Groin Swelling Research Articles

False Aneurysm of the Superficial Femoral Artery after Total Hip Arthroplasty: A Case Report

Vascular lesions in hip prosthetic replacement are rare events; it is mandatory to be aware of the risk, though, in order of the vascular bundle's proximity to the surgical field. A 74-year-old patient was admitted to our department for primary hip arthroplasty for osteoarthritis. The patient was healthy but had mild hypertension. A cemented total hip prosthesis was implanted. The patient complained of growing groin pain and swelling from the third postoperative day. The suspicion of a vascular injury arose with worsening pain and low haemoglobin at blood tests. Then ultrasonography scans and digital angiography were performed, showing a superficial femoral artery pseudo-aneurysm. The patient had further surgery to repair the lesion. In the described case, the pseudo-aneurysm might have been caused by the pulling of a Hohmann retractor on arterial vessels possibly affected by atherosclerosis. The final output was favourable, but the authors point out that knowledge of neurovascular anatomy is necessary as well as postoperative surveillance of the clinical presentation of the patient if groin pain or swelling should arise. In the case of suspicion of vascular lesions, ultrasound and angiography will allow diagnosis and confirm the indication for surgical repair.

Ovarian Carcinoma Presenting With Isolated Contralateral Inguinal Lymph Node Metastasis: A Case Report

Ovarian carcinoma usually presents at an advanced stage with diffuse intraabdominal manifestations. We report a patient who presented with a right groin swelling. The only clinical abnormality was an enlarged right inguinal lymph node (3 x 2 cm), for which excision biopsy revealed metastatic adenocarcinoma. A computed tomography (CT) scan showed an enlarged left ovarian lesion (9.0 x 6.4 cm). Laparotomy with total hysterectomy, bilateral salpingo-oophrectomy and partial omentectomy were performed. Histology confirmed left ovarian adenocarcinoma, consistent with the earlier histology of the right inguinal lymph node. There were no other sites of involvement. Postoperatively, the patient received adjuvant chemotherapy for treatment of FIGO Stage IIIc ovarian carcinoma and is clinically disease free 13 months after surgery. Ovarian cancer presenting with inguinal lymph node metastases is uncommon. Ovarian cancer which manifests solely as a contralateral inguinal lymph node metastasis has not been previously reported. This case illustrates a rare presentation of ovarian carcinoma, and underscores the need to consider ovarian carcinoma in the differential diagnosis of women with inguinal lymphadenopathy.

Hydrocele of the canal of Nuck: Sonographic and MRI appearances

Hydrocele of the canal of Nuck is a rare disorder in females. A 50-year-old female presented with the complaint of swelling and occasional pain in the right groin. Sonographic examination revealed a proximal dilatation at the inguinal canal with a 3-cm ovoid, septated cystic lesion at the distal end. The mass appeared as a simple cyst on MRI. Valsalva's maneuver during real-time sonography helped differentiate the hydrocele of the canal of Nuck from an inguinal hernia.

De Garengeot hernia: an analysis of our experience

The presence of a vermiform appendix in a femoral hernia sac is termed De Garengeot hernia. It may present as a tender and/or erythematous groin swelling and is often misdiagnosed as an incarcerated or strangulated femoral hernia. The purpose of this study is to review the management of De Garengeot hernia at a single institution since 1991. A retrospective analysis of seven consecutive patients operated upon at our institution from 1991 to 2006 with De Garengeot hernia was undertaken. Patients' demographics, treatment performed and postoperative outcome were analysed. There were three men and four women. The median age was 55 years. None of the patients were diagnosed preoperatively. The commonest presenting symptom was painful groin swelling. All patients therefore underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated femoral hernia. Operative findings included four normal appendices, two inflamed appendices and one perforated appendix in the femoral hernial sac. Patients with normal appendix (n = 4) had mesh hernia repair without an appendicectomy. The rest of the patients (n = 3) with abnormal appendix underwent emergency open appendicectomy followed by sutured hernia repair. We had no deaths in this series and one minor wound infection. No recurrent hernia has been detected to date. Inflammation of the appendix determines the type of hernia repair and surgical approach. Incidental appendicectomy in the case of a normal appendix is not preferred.

