Morning Report: Irreponible Scrotalis Hernia

Morning Report
IRREPONIBLE SCROTALIS HERNIA

PATIENT’S IDENTITY
• Name : Mr. GR
• Age : 35 years old
• Religion : Moslim
• Address : Budi Luhur, Pekanbaru
• Job : Labourer
• Entry Date : July 10, 2017
CHIEF COMPLAINT
Pain in right inguinal area since 3

hour before admission
HISTORY
Patient admitted that there was pain in

right inguinal area since 3 hour before
admission. The pain was felt continuously.
There was a lump as big as adult fist in right
scrotal area and there was no pain.
HISTORY
3 hour before admission, when patient was

working as a labourer, suddenly the lump descended
into right hemiscrotal cavity and the patient cannot
pushes the lump back into abdominal cavity. Patient
have regurgitated food once. There was neither nausea
nor fever on the patient. No complaint of urinating and
defecating
HISTORY
The patient had history of lump in right

hemiscrotal area since birth. On this age, the lump
was as big as a tennis ball. Normally, the lump can be
pushed back into abdomen by hands. The lump
descended to scrotal area when standing, when
working as a labourer and straining and will
ascended in supine position and when resting.
HISTORY
Patient has been working as a labourer at local brick

company for 10 years. Usually the patient carries 12-15 kg of
bricks when working.
Patient has been smoking for 5 years, ½ pack/day.
Patient never had chronic lung disease and trauma.
Patient never had any history of constipation.
There was no history of operation or hospital admission.
Patient admitted that his 3 years old daughter also have lump
in her inguinal area since birth.
PHYSICAL EXAMINATION
Generalized state Vital Sign

• General appearance: • BP : 140/90 mmHg
Medium sickness
• HR : 72 x/mt
• Consciousness :
Composmentis cooperative • RR : 16 x/mt
•Height : 168 cm • T : 36 oC
•Weight : 53 kg
•BMI : 18,7
PHYSICAL EXAMINATION
• Head : Anemic (-)

• Neck : Normal limit
• Chest : Normal limit
• Stomach : Localized State
• Extremity : Normal limit
• Genitourinary : Localized State
LOCALIZED STATE : ABDOMEN
• Inspection
Flat surface in umbilical-simfisis pubis area, Distension (-)
• Auscultation
Intenstinal peristaltic (+)
• Palpation
Smooth palpable, tenderness (-)
• Percussion
Tymphany
LOCALIZED STATE : GENITOURINARY
LOCALIZED STATE :GENITOURINARY
• Inspection There was a lump in
right scrotal area, as big as adult
fist. There were no inflammation
dan oedema on penis.
• Palpation Smooth palpable, flat
surface, tenderness (-) and
irreducible. Testis cannot be
palpated.
• Auscultation Intenstinal
peristaltic (+)
• Translumination (-)
WORKING DIAGNOSIS
Irreponible Scrotalis Hernia Dextra

ADJUNCTS
• Routine blood test
ADJUNCT EXAMINATION
• Routine blood
Hb : 13,9 g/dL
WBC : 11,8 x 103 / uL (>>)
PLT : 301 x 103 / uL
DIAGNOSIS
Irreponible Scrotalis Hernia

Dextra
TREATMENT
Farmakotherapy
• IVFD Asering 20 dpm
• Inj. Ketorolac 2x30mg IV
• Inj. Ranitidine 1x 50 mg IV
• Inj. Luminax 1x200 mg IM
• Inj Ondansentron 1x200 mg IV
HERNIA
TREATMENT
Non Farmakoteraphy
• Trendelenburg Position
• Operative - Hernioraphy
Hernia is a bulge or protrusion
of an organ or tissue through an abnormal opening
within the anatomic structure.
CLASSIFICATION
GROIN HERNIA
• Groin hernias are the most common

conditions for which primary care physicians
refer patients for surgical management.
• Approximately 96% of groin hernias are

inguinal and 4% are femoral.
ETIOLOGY / RISK FACTORS
OF INGUINAL HERNIA
• In addition to male sex and increased age

• Having a family history of hernias
• Smoking, which causes a defective connective
tissue metabolism
• Chronic obstructive pulmonary disease
• Condition that increases the pressure in the intra-abdominal
cavity may contribute to the formation of a hernia, including the
following:
o Marked obesity
o Heavy lifting
o Coughing
o Straining with defecation or urination
o Ascites
o Peritoneal dialysis
o Ventriculoperitoneal shunt
o Chronic obstructive pulmonary disease (COPD)
o Family history of hernias
EPIDEMIOLOGY
• More common in men > women.

