HERNIAS abdominal wall.pdf types diagnosis

Abdominal wall hernias general surgery

1. Hernias
Types, Diagnosis, management and
complications
Dr. Mahmoud W. Qandeel

2. •Introduction
•Etiology
•Features
•Complications
•Examination
•Inguinal anatomy
•Types
–Indirect inguinal
–Direct inguinal
–Femoral
–Umbilical
–Epigastric
–Ventral
Dr. Mahmoud W. Qandeel
Outlines

3. Hernias
Definition:protrusion of a viscus or part of it through a normal
or abnormal opening in the wall of its containing cavity.
Dr. Mahmoud W. Qandeel

4. Frequency of external hernias
•Inguinal 78%
•Incisional 10%
•Femoral 7%
•Umbilical3%
•Epigastric 1%
•Rare 1%
Dr. Mahmoud W. Qandeel

5. Etiology
➢Congenital: pre-formed sac
•Congenital I H (patent process vaginalis)
•Congenital U H (exomphalos)
➢Acquired hernias
•Raised intra-abdominal pressure
•Weak abdominal wall
Dr. Mahmoud W. Qandeel

6. Increased intra abdominal pressure
•Heavy lifting
•Cough > COPD
•Straining to pass urine > BPH
•Constipation
•Abdominal distension > pregnancy
•Change in abdominal content > tumors
Dr. Mahmoud W. Qandeel

7. Weak abdominal wall
•Malnutrition
•Advancing age
•Damage to motor nerves like ?
•Abnormal collagen metabolism > CTDs
Dr. Mahmoud W. Qandeel

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9. Anatomical features
•Sac
•Covering
•Content
Dr. Mahmoud W. Qandeel

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12. Contents
Most common herniated organ in inguinal hernia in males is small bowel
and in females is ovary. Dr. Mahmoud W. Qandeel

13. Basic features of a hernia
•Abdominal wall defect( congenital-acquired)
•Expansile impulse on cough
•Reducibility.
Dr. Mahmoud W. Qandeel

14. Complications of hernias
▪Irreducibility (Incarcerated)
Narrow neck
Adhesions
▪Obstruction
▪Strangulation
▪Inflammation
▪Torsion of omentum
▪Hydrocele of cord
Dr. Mahmoud W. Qandeel

15. Signs of strangulation
•Tense swelling.
•Tender.
•Irreducible.
•Warm, inflamed, and indurated.
•Skin changes.
•No impulse on cough.
•Signs of obstruction. ?
•Tachycardia, leukocytosis, acidosis.
•Late septic shock.
Dr. Mahmoud W. Qandeel

16. Strangulated paraumb. H
Dr. Mahmoud W. Qandeel

17. Gangrenous bowel
Dr. Mahmoud W. Qandeel

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19. Clinical Examination
•Position for Examination
–Expansile cough impulse in a hernia.
•Consistency and Reducibility
–Hernias are usually soft and ‘squishy’
–the most reliable diagnostic sign is if the lump reduces when the patient lies flat
–Incarcerated vs strangulated
•Relationship to the Inguinal Ligament
–inguinal hernias always originate above the inguinal ligament, whereas femoral
hernias, saphenavarices and femoral artery aneurysmsalways arise below it.
Dr. Mahmoud W. Qandeel

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21. Contents, how to know?
OmentumIntestine
DoughySoftConsistency
NoneDuring reductionGurgling
Last part more
difficult
First part more
difficult
Ease of reduction
DullResonantPercussion
Dr. Mahmoud W. Qandeel

22. DDx and Examination
Dr. Mahmoud W. Qandeel

23. Inguinal Anatomy
Dr. Mahmoud W. Qandeel

24. Layers of abdominal wall
Dr. Mahmoud W. Qandeel

25. Inguinal ligaments
Dr. Mahmoud W. Qandeel

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27. Femoral ring
Dr. Mahmoud W. Qandeel

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29. Inguinal canal
Dr. Mahmoud W. Qandeel

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37. Hesselbach'striangle
Dr. Mahmoud W. Qandeel

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42. Laparoscopic hernial anatomy
Dr. Mahmoud W. Qandeel