A hernia in the inguinal region is not always an inguinal hernia

A male patient of 60 years presented with a swelling in the left groin of 10 months duration. Past records showed bilateral lumbar sympathectomy and omentopexy done 20 and 6 years back, respectively, for Buerger's disease. Abdominal examination revealed a huge hernial swelling in the left groin extending from the symphysis pubis to anterior superior iliac spine measuring 25 x 18 cm. On exploration, the contents were intestines and omentum, which were coming out through a defect of 5 x 3 cm in the lower fibers of the conjoint muscle 4 cm cephalad to the deep ring, a finding which made the final diagnosis as an incisional hernia. We present this interesting case as a very rare complication of omentopexy, probably not reported previously, and an unusual case of an incisional hernia presenting as an inguinal hernia which is very difficult to diagnose unless encountered before. Its rarity and clinical challenge is highlighted.

False aneurysm of the superficial femoral artery after total hip arthroplasty: a case report

Vascular lesions in hip prosthetic replacement are rare events; it is mandatory to be aware of the risk, though, in order of the vascular bundle's proximity to the surgical field. A 74-year-old patient was admitted to our department for primary hip arthroplasty for osteoarthritis. The patient was healthy but had mild hypertension. A cemented total hip prosthesis was implanted. The patient complained of growing groin pain and swelling from the third postoperative day. The suspicion of a vascular injury arose with worsening pain and low haemoglobin at blood tests. Then ultrasonography scans and digital angiography were performed, showing a superficial femoral artery pseudo-aneurysm. The patient had further surgery to repair the lesion. In the described case, the pseudo-aneurysm might have been caused by the pulling of a Hohmann retractor on arterial vessels possibly affected by atherosclerosis. The final output was favourable, but the authors point out that knowledge of neurovascular anatomy is necessary as well as postoperative surveillance of the clinical presentation of the patient if groin pain or swelling should arise. In the case of suspicion of vascular lesions, ultrasound and angiography will allow diagnosis and confirm the indication for surgical repair.

Prevalence and awareness about sexually transmitted infections among males in urban slums of Delhi

India is at present facing an emergence of sexually transmitted infections (STIs) and human immunodeficiency virus. Community-based studies on the prevalence of STIs among males are scanty. (i) To study the prevalence of STIs and (ii) to assess the level of awareness about STIs among males belonging to the reproductive age group residing in an urban slum. This is a cross-sectional study conducted in selected areas of Delhi, using a camp approach. One hundred ninety-six males in the reproductive age group were interviewed regarding their awareness about STIs, past history and present complaints of any symptoms suggestive of an STI. This was followed by a clinical examination. Required samples were also collected for microbiological tests. Simple proportions and Chi-square test. As many as 70% of the study participants were unable to mention even one symptom of an STI. About 73.4% of the study participants stated that staying in a monogamous relationship could help prevent STI, while only 39.2% were aware that condoms could afford protection against an STI. As many as 8.7% complained of urethral discharge, while 5.6% complained of itching, 2.5% reported presence of genital ulcer and 1.0% complained of groin swelling. We found a seroprevalence rate of 1.5% for trichomoniasis and 3.6% for syphilis. Thus the overall awareness level about STIs and their prevention was rather low. Poor treatment-seeking behavior was also observed. The actual prevalence rate in the general population might be higher due to the likelihood of presence of an asymptomatic infection. The present study calls for a multipronged approach which also includes targeted interventions and strategies to be adopted in the reproductive health programs for males who have been neglected by the program managers so far.

