diagnose it, do we need further imaging to confirm a diagnosis? And of course, the stem is required because we need to use the question stem, filter out all the data and come to the correct diagnosis.

02:30 Now let's go -- let's walk through the question.

02:33 We have a 56-year-old male patient coming in with the chief complaint of pain and swelling in the inguinal region.

02:41 It's also accompanied by nausea.

02:44 Now, we're told it's sudden in onset and it occurred while lifting something heavy.

02:51 Now, the patient's history is significant for swelling for the last several years.

02:56 Now, the clinical examination.

02:59 We see that it's significance for a non-reducible erythematous swelling and also moderate abdominal distention.

03:09 Now when we look at that, you know he has this non-reducible erythematous swelling around the scrotum region.

03:16 He has moderate abdominal distention.

03:19 Our differential diagnosis here is actually fairly broad.

03:22 We have -- first you can think about infection or inflammation and that's supportive by the fact that he is nausea but it's kind of unlikely, given that he's had this swelling for several years.

03:35 So, he's not gonna have an infection for that long.

03:37 A tumor is also possible but again, unlikely because he has this sudden episode occurring.

03:45 Lymphadenopathy is possible but kind of unlikely given the presentation in the clinical situation that we're hearing.

03:53 Now, inguinal hernia is also very likely, given the presence of swelling in the actual scrotal region and also the history of a high abdominal pressure in the past.

04:06 Also, by the fact that having episodes of increased abdominal pressure with coughing, or physical straining make it worse.

04:15 Now, if it is an inguinal hernia, there are two types: you can have a not incarcerated or an incarcerated.

04:22 Now, if it's not incarcerated, that doesn't sound to be the case here because the exam, they cannot reduce the hernia so this is likely then an incarcerated hernia.

04:34 An incarcerated inguinal hernia is actually consistent with the abdominal distention that he has because when the hernia is incarcerated, you have a trapped bowel segment causing air outflow obstruction.

04:49 Now, this is very important to actually understand because you need to be able to distinguish the incarcerated versus the non-incarcerated hernia because if it is incarcerated, you often require surgical repair.

05:03 Now, so our suspected diagnosis here then is an incarcerated inguinal hernia.

05:09 Now we need to figure out, the question being asked, which test should be performed to confirm the diagnosis.

05:17 Now, the patient's clinical presentation is really quite consistent with the diagnosis of an incarcerated inguinal hernia and we don't really have any significant suspicion of any other cause.

05:29 So in this case, if we were not sure, say, we could do other tests.

05:36 We could an ultrasound, we could do a CT, we could even do an MRI.

05:39 But in this case, it's pretty unequivocal. We know what's going on.

05:42 It's an unequivocal case of an incarcerated inguinal hernia so no further tests are required because the clinical picture in history and examination are really quite sufficient for the diagnosis.

05:56 So, the correct answer here is answer choice B, no further workup is necessary.

06:01 Now, let's go through all the answer choices in a bit more detail to figure out why.

06:05 Now, look at answer choice B, no further tests are necessary.

06:09 Patient presents with what we're talking about which are signs and symptoms that are concerning for an incarcerated inguinal hernia.

06:17 He has a tender erythematous swelling that cannot be manipulated or reduced.

06:22 The diagnoses here for these hernias is usually just clinical.

06:28 An inguinal hernia, again, is a protrusion of the abdominal wall contents of the abdominal cavity through a weakened area of the posterior wall of the inguinal canal.

06:39 Important to remember, it's the posterior wall of the inguinal canal.

06:44 Inguinal hernias are the most commonly encountered hernias of all types of hernias and they account for more than 70% of cases of hernia.

06:55 There are two types like we said, of the inguinal hernias.

06:58 They can be direct or indirect, and that's an anatomical distinction.

07:03 Now the type is defined by the relation of the hernial sac to the inferior epigastric vessels.

07:11 Now, you can refer to your image as I go through it to kind of help you understand what is the differentiation between an indirect or a direct inguinal hernia.

07:20 We'll go through this image again in high-yield facts but I want you to kind of follow along if you like or just listen.

07:26 So a direct hernia is located medial to the inferior epigastric blood vessels and typically protrudes through the superficial or external ring.

07:38 On the other hand, an indirect hernia is located lateral to these inferior epigastric vessels and protrudes to the deep or internal inguinal ring.

07:49 Clinically, inguinal hernias manifest as a visible or palpable scrotal mass and the protrusion of the hernia and the associated symptoms can be aggravated by episodes in which you have increased intra-abdominal pressure such as physical straining, coughing, or laughing.

08:07 Now when the contents of the hernial sac, which may contain fascia, fat, or bowel becomes incarcerated.

08:15 The mass may become edematous, red, and painful.

08:20 Now, in cases where the strangulation of the bowel occurs, the clinical presentation is similar actually to just bowel obstruction.