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45. Special types of hernias
Indirect inguinal hernias:
•Passes from the peritoneal cavity
•Through the internal inguinal ring (i.e., lateral to the epigastric vessels)
•Spermatic cord hydrocele: may occur if the processusvaginalis is
incompletely obliterated
•Incidence: Indirect inguinal hernias are the most common type of hernia
and are 5 more common than direct hernias.
Dr. Mahmoud W. Qandeel

46. •Gender: 10 more common in men than in women. At least 5% of men
develop an inguinal hernia.
•Age: may occur from infancy to old age but generally occur by the fifth
decade of life.
•Pediatric inguinal hernia: Almost always indirect and has a high risk o
incarceration. It is more common on the right (75%).
Dr. Mahmoud W. Qandeel

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48. Direct inguinal hernias:
•Occurs through the floor of the inguinal canal (i.e., through Hesselbach
triangle) because of an acquired weakness in the tissue
•Site: Direct hernias occur medial to the epigastric vessels and are direct
protrusions of abdominal structures into the floor of the canal posterior
to the spermatic cord.
Dr. Mahmoud W. Qandeel

49. •It is not contained in the cord as is an indirect hernia.
•Sac: broadly based defect; much less often associated with
strangulation than an indirect inguinal hernia
•Cause: increases in occurrence with age and is related to
physical activity
Dr. Mahmoud W. Qandeel

50. Rt and ltInd. Ing H
Dr. Mahmoud W. Qandeel

51. Difference between indirect, direct I H
DIRECTINDIRECT
oldUsually youngAge
acquiredMay be congenitalcause
50%20%Bilateral
straightobliqueProtrusion on cough
Does reachDoes not reach full size
immediately
Appearance on standing
reduceMay not reduceReduction on lying down
Dr. Mahmoud W. Qandeel

52. Difference between indirect, direct I H
widenarrowNeck of sac
unusualNot uncommonstrangulation
mediallateralRelation to inferior
epigastric
rarecommonDescent to scrotum
No controlcontrolInternal ring test
Dr. Mahmoud W. Qandeel

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56. Pantaloon Hernia
Dr. Mahmoud W. Qandeel

57. Sliding hernia
•Extra-peritoneal structure form part of the wall of the sac.
•5% Of all hernias
•Incidence increase with age
•Usually indirect
•Colon, bladder, ovary.
•Partial reduction
Dr. Mahmoud W. Qandeel

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60. ➢Richter's hernia
•Part of bowel wall is trapped
•Strangulation without obstruction
➢Hernia EN W -Maydal’shernia
•Two loops of bowel in, one loop out
Dr. Mahmoud W. Qandeel

61. Richter's hernia
Dr. Mahmoud W. Qandeel

62. Special Names
of inguinal hernia
Dr. Mahmoud W. Qandeel

63. Femoral Hernia
•7% of all hernias, strangulation 20%
•33% of female groin hernias
•5% in male hernias, Bilateral in 20%
•Always acquired hernia
•occurs along the femoral sheath in the femoral canal
Dr. Mahmoud W. Qandeel

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66. •Site: Hernia contents protrude posterior to the inguinal ligament,
anterior to the pubic ramus periosteum (i.e., Cooper ligament), and
medial to the femoral vein.
•The hernia traverses the femoral canal and may also turn cephalad once
it has exited the foramen ovaleand can cross anteriorly to the inguinal
ligament.
•Sac: Narrow neck; 30%–40% of femoral hernias become incarcerated or
strangulated.
•Cause: more common in women than in men and are associated with
female gender, prior pregnancy, and prior inguinal hernia repair
Dr. Mahmoud W. Qandeel

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71. Inguinal swelling resemble F H
Above and medial to P TInguinal hernia
Multiple, mobile seek causeEnlarged lymph node
Compressible
Palpable thrill on cough
Saphenavarix
Soft, not reduciblelipoma
Empty scrotumEctopic testis
Expanding pulsation, bruitFemoral artery aneurysm
Fluctuant, lateral to femoral artery,
loin mass
Psoas abscess
Dr. Mahmoud W. Qandeel

