Case Presentation

CASE PRESENTATION
RIGHT INGUINAL SWELLING

RAJENDRA MAHARJAN
SURGERY RESIDENT
PARTICULAR
 MR BHANDARI ,
 66 yrs, male,
 chitwan,
 farmer
 hindu
 Married
 Literate
CHIEF COMPLAIN
 Right inguinal swelling for 2 months
History of present ill ness
 Noticed swelling in right in inguinal region for 2 months while lifting weight,
 initially of tt ball size, gradually increasing , now hen egg size
 Swelling present initially while straining and coughing , now seen on upright
position and disappear on lying down
 No hx of pain over swelling
 No swelling on oppisite side
 no hx of fever, weight loss
 Hx straining during defecation and passing of hard stool present , but non blood
mixed, non mucus mixed
 no straining during micturition or other complain of urination
 No hx of chronic cough, chest pain , sob , hemoptysis
 Non iv drug user
 No hx of trauma
 No other lesion on genital region or right leg
 No hx of difficulty in walking
 no hx of nausea , viomitting , pain abdomen, abdomen distension , water brass ,
heart burn , hematemesis, diarrhea, hematochesia
 No hx palpitation, pedel edema , facial pufyness
 No hx of hearing , vision , or speech impairment , convulsion , focal motor or
sensory impairment
 no hx of petechiae, perpura , joint swelling
Past hx
 Hx of DM with controlled sugar level with medication metformin 500mg bd
 Modified grahm patch repair done 1 year back for du perforation
 Non HTN , TB, STDS ,lymphoma or other surgical intervention
Personal hx
 Non alcoholic non smoker, consumes mixed diet
 no known drug allergy history
Family hx
 No documented hx of dm htn ptb malignancy hernia to parents and brother and
sister
Examination
Genaral examination
 Setting comfortably on bed, conscious, co operative, Well oriented to
time ,place , person,
 wt 65 kg bmi 23.3 kg/m2
Vitals
 bp 110/70 mm hg,
 pulse 80 bpm
 Respiatory rate 16/min
 Temp 98.6’f
No pallor, icterus, edema, cyanosis ,lymph node palpable
On inguino scrotal examination exposure
Inspection
on standing :
swelling on right inguinal region, pyriform shape tip directining medial and
downward, about 7cm along ligament and 5cm perpendicular to it, smooth, ill
defined margin, expansile on coughing
 No reddnes , ulcer, puntum, scar, engorged vein pigmentation on skin over
swelling
 no visible pulsation
 Swelling disappeared on lying down
 Penis in midline, no deviation
 Scrotum is separated from swelling , b/l equal in size, no deviation, with presence
of b/l testis
Palpation
 No local rise of temperature over swelling
 No tenderness over swelling
 Getting over swelling absent
 Swelling present On inguinal region about 3 cm downward and medial to ASIS ,
oblique toward penis and 10 cm downward and lateral from umbilicus toward mid
inguinal ligament,
of length 7cm along inguinal ligament and 5 cm perpendicular to it,2 cm
height , pyramidal shape directed downward
 Smooth surface and margin
 Soft consistency
 Reducible,
 Non transilluminent, non fluctuant
 Dull on percussion
 Bowel sound present
 Finger invagination test not done
 Deep ring occlusion test : no bulge medial to swelling,
 Ziemann’s test impulse felt in index finger
Abdomen examination:
Inspection:
abdomen flat, umbilicus central, presence of midline scar mark extending 5 cm
down to xiphisternum to 5 cm below umbilicus,abdomen moves with respiration,no
scar pigmentation, pulsation swelling
Palpation:
 No local rise of temperature, tenderness, guarding rididity,liver spleen kidney not
palpable
Percussion: Tympanic
Auscultation: Bowel sound heard 2 times / min
On digital rectal examination:
no skin tag ,fissure , discharge, sinus, fistula, hemorrhoid, mucosa smooth ,prostate
non tender firm upper margin palpable with size approx. 20 gm
Chest examination :
 Inspection b/l symetricat eliptrical chest, no visible scar ,swelling b/l
equal chest movement rr 18/ min, apical impulse below and lateral to
nipple
 Palpation: b/l equal chest expansion apex beat at 5th ics at mcl
 Percussion :resonant, liver dullness from 6th ics at right mcl
 Auscultation:b/l vesicular breath sound heard, s1 s2 heard no murmur
CNS :no focal motor or sensory deficit

Musculoskeletal : spine straight no visible swelling , ulcer discharge, no
difficulty in moving all limbs , no joint swelling , petichiae , perpura
Summary of case
66 yrs male with diagnosed and controlled dm with medication presented with c/o of
painless, redicuble swelling in right inguinal region for 2 monthswhich progressively
increased in size,initially appear on straining and coughing but now on standing and
redicued on lying down. He has hx of constipation but no feature of bowel
obstructuion, luts, chronic cough, no other surgical intervention except modified
graham patch repair.
on examination, general physical examination is normal , local examination of right

inguinal region revealed7*5 *2 cm pyriform swelling within inguinal canal, non tender
,soft, non fluctuant, non transluminent,dull on percution ,bowel sound present over
swelling,deep ring occlusion test negative, zeman test impulse felt on index finger,
scrotum normal and b/l testis present
 Provisional diagnosis:
Right sided incomplete , redicuble , indirect inguinal hernia containing intestine
With dm under medication
Differential diagnosis
Enlarged lymph node
Cord lipoma
Hematoma
Encysted cord hydrocele
Undisended testis
Psoas abscess
Investigation
 HB : 13.7 GM %
 TWBC :7600 / mm3
 Platelet 194000 / mm3
 RBS: 116 mg%
 RFT :WNL
 Urine re :wnl
 SEROLOGY : non reactive
 PT /INR: 14/1.2
 COVID 19 : negative
 CXR : no abnormality seen
 ECG: sinus rhythm
Management
 Planned hernioplasty on spinal anesthesia

 Metformin stopped and started sliding scale for regular insulin
 Kept npo from mid night
 Started GIK from 5 am morning
operative procedure: right side hernioplasty

anesthesia : spinal
Operative finding:
- Right sided incomplete indirect inguinal hernia
- empty sac lying over spermatic cord in anterio-lateral position within inguinal
canal
- Deep ring defect of 2 cm
- Sliding of cecal wall from medial side of deep ring
Final diagnosis
 Right sided reducible incomplete indirect inguinal and cecal sliding

hernia with empty sac
 EHS CLASSIFICATION : Right sided PL1
 NHYUS : RIGHT SIDED TYPE 2 HERNIA
 THANK YOU

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CASE PRESENTATION

RIGHT INGUINAL SWELLING

CNS :no focal motor or sensory deficit

on examination, general physical examination is normal , local examination of right

 Planned hernioplasty on spinal anesthesia

operative procedure: right side hernioplasty

 Right sided reducible incomplete indirect inguinal and cecal sliding

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