Case presentation:-

Intern :- Amrit PokhrelGMCTH,Pokhara

Personal details:-

A 49 yrs female residing on Baglung, Housewife by occupation presented at Surgery-OPD with

Chief complaints:- Swelling on right inguinal region since 4 yrs. Pain for 15 days

History of present illness:-

Swelling on rt.inguinal region:- Since 4 yrs. Develops spontaneously. Associated with pain. Grows slowly. Not a/w fever, ulceration, loss of body weight and

swelling is single.

Pain:- At rt.inguinal region. Insidious onset. Pin pricking. Radiates toward thigh. Aggravated by standing & weight lifting. Relief by rest on supine position. Pain is mild.

Past history:-

No significant past medical ( like:- chronic cough, constipation and retention of urine ) and surgical history in past.

Personal history:-

Patient is non-alcoholic, non-smoker, non-vegetarian diet.

Family history:-

No significant family history. Eight member family with five kids.

General physical examination:- General condition – fair Jaundice Anemia Cyanosis Clubbing Lymph adenopathy Edema Well hydratedVital signs:- B.P. - 110/70 mm of Hg. Pulse – 76 beats/minute – regular. Temperature – 98.F RR – 18 breathe / minute Spo2 – 98 %

Not found

Systemic examination:-

Chest:- normal vesicular breathe sound present.

CVS :- S1 + S2 + Mo

CNS:- grossly intact.

Per abdomen:- Inspection:- Scaphoid shape. Umbilicus inverted and centrally located All quadrants moves equally with respiration. Visible pulsation and peristalsis are absent. Protrusion from right sided saphenous opening.

On palpation:-

On percussion:- Tympanic sound found.

On Auscultation:-

Bowel sound present – 3/ minute.

No localize rise of temperature.

No tenderness. No organomegaly

detected.

Local examination:-

On standing position:- Inspection:- single swelling - at upper – medial thigh. - cough impulse present. - similar to skin color. - globular. - 2.5 x 2.5 cm - well defined edge. - no pulsation & peristalsis. - no move with respiration. - skin over swelling normal.

On supine position:-

There is no alteration of shape and size of the swelling i.e. similar to standing position.

Palpation:-- No localize rise of temperature.- No tenderness.- Size 2.5 x 2.5 cm, globular.- Smooth surface.- Cough impulse present.- Distinct edge but not palpable upper edge.- Firm consistency.- Non fluctuating.- No fluid thrill.- Non translucent.- Non reducible.- Compressible.- Non pulsatile and not fixed to overlying skin.

on percussion:-

- Dull on percussion.

On Auscultation:-- No bruits.- No gurgling and bowel sound.

Laboratory findings:- TLC – 8200 Hb – 13.5 ESR – 10 RBS – 80 Urea – 31 Creatinine – 1.0 Na+ - 145 K+ - 4.1 BT – 2’ 15” CT – 7’ 30” PT/INR – 13”/1.0 Serology – negative Urine R/E – Pus cell – 12 to 14 - Epithelial cell – 1 to 3 - RBC – nil USG abdomen and pelvis. - Right Femoral Hernia.

Provisional diagnosis:-

- Irreducible Right Femoral Hernia ( Non – obstructed ).

Differential diagnosis:- Rt.inguinal hernia. Rt.inguinal lymph node. Lipoma. Psoas abscess. Femoral Artery Aneurysm.

Surgical treatment:- Open surgery – LOCKWOOD approach under Spinal

Anesthesia. Intra operative findings are:- Rt.femoral hernia with

peritoneal fluids approx. amount 20 ml

Topic of Discussion:-

Anatomy:-Boundary of femoral canal:- Supero-anteriorly :-

Inguinal ligament.

Infero-posteriorly:- Iliopectineal ligament (cooper)

Medially:- Lacunar ligament ( Gimbernats ligament ).

Laterally:- femoral vein

Hernia:-

Femoral hernia :-

Clinical presentation:-

Clinical features:- Usually presents with pain or discomfort in groin. Groin lump. Usually not reducible. Mild pain exacerbated by bending or lifting. Mild tenderness.

In case of obstruction:- Colicky abdominal pain. Vomiting, constipation Abdominal distension. Lump irreducible and tender.

In case of strangulation:-

Lump is very tender. Skin over the lump red and hot. Features of shock.

Diagnosis:-

History and Clinical examination.

Ultrasonography – abdomen and pelvis.

Differential diagnosis:-

Inguinal hernia.Saphena varix.Lipoma.Femoral artery aneurysm.Psoas abscess.Ectopic testis.

Treatment:-