• In general, inguinal hernia affects all ages, but
the incidence increases with age.
• 150,000-500,000 hernias repaired annually in
U.S. (Choi et al. Annals of Surgery 2012)
• The prevalence of all varieties of hernias increases with
age
• Inguinal hernias are the most common type in both
males and females; approximately 25% of males and
2% of females have an inguinal hernia over the course
of their lifetime.
• The male-to-female ratio for indirect inguinal hernia is
7:1.
TWO TYPES OF INGUINAL HERNIA
• Abdominal contents protrude through

Indirect/ the deep inguinal ring, lateral to the
Lateralis inferior epigastric vessels.
• Defect in the abdominal wall that is
(60%) congenital.
• Occur medial to the inferior epigastric

vessels when it through a weak spot in
Direct/ the fascia of the posterior wall of the
inguinal canal
Medialis (25%) • Are caused by a weakness in the
muscles of the abdominal wall that
develops over time.
CLASSIFICATION HERNIA INGUINALIS
DIFFERENTIAL OF H. INDIRECT DAN H. DIRECT :
• Indirect : • Direct :
1. Oval shape 1. Round shape
2. Incerceration (>>) 2. Incerceration (<<)
3. Compress annulus int  3. Compress annulus int. 
hernia cannot turn out hernia can turn out.
4. Finger test : palpable in 4. Finger test : palpable in
tip of finger medial of finger
5. Defect : Annulus 5. Defect : Trigonum
internus Hasselbach
CHARACTERISTIC OF HERNIA
• A reponible hernia is one in which

the contents can be pushed
Reponible back into the abdomen by putting
manual pressure on it.
• The contents cannot be pushed

Irreponible back into the abdomen by applying
manual pressure.
SIGNS AND SYMPTOMS OF INGUINAL HERNIA?
• Small bulge on one or, • Discomfort or pain in
Other signs and

The first sign
symptoms
rarely, on both sides of the groin— especially
the groin. when straining, lifting,
• The bulge may coughing, or exercising
increase in size improves when resting
over time and • Weakness, heaviness,
burning, or aching in the
usually disappears
groin
when lying down.
• A swollen or an enlarged
scrotum
FINGER TEST
Hernia inguinalis
lateralis/indirect Hernia inguinalis
medialis/direct
TREATMENT
Conservatif Reposition
Treatment Herniotomy
Operative Hernioplasty
Hernioraphy
WHAT ARE THE COMPLICATIONS OF INGUINAL
HERNIAS?
• Incarceration and Strangulation

- The contents of the hernia are wedged by the
ring
- Intestinal passage disruption (incarcerated)
- There is a vascularisation disorder (strangulate)
- Ischemia until necrosis
- Is an emergency case
• An incarcerated hernia may be associated with the
following:
`
o Painful enlargement of a previous hernia or defect
o Inability to manipulate the hernia (either spontaneously
or manually) through the fascial defect
o Nausea, vomiting, and symptoms of bowel obstruction
(possible)
• A strangulated hernia may be associated with the following:
o Symptoms of an incarcerated hernia, combined with a
fever & toxic appearance
o Possibility of systemic toxicity secondary to ischemic
bowel
o Probability of strangulation if pain and tenderness of an
incarcerated hernia persist after reduction
THANK YOU

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Morning Report

IRREPONIBLE SCROTALIS HERNIA

Pain in right inguinal area since 3

Patient admitted that there was pain in

3 hour before admission, when patient was

The patient had history of lump in right

Patient has been working as a labourer at local brick

Generalized state Vital Sign

• Head : Anemic (-)

Irreponible Scrotalis Hernia Dextra

Irreponible Scrotalis Hernia

• Groin hernias are the most common

• Approximately 96% of groin hernias are

• In addition to male sex and increased age

• More common in men > women.

• Abdominal contents protrude through

• Occur medial to the inferior epigastric

• A reponible hernia is one in which

• The contents cannot be pushed

• Small bulge on one or, • Discomfort or pain in

Other signs and

• Incarceration and Strangulation

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