Appendicitis in a Preterm Infant with Incarcerated Inguinal Hernia

We report a case of appendicitis and incarcerated inguinal hernia in a preterm triplet with Enterococcus faecalis sepsis. After a course of antibiotic treatment for three days, the four week old boy presented with a distended abdomen and right groin swelling due to a suspected incarcerated hernia. Surgical examination revealed an incarcerated inflamed appendix inside an inguinal hernia.

Endometriosis presenting as pleural effusion and haemoperitoneum: case report and a review of the literature

A case of endometriosis presenting as haemorrhagic pleural effusion and ascites in a 40 year old multiparous woman is described. Her main clinical features were left groin swelling 12 years prior to this presentation which was confirmed at histology (after excision) to be endometriosis; secondary infertility, peri-umbilical nodule with cyclic pain especially during the menstrual flow; secondary dysmenorrhoea, dyspareunia, irregular menses, inter-menstrual bleeding, dyspnoea and abdominal swelling. Investigations revealed pleural effusion on chest X-ray and a complex pelvic-abdominal mass with ascites on ultrasonography. She was managed with danazol, thoracotomy and, eventually, laparotomy. Subtotal hysterectomy with bilateral salpingoophorectomy was performed and histological examination of the tissues confirmed endometriosis and adenomyosis. Keywords: endometriosis, pleural effusion, ascites Tropical Journal of Obstetrics and Gynaecology Vol. 23(1) 2006: 77-79

Eighteen Year Old Male with Right Hip Pain

Purpose: An eighteen-year old Caucasian male presented with complaints of right hip pain for ten days. The pain was sudden in onset, constant, worse with leg flexion and internal rotation also associated with groin swelling. The patient denied fevers, weight loss, change in bowel pattern or prior history of similar complaints in the past. He has never been sexually active and denied the use of alcohol, smoking and illicit drug use. The patient has had no known tuberculosis exposure. Physical exam revealed tenderness in right lower quadrant with voluntary guarding and a positive psoas sign. Lab studies found him to be anemic with mild thrombocytosis. A CT scan of the abdomen revealed a right psoas abscess with bowel wall thickening (Figure 1). The patient subsequently had a colonoscopy which revealed multiple ulcerations within the ileocecal region. The biopsy demonstrated pathological findings consistent with Crohn's ileitis (Figure 2).FigureFigurePsoas abscess is an uncommon complication of Crohn's disease (< 2%) and a rare initial presentation. Psoas abscess occurs as a result of retroperitoneal perforation of the ileocecal region. Patients can present with sepsis or severe muscle spasm with flexion and internal rotation of the hip. The diagnosis is made with CT scan. Treatment includes drainage of the abscess and appropriate antibiotics. Our patient was found to have Streptococcus anginosis, E. coli and H. parainfluenza cultured from the abscess after surgical drainage. He was placed on antibiotics and started on mesalamine 1gm QID after segmental resection of the diseased area. Since discharge and initiation of therapy, the patient has reported improvement of his symptoms. [figure 1] [figure 2]

Appendicitis Within a Femoral Hernia

Appendix within a femoral hernia was first described by the Parisian surgeon Rene Jacques Croissant de Garengeot in 1731 and is a rare, often incidental finding at surgery. Appendicitis in a femoral hernia is even more rare, and although it has been well reviewed in the medical literature, its sonographic appearance has been described only once. We report the sonographic findings of appendicitis in a femoral hernia and stress the potential benefits of this imaging modality in cases of acute groin pain and swelling.

