CASE REPORT Dr E VAMSHI KRISHNA 2 ND YR POST GRADUATE Dept of - - PowerPoint PPT Presentation

CASE REPORT

Dr E VAMSHI KRISHNA 2ND 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.

• 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

LOCAL EXAMINATION

Inspection

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

• Dull note ( omentocele)

Percussion Auscultation

• No peristaltic sounds heard over the swelling

( omentocele)

Left inguinoscrotum - normal

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

EXAMINATION OF ABDOMEN

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

• Under spinal anesthesia
• With all aseptic precautions
• 2.5 cm transverse incision given above and

lateral to pubic tubercle

OPEN MINIMAL ACCESS APPROACH WITH MESH REPAIR

LICHTENSTEIN- REPAIR

OPEN MINIMAL ACCESS

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 0

• 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

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
• 1st followup – 1 week, wound is healthy
• Next followup – 1 month, no complaint of pain, no

evidence of recurrence, scar healed

THANK YOU