Examination of an inguinal hernia is a vital part of surgical examination methods. It is one of the most basics skills that every medical student and doctor should be aware of.
More importantly, differentiating between a femoral and inguinal hernia plays a major role here.
Firstly, introduce yourself and get consent before you proceed to examine the patient.
You will be asked to examine the groin area of a patient who is lying supine, but always remember to examine the patient in the erect position as well, at some point in your examination.
This patient has got a globular shaped lump in the right groin region. It has visible and expansile cough impulse. The hernia can be completely reduced and cannot be controlled by applying firm pressure over the deep inguinal ring. He has got no phimosis and there are no coexisting scrotal lumps. The contralateral groin is normal. So my probable diagnosis is uncomplicated right-sided direct inguinal hernia and I would like to offer him inguinal hernia repair under spinal anesthesia.
Method One – 1 cm above the femoral pulse (Easy way).
Method Two – 1 cm above the mid inguinal point (midpoint between the anterior superior iliac spine and pubic symphysis).
No. Once a hernia is repaired, its anatomy is disturbed. So a recurrence of a hernia arises from the weakest part of it. Hence it is neither direct nor indirect.
Yes, it can be.
1. Not enough pressure applied.
2. Finger is not on the deep inguinal ring.
Anyway, this method is just for crude assessment. The direct or indirect nature of a hernia is best identified during the surgery.
It comes from deep inguinal ring, passes obliquely through the inguinal canal and may continue through the superficial inguinal ring to the scrotum. It arises lateral to the inferior epigastric artery. Commonly due to persistent processes vaginalis.
It occurs as a result of weakened posterior wall of the inguinal canal and arise medial to the inferior epigastric artery. So a direct inguinal hernia is not within the spermatic code. It may descend to the scrotum though.
No importance! Management is the same for both.
Inferior epigastric artery.
As early as possible due to the high risk of strangulation.
1. Mesh repair (Gold standard).
2. Darning repair.
3. Bassini repair.
4. Shouldice repair.
Indirect inguinal herniae require both herniotomy (excision of the hernia sac) & herniorrhaphy (hernial repair) while direct inguinal herniae usually only necessitate herniorrhaphy.
1. Chronic cough.
3. Cigarette smoking.
4. Bladder outflow obstruction (BOO)
1. Acute urine retention.
2. Hematoma formation.
5. Ischemic orchitis.
Less than 1%.
Ulcer Examination is a basic short case OSCE skill for all doctors and medical students.
Firstly, introduce yourself and get consent before you proceed to examine the patient. Examination of an ulcer is more or less similar to an examination of a lump. But some additional features have to be kept in mind.
2. Size (Extent).
3. Margin (Shape) – Regular? Irregular?
4. Edge – Sloping? Punched-out? Undermined? Rolled-out? Everted?
5. Floor – Healthy? Granulation tissue? Slough?
6. Discharge? – Serous? Serosanguinous? Purulent? Amount and smell?
Palpation (With a gloved hand)
1. Palpate the margin and edge.
2. Palpate the base – Muscle? Bone?
Palpation (Without gloves) – depending on the type of suspected ulcer from above
1. Temperature of the surrounding skin.
2. Regional lymphadenopathy.
3. Peripheral pulses.
4. Peripheral sensation and joint position sensations (JPS)
There is an ulcer over the right ankle just above the medial malleolus (Gaiter’s area). It is oval in shape, approximately 2cm x 3cm in size. Its margin is irregular, edge is sloping and the floor contains healthy granulation tissue. There is a serous discharge from the ulcer. The ulcer is superficial and the base contains subcutaneous tissue. The surrounding skin is warmer, pigmented and thickened. There are associated varicose veins. Peripheral pulses and sensation are normal and there is no inguinal lymphadenopathy.
There is an ulcer over the sole of the right foot which is oval in shape, approximately 3cm x 4cm in size. Its margin is regular, edge is punched-out and floor contains healthy granulation tissue. There is no discharge from the ulcer. Ulcer is painless, the base contains flexor tendons of toes, surrounding skin and peripheral pulses are normal. Peripheral sensation to pain is absent up to ankles and joint position sensation is impaired.
There is an ulcer over the tip of the 2nd toe of the right foot which is round in shape, approximately 1cm x 1cm in size. Its margin is irregular, edge is punched out and floor contains slough. There is a purulent discharge from the ulcer. The base contains bone of the distal phalanx. The surrounding skin is colder and blackish in colour. Dorsalis pedis and posterior tibial pulses are absent and the femoral pulse is weak on the right side. The peripheral sensations are normal and there is no inguinal lymphadenopathy.
There is an ulcer over the dorsum of the right foot which is irregular in shape, with a maximum diameter of 6cm. There is a purulent discharge from the ulcer. Its margin is irregular, the edge is raised & everted. Floor is reddish-brown and contains slough. There is hard inguinal lymphadenopathy on the right side. Peripheral pulses and sensation are normal.
It is a break in the continuity of an epithelial surface.
1. Margin – The line of demarcation between normal and affected tissue.
2. Floor – Exposed bottom of the ulcer.
3. Edge – It connects the margin to the floor.
4. Base – The area in which the ulcer rests.
1. Sloping – Venous ulcer.
2. Punched-out – Ischemic ulcer.
3. Undermined – Tuberculous ulcer.
4. Rolled-out – Basal cell CA.
5. Everted – Squamous cell CA.
1. Peripheral vascular disease.
2. Varicose veins.
3. Peripheral neuropathy.
4. Squamous cell carcinoma.
5. Sickle cell disease.
1. Uncontrolled diabetes.
2. Chronic alcoholism.
3. Vitamin B12 deficiency.
1. Painless ulcers.
2. Associated glove & stocking type of sensory loss.
3. Normal surrounding skin.
1. Peripheral neuropathy.
2. Peripheral vascular disease.