Comparative Study of Tailor-made Mesh Plug Herniorrhaphy Versus Lichtenstein Herniorrhaphy Versus Bassini Operation: A Prospective Clinical Trial

Operations to cure inguinal hernia are among the most common surgical procedures. However, the most effective surgical technique for inguinal hernia repair is unknown, and the recurrence at 5 years varies between 1% and 10%. Surgical techniques and implanted materials are crucial to the result of and costs associated with hernia repair. The objective of this study was to determine whether the tailor-made mesh plug for inguinal hernia repair was as effective and safe as other methods of herniorrhaphy. Of 94 patients who had a primary diagnosis of inguinal hernia prospectively included in the study, 25 were treated with tailor-made mesh plug herniorrhaphy, 26 with Lichtenstein herniorrhaphy and 36 with the Bassini operation. The primary outcome was the recurrence of hernia at 1 year, and secondary outcomes included surgical complications and hospital stay. There was no postoperative mortality in this study. Three patients had recurrence after Bassini operation, but there was no recurrent hernia after Lichtenstein or mesh plug herniorrhaphy. Groin swelling and ecchymosis were found in two patients (1 tailor-made mesh plug, 1 Lichtenstein herniorrhaphy). No surgical site infection occurred. Mean operating time was 60 minutes (range, 45-75 minutes) for tailor-made mesh plug herniorrhaphy, 82 minutes (range, 30-120 minutes) for Lichtenstein herniorrhaphy, and 82 minutes (range, 30-135 minutes) for the Bassini operation. Tailor-made mesh plug herniorrhaphy is a safe operation. The mesh plug material (Mersilene) was cheap. The recurrence rate was lower with tailor-made mesh plug herniorrhaphy than with the Bassini operation, but equal to that with Lichtenstein herniorrhaphy. Postoperative complications did not differ among all operations.

Infected false aneurysms in the groin of intravenous drug abusers

The hazards of dealing with infected false femoral aneurysms resulting from intra-arterial narcotic injection are highlighted in six patients. Two patients were human immunodeficiency virus positive and three patients were hepatitis B surface antigen positive. Because of these infections exploration of groin swellings as presumed soft tissue abscesses is potentially hazardous without proper proximal vascular control. All patients underwent reconstruction following arterial ligation and five grafts became infected, with life threatening haemorrhage occurring in four patients. Five grafts have subsequently occluded or have been removed without loss of limb viability, although two patients have been regrafted. A high index of suspicion and assessment by a vascular surgeon, with angiography if indicated, is required in any intravenous drug abuser presenting with a groin swelling following injection. Because of the great risk of graft infection, it is suggested that ligation and debridement alone be carried out, with immediate arterial reconstruction only for non-viability.

Femoral hernia: intestinal obstruction is an unrecognized source of morbidity and mortality.

A total of 180 consecutive femoral hernia repairs, consisting of 100 emergency and 80 elective admissions between January 1979 and December 1986, were reviewed. Morbidity was greater in the emergency than in the elective group (P < 0.01) and was significantly related to intestinal obstruction (P < 0.001), a feature not previously highlighted. Intestinal obstruction also had an important association with mortality, which was confined to patients undergoing emergency surgery. Patients with intestinal obstruction are a high-risk group and require careful perioperative management. Wound infection predisposed to recurrence of femoral hernia (P < 0.01). Repair of recurrent hernia in patients treated electively was associated with an increased incidence of chest infection (P < 0.001). Prophylactic measures, including antibiotics, may help to reduce recurrence and its associated morbidity. Patients referred with an inguinal lump or hernia, as opposed to a femoral hernia, had a later outpatient appointment and consequently a later operation date (P < 0.02). All elderly patients referred with any groin lump should receive an early outpatient appointment.

Broken needles

A 35-year-old male intravenous drug user was admitted for left groin swelling and fever. On examination, we found a football-sized abscess in his left groin and pitting oedema of the whole left lower limb. A radiograph showed many retained broken needles (figure). CT showed that some needles were in the rectus femoris, and some were pointing towards the skin surface. The patient had a deep vein thrombosis, his left femoral artery was patent and there was no pseudoaneurysm. Broken needles in intravenous drug users are not uncommon. The possibility of sustaining injuries from sharp protruding objects should be kept in mind when examining patients. A 35-year-old male intravenous drug user was admitted for left groin swelling and fever. On examination, we found a football-sized abscess in his left groin and pitting oedema of the whole left lower limb. A radiograph showed many retained broken needles (figure). CT showed that some needles were in the rectus femoris, and some were pointing towards the skin surface. The patient had a deep vein thrombosis, his left femoral artery was patent and there was no pseudoaneurysm. Broken needles in intravenous drug users are not uncommon. The possibility of sustaining injuries from sharp protruding objects should be kept in mind when examining patients.

