DIRECT INGUINAL HERNIA
A 65-year-old male patient, manual labourer by occupation, came with H/o
swelling in right groin and scrotum for last 2 years.
H/o pain over the swelling for last 6 months.
Swelling disappears when the patient lies down.
No other positive history.
Known diabetic for past 5 years and is not on regular medication.
O/E, a 5*10 cm swelling extending 10 cm from ASIS to the bottom of
scrotum.
DROT
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Name: Thirukumaran
Age/Sex: 65/M
Address: Pallavaram
Occupation: Manual labourer
C/C:
Swelling in the right groin and scrotum for 2 years
HOPI:
The patient was apparently normal 2 years back after which he
noticed a swelling in the right groin which was insidious in onset,
initially small in size and gradually progressed to attain the current
size, developed in the inguinal region and then slowly progressed to
the base of scrotum, increases in size on coughing and straining,
reduces on lying down.
H/o pain over the swelling for 6 months which is insidious in onset,
dragging pain, continuous, aggravated on walking long distance,
straining and relieved with rest.
H/o weight lifting.
No H/o trauma.
No H/o chronic fever with cough with expectoration.
No H/o chronic constipation.
No H/o difficulty in micturition.
Past H/o
No H/o similar complaints in the past.
No H/o DM, HTN, TB, Asthma.
No H/o any lower abdomen surgeries with transverse incision.
(Previous surgery)
Personal H/o
Mixed diet.
Normal bowel and bladder habits.
Normal sleep pattern.
Non-smoker and non-alcoholic.
Family H/o
No significant family H/o.
General examination
The patient is conscious, oriented, moderately built and nourished.
No pallor, icterus, cyanosis, clubbing, significant lymphadenopathy
and pedal edema.
Vital signs
Afebrile.
Pulse: 74/min, regular in rate and rhythm, normal in volume and
character. No radio radial or radio femoral delay. All peripheral
pulses felt equally.
RR: 16/min
BP: 110/70 mm Hg, left upper limb in sitting position.
Local examination
After getting consent from the patient, the patient was exposed from
umbilicus to mid-thigh and examined in standing as well as supine
position in a well-lit room.
Inspection:
A swelling of size 5*10 cm visible in the right groin, oval in shape,
extending 15 cm from ASIS to the bottom of scrotum.
Skin over swelling appears to be normal.
No scars, sinuses, dilated veins.
Cough impulse is seen.
On putting in supine position, the swelling is reducible
automatically.
Palpation:
No warmth and tenderness.
All inspectory findings are confirmed on palpation.
A mass of size 5*10 cm is palpable at right inguinoscrotal region,
extending 15 cm from ASIS to base of the scrotum.
Elastic in consistency.
Expansile cough impulse felt.
Deep ring occlusion test: Swelling appears on the finger on
coughing.
Zeimann’s test: Impulse felt over index finger on coughing.
Ring invagination test (lying down position): Impulse felt over tip
of finger.
Percussion:
Resonant note on percussion.
Auscultation:
Normal bowel sounds heard.
(Need not mention percussion, auscultation unless the examiner
wants you to tell)
Examination of left inguinal region: Normal
Examination of scrotum:
Testis, cord structures are felt normally.
No associated hydrocele.
Examination of penis:
No phimosis.
No pinhole meatus.
No urethral strictures.
Examination of regional lymph nodes:
No enlarged lymph nodes present.
Examination of abdomen:
No palpable mass, ascites.
No Malgaigne’s bulges seen on head raising test.
Other systems
CVS: S1S2 hears, No murmurs.
RS: NVBS heard.
CNS: No focal neurological deficit.
Provisional diagnosis:
Right sided complete direct inguinal hernia.
Investigations:
Routine:
Blood- Hb, TC, DC, ESR, BT, CT
Blood grouping and typing.
Urine- Sugar, protein, deposits
Serum- Urea, creatinine
ECG
CXR
Specific:
USG Abdomen and pelvis (only for patients above 50 years to find
out if prostatomegaly is present)
MX:
Herniotomy
Herniorraphy
Hernioplasty