08:27 Namely, abdominal distention, pain, no bowel movement, no flatus, and abdominal tenderness with rebound, and guarding.

08:36 Now, the diagnosis of inguinal hernia is almost always made clinically with clinical examination alone.

08:44 Surgery will come by with doing an evaluation of the patient and they're usually diagnosed clinically.

08:49 Now, sometimes diagnostic imaging is required in equivocal cases.

08:54 You can use ultrasound, CT, or even MRI. Now, in the cases of an incarcerated or strangulated hernia, surgical repair is necessary and is often emergent.

09:07 In mild reducible hernias, observation or elective surgery are really reasonable options.

09:13 The major steps of an inguinal hernia repair surgery can be laparoscopic or open and the goal is to excise the hernia sac and reinforced the posterior wall of the inguinal canal to prevent another episode.

09:29 Now, various techniques exist for reinforcing the wall.

09:34 For example, there's an open Lichtenstein repair, which is a synthetic mesh is installed between the internal oblique muscle and the aponeurosis of the external oblique muscle.

09:45 Now, there's also an open Shouldice repair, in which the transverse fascia is doubled and the abdominal internal oblique muscle and transverse muscles are fixed to the internal canal.

09:57 Now, laparoscopic approaches include a transabdominal, preperitoneal repair or TAPP, in which the mesh is actually installed in the abdominal cavity over the hernia sites through an incision in the peritoneum.

10:13 It is also a total extraperitoneal repair or a TEP in which a mesh is installed over the hernia sites, outside of the abdominal cavity over the peritoneal.

10:23 Now let's go through some of the other answer choices now that you're an expert in hernia repair.

10:29 Ultrasonography, answer choice A.

10:31 Ultrasonography is the preferred initial imaging modality to confirm the diagnosis of an inguinal hernia in equivocal cases.

10:40 But in this case, again the clinical history is enough to make the diagnosis.

10:44 Now you can refer to our image here, which actually shows an ultrasound image of an indirect inguinal hernia seen on ultrasound.

10:54 And again, we'll go through this again on high-yield facts, but I want you to see things multiple times so you can appreciate that ultrasound can be used and is the preferred modality in equivocal cases.

11:04 Answer choice C is fine needle biopsy.

11:07 Now, in cases of lymphadenopathy, when you're worried about it and the differential of an inguinal mass, it can be assessed with the fine needle biopsy.

11:15 But again, in this case, the case is quite clear clinically and we don't need to do that.

11:21 Answer choice D is laparoscopy. Now diagnostic laparoscopy is not recommended as a diagnostic modality.

11:28 It's not appropriate. We have much easier, less invasive imaging to pick from.

11:32 Answer choice E is a CT scan.

11:35 Now, that can be used to be an aid in the diagnosis of inguinal hernia when the findings are equivocal, even after ultrasound, and then you can try CT.

11:45 Now, let's review some high-yield facts regarding inguinal hernias.

11:51 Now, an inguinal hernia is a protrusion of the abdominal cavity contents through weakened abdominal wall.

11:57 Like we said, there are different types.

11:59 You can have a not incarcerated versus an incarcerated type when we discussed.

12:04 Now it can also be direct vs indirect, depending on the location relative to the epigastric vessels.

12:11 Now we had mentioned and again, refer to our image here in which we're showing you the location of a n indirect versus a direct inguinal hernia.

12:20 A direct is when you have medial, that's where the hernia is, medial to the epigastric vessels and then indirect is when it's lateral to these epigastric vessels.

12:32 Now, the diagnosis is generally clinical without further tests being required and the imaging is used in uncertain cases.

12:39 Ultrasound being preferred and if that still has equivocal, we can go to CT scan.

12:44 Now, you can look at our image here again of an ultrasound of an indirect inguinal hernia seen on ultrasound and then testicle is labeled for you and the arrow shows the hernia going through the abdominal wall.

12:57 Now, the treatment here is the surgical repair of the abdominal wall in the case of an incarcerated or at-risk hernia.

13:05 If it's reducible, you can do observation or a possible outpatient surgery.

13:10 Now let's go through our image one more time cuz I really want you guys to get this anatomy. It's outrageously important.

13:16 So, looking our image, Number 9 label is the inferior epigastric artery.

13:21 Number 10 is the internal inguinal artery, and there you see the site of the indirect inguinal hernia.

13:29 Number 11 is the actual inguinal canal itself and number 12 is the subcutaneous inguinal ring and the site of our direct inguinal hernia and then number 13 is the femoral ring.

13:42 Now if you recall, we talked about direct exam being medial to the epigastric vessels and you can see that, number 12 is medial to number 9 and we had mentioned that indirect is lateral to the epigastric vessels and you can see that again here. Number 10 is lateral to number 9.