Early Postoperative Evaluation of Groins After Laparoscopic Total Extraperitoneal Repair of Inguinal Hernias

Minimally invasive laparoscopic total extraperitoneal (LTEP) repair of bilateral and/or recurrent groin hernias has been popularized as one of the procedures of choice in the past decade. The early postoperative course is uneventful in most cases. A few patients, however, will develop temporary postoperative groin swelling. The aim of our study was to evaluate clinical and sonographic findings in the groin during the early postoperative period following LTEP. One hundred and five consecutive patients with primary bilateral (n = 90), recurrent unilateral (n = 12), and primary unilateral (n =3) groin hernias operated on during an 18-month period underwent clinical and sonographic examination two to three weeks after LTEP. On clinical examination, a localized groin swelling was found in 21 patients (20%). The most frequent sonographic findings were localized groin collections compatible with seroma or hematoma, found in 35 patients (33%). Hypoechoic diffuse tissue swelling around the mesh, lipomas, and residual hernias was found in four patients each (4%). None of the patients with hypoecoic mass had any clinical manifestations postoperatively. Extraperitoneal close suction drains were left for 8-12 hours in 46 patients. The average volume of fluid drained was 62 mL (range, 30-200 mL). There was no correlation between the use of suction drains and the frequency of fluid collections detected on sonography. Cord lipoma was detected postoperatively in four patients and was excised in one using an open anterior approach. Residual or recurrent hernia was detected postoperatively on sonography in four patients, but only one developed a symptomatic and clinically detectable hernia during eight months of follow-up. Overall, postoperative ultrasonographic findings following LTEP repair were found in 37% of patients. Clinical and sonographic findings such as localized fluid collections compatible with seroma or hematoma are common following LTEP. Postoperative suction drains did not reduce the frequency of sonographically detected collections. The clinical relevance of suspected postoperative hernia detected on sonography without clinical manifestations remains uncertain, and has to be determined on long-term follow-up.

Early Postoperative Evaluation of Groins After Laparoscopic Total Extraperitoneal Repair of Inguinal Hernias

Background: Minimally invasive laparoscopic total extraperitoneal (LTEP) repair of bilateral and/or recurrent groin hernias has been popularized as one of the procedures of choice in the past decade. The early postoperative course is uneventful in most cases. A few patients, however, will develop temporary postoperative groin swelling. The aim of our study was to evaluate clinical and sonographic findings in the groin during the early postoperative period following LTEP. Method: One hundred and five consecutive patients with primary bilateral (n = 90), recurrent unilateral (n = 12), and primary unilateral (n =3) groin hernias operated on during an 18-month period underwent clinical and sonographic examination two to three weeks after LTEP. Results: On clinical examination, a localized groin swelling was found in 21 patients (20%). The most frequent sonographic findings were localized groin collections compatible with seroma or hematoma, found in 35 patients (33%). Hypoechoic diffuse tissue swelling around the mesh, lipomas, and residual hernias was found in four patients each (4%). None of the patients with hypoecoic mass had any clinical manifestations postoperatively. Extraperitoneal close suction drains were left for 8–12 hours in 46 patients. The average volume of fluid drained was 62 mL (range, 30–200 mL). There was no correlation between the use of suction drains and the frequency of fluid collections detected on sonography. Cord lipoma was detected postoperatively in four patients and was excised in one using an open anterior approach. Residual or recurrent hernia was detected postoperatively on sonography in four patients, but only one developed a symptomatic and clinically detectable hernia during eight months of follow-up. Overall, postoperative ultrasonographic findings following LTEP repair were found in 37% of patients. Conclusion: Clinical and sonographic findings such as localized fluid collections compatible with seroma or hematoma are common following LTEP. Postoperative suction drains did not reduce the frequency of sonographically detected collections. The clinical relevance of suspected postoperative hernia detected on sonography without clinical manifestations remains uncertain, and has to be determined on long-term follow-up.

