CASE REPORT Dr E VAMSHI KRISHNA 2 ND YR POST GRADUATE Dept of General Surgery
CHIEF COMPLAINTS A male patient of age 60yrs, occupation by farmer, resident of NARAYANAPURAM presented with complaint of- swelling in right groin since 1yr
H/O PRESENT ILLNESS • Patient was apparently asymptomatic 1year back, later he presented with complaints of swelling in right groin for 1 year. • Single swelling initially appeared in right inguinal region, above the groin crease and then extended into the scrotum • Initially small in size gradually increased • Swelling increases in size with cough, straining, lifting of weight • Swelling disappears on lying down position
• No h/o pain over swelling, pain abdomen • No h/o fever • No h/o vomittings • No h/o constipation • No h/o cough • No difficulty in micturition • No h/o swelling in contralateral side, other regions of body
PAST HISTORY • No H/O HTN/ DM/ TB/ EPILEPSY / Bronchial Asthma. • No H/o any surgery in the past. • No H/o any cardiac problems.
PERSONAL HISTORY • Built - moderate • Diet-Mixed • Appetite-Good • Sleep- adequate • Bowel and Bladder – regular • No addictions No Significant family history. No known history of drug allergies.
GENERAL EXAMINATION • On examination patient is conscious, coherent, cooperative. • Moderately built and moderately nourished. • No -pallor . • No -icterus, no- clubbing, no- cyanosis, no- lymphadenopathy, no- edema Vitals: • Temp = 98 F • PR-96 bpm, regular, rhythmic normovolemic. • BP-130/80 mmHg measured on Rt arm in supine position.
LOCAL EXAMINATION Inspection • A single pyriform shaped swelling of size 10 X 4 cm • Extending from above and medial part of right inguinal ligament down into the scrotum up to upper pole of right testis • No visible peristalsis over the swelling • Skin over swelling is normal • Cough impulse – present • Penis is in midline • In supine position swelling reduced spontaneously • Left inguinal region, scrotum, testis - normal
Palpation • No local rise of temperature, no tenderness • Swelling is above the right inguinal ligament and medial to the pubic tubercle • Extends into the scrotum upto the upper pole of Rt testis • Cannot get above the swelling • Consistency – doughy, granular • Testes palpable separately from the swelling • Ring occlusion test – on occlusion of deep ring with thumb, swelling did not appear • Ziemans test- cough impulse felt at right index finger • Finger invagination test – felt at tip of index finger
Percussion • Dull note ( omentocele) Auscultation • No peristaltic sounds heard over the swelling ( omentocele) Left inguinoscrotum - normal
EXAMINATION OF ABDOMEN INSPECTION • Abdomen is not distended. umbilicus central in position • No sinuses/scars. • All quadrants are equally moving with respiration PALPATION • No organomegaly, no mass per abdomen PERCUSSION • Tympanic note all over the abdomen AUSCULTATION • Bowel sounds heard
Abdominal muscle tone: • Normal • No molgaigne’s bulgings appeared on raising of shoulders against resistance in supine position
PER RECTAL EXAMINATION • No fissure, • No external hemorhhoids, • Sphincter tone normal • NO prostatomegaly
• Cardiovascular system : S1 S2 heard, no murmurs NAD • Respiratory system : normal vesicular breath sounds heard NAD
PROVISIONAL DIAGNOSIS • Right reducible uncomplicated incomplete indirect inguinal hernia with omentocele
INVESTIGATION Hb- 13.5 gm% Tlc-7,200 /cu.mm Platelet count: 1.5 lakhs/cumm Blood group- O +ve CUE = WNL BT-2mins 30 sec CT-4mins HIV-Non reactive HbsAg-Negative HCV-Negative RBS- 96mg/dl
RFT - • Blood Urea- 26mg/dl • Creatinine- 0.7mg/dl • Sr Na = 138 m.mol/l • sr K = 3.8 m.mol/l • Sr cl = 98 m.mol/l LFT- • Total bilirubin = 1.42m/dl • Direct bilirubin = 0.64m/dl • Total proteins = 6.5 g/dl • Albumin = 3.7 g/dl
CHEST XRAY PA VIEW
ECG
USG –abdomen, ingiuno scrotal region • Content – omentum • Prostate – 16 cc • Both testes- normal • Liver, spleen - normal
DIAGNOSIS • Right reducible uncomplicated incomplete indirect inguinal hernia with omentocele
SURGERY OPEN MINIMAL ACCESS APPROACH WITH MESH REPAIR • Under spinal anesthesia • With all aseptic precautions • 2.5 cm transverse incision given above and lateral to pubic tubercle
LICHTENSTEIN- REPAIR
OPEN MINIMAL ACCESS
POD 0 Nbm for 6 hours • Iv fluids-1 pint RL , and 1 pint DNS@ 100 ml/hr • Inj. MONOCEF 1gm/iv/BD • Inj.Pan 40 mg/iv/OD • Inj ZOFER 4mg /iv/sos • Inj TRAMADOL 50mgslow iv/ diluted in 50cc ns/ BD • Scrotal support
POD 1 • patient is conscious • Afebrile • PR = 90 / min • BP = 120/80 mmHg • p/a = soft, no distension, no tenderness, passed stools l/e dressing – clean , no soakage Scrotal region – no edema / collections •
POD 1 • Soft diet • Inj. MONOCEF 1gm/iv/BD • Tab. PANTOPRAZOLE 40 mg/OD • Inj TRAMADOL 50mgslow iv/ diluted in 50cc ns/ BD • scrotal support • Active ambulation
• oral antibiotic tab. CEFIXIME 200mg /twice daily and analgesics given for 5 days • Sutures removed on POD 9 • Wound is healthy and healing, no gaping, no discharge • Pt is discharged • 1 st followup – 1 week, wound is healthy • Next followup – 1 month, no complaint of pain, no evidence of recurrence, scar healed
THANK YOU
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