Symptomatic Desmoid Tumour in a Patient with Klippel Trenaunay Syndrome

Radiology, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UKIntroductionKlippel trenaunay syndrome (KTS) comprises anunusual triad of signs: capillary malformation, var-icosities and bone and soft tissue hypertrophy. Thishypertrophy is often asymmetrical affecting one limb.KTS has no known association with soft tissuetumours. Here, we describe a desmoid tumourcompressing the external iliac vein resulting insymptomatic pelvic varicosities in a patient with KTS.ReportA 33-year-old mother presented with a history of rightleg swelling following intercourse, preventing herfrom standing during the following hour. She alsocomplained of vulval discomfort, and symptomaticextensive varicose veins in her right leg and vulva,which increased in severity during the week prior tomenstruation. She had been diagnosed 12 years earlierwith KTS.Duplex scanning revealed an incompetent longsaphenous system with varicosities arising from this.MR venography showed large uterine and pelvicveins, and an enhancing area compressing the rightexternal iliac vein (Fig. 1).On pelvic venography a May–Thurner lesion wasseen to almost occlude the left common iliac vein andthe right external iliac vein appeared to be compro-mised due to palpable inguinal lymphadenopathy.Bilateral venous occlusion was thought to haveresulted in shunting via pelvic collaterals and be thelikely cause of her discomfort. A left sided ovarianvarix was seen arising from the left renal vein and wasembolised with coils.Her symptoms failed to improve and 1 year latershe noticed a swelling in the right groin thought to bean inguinal hernia. On surgical exploration no herniawas found, but at the edge of her Pfannenstial scar amass of infiltrative fibrous tissue within the muscles ofthe anterior abdominal wall was present. Biopsyrevealed a desmoid fibromatosis with fascicles ofspindle cells with elongated nuclei. Minimal nuclearpleomorphism was seen with occasional mitoses andno necrosis. Less than 1% of the tumour cells were inthe active cell cycle.MRI showed a 4!3!3cm

Endoscopic Totally Extraperitoneal Repair for Occult Bilateral Obturator Hernias and Multiple Groin Hernias

An obturator hernia is a rare hernia that is bilateral in about 6% of patients. Most patients present with chronic pelvic pain although a few patients may present with features of intestinal obstruction. Only about 10% of obturator hernias are diagnosed preoperatively. A 65-year-old female patient with chronic obstructive pulmonary disease presented with bilateral groin swellings associated with local pain and heaviness. She also suffered from recurrent episodes of abdominal distension. She was diagnosed to have bilateral direct inguinal hernias and a left femoral hernia. At endoscopy under epidural anesthesia she was found to have a direct inguinal, an indirect inguinal, and a femoral hernia on the left side and an indirect inguinal hernia on the right side. Additionally, the endoscopic totally extraperitoneal approach to inguinal hernias identified hitherto undiagnosed bilateral obturator hernias. The hernias were reduced and polypropylene mesh was placed bilaterally covering the myopectineal orifice and pelvic floor bilaterally. The patient was discharged the next day and is symptom-free on followup at eight months. Endoscopic repair of groin hernias allows the surgeon not only to diagnose and treat unsuspected groin hernias but also allows identification, dissection, and repair of coincidental occult pelvic hernias like obturator hernias at the same time.

Acute epididymo-orchitis in an undescended testicle

Establishing the diagnosis of a groin lump may be difficult, largely due to the large number of potential differential diagnoses. Indeed, this case was originally referred as a strangulated hernia. Despite the final diagnosis being infection of an undescended testicle, the patient did not report that he only ever had one scrotal testicle despite his 78 years of age.