72. Why F H is common in females?
▪Wide pelvis
▪Lax pelvic ligaments after repeated pregnancies
▪Weight loss in old age
Dr. Mahmoud W. Qandeel

73. Symptoms and signs
•Lump below and lateral to P T
•RARELY!! impulse on cough
•Lump consistency according to content
•First presentation S B obstruction
•Richter’s hernia in 30%
•Gastro-enteritis !! Like symptoms
•Peritonitis
Dr. Mahmoud W. Qandeel

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75. Treatment of groin hernias
•Repair: Surgery is the only curative procedure for inguinal hernias.
Indirect inguinal hernia:
Repair involves returning hernia contents into the peritoneal cavity.
1. Division and/or ligation of the base of the hernia sac at the level of the peritoneal
cavity: Sac is always anteromedial to the cord at the level of the internal ring.
2. In adults: to prevent recurrence, the internal inguinal ring must be tightened in
addition to repair of any defect of the floor of the inguinal canal.
Dr. Mahmoud W. Qandeel

76. •Direct inguinal hernia: Repair is based on reinforcement of the inguinal
canal floor after invaginating the hernia sac.
•Femoral hernia: Repair involves approaching the femoral sheath
through the floor of the inguinal canal.
•The space is usually closed by apposing the posterior reflection of the
inguinal ligament to Cooper ligament (Cooper ligament repair).
Dr. Mahmoud W. Qandeel

77. •Inguinal canal floor: Repair can be done with many techniques. two classic
techniques used less commonly now are described first, and then two newer
techniques are described.
➢Bassinirepair: transversalis fascia and conjoint tendon above are sutured to the
reflection of the inguinal ligament (i.e., the shelving edge of Poupart ligament)
below.
a. In men: Spermatic cord is returned to its normal anatomic location between the
reinforced inguinal canal floor and the external oblique aponeurosis.
b. In women: Round ligament may be ligated and the internal ring closed.
Dr. Mahmoud W. Qandeel

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79. ➢Cooper ligament repair (McVaymethod): similar to the Bassinirepair
except that the transversalis fascia and conjoint tendon are sutured to
Cooper ligament
•a. Relaxing incision: Because Cooper ligament is more posterior than
the inguinal ligament and subjects the repair to increased tension, this
counter incision is often made superiorly and allows the conjoint tendon
to be sutured to Cooper ligament with less tension.
•b. Disadvantage: tension is the problem with this technique, causing
both postoperative pain and early and late recurrences.
Dr. Mahmoud W. Qandeel

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81. ➢Shouldice repair: Uses the transversalis fascia, which is divided longitudinally and
imbricated upon itself in two layers.
•The internal oblique muscle and conjoint tendon are then sutured to the reflection
of the inguinal ligament in two layers.
Dr. Mahmoud W. Qandeel

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83. ➢Prosthetic mesh repairs (Lichtenstein repairs): have supplanted other techniques
•a. Procedure: involves repairing the inguinal oorby using mesh to close the space,
suturing it (as in a Bassinirepair) to the transversalis fascia and conjoint tendon above
and to the reflection of the inguinal ligament below
•b. Open and laparoscopic techniques: Used to place polypropylene mesh to reinforce
the weakened transversalis fascia. Open techniques also place mesh into the defect.
•1. Indirect hernias: Cone-shaped polypropylene mesh may be placed adjacent to
(anteromedial to) the spermatic cord.
•2. Direct hernias: Cone-shaped mesh is used to “plug” the transversalis fascia defect.
Dr. Mahmoud W. Qandeel

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85. •Recurrence rates : Vary depending on the type o hernia;
generally, inguinal hernias recur in less than 10% o cases.
•This figure is usually higher for hernias at other sites.
Dr. Mahmoud W. Qandeel

86. Special situations
•Strangulation or necrosis of the incarcerated bowel: If the bowel returns to the
peritoneal cavity spontaneously before visual examination, the abdomen is usually
opened to resect any necrotic bowel.
•Recurrent hernias or hernias with large defects: may require the insertion of
prosthetic material such as polypropylene mesh to repair the abdominal wall defect
adequately
•Pediatrics: Simple high ligation o the hernia sac is used or hernias in this age group.
No floor repair is needed.
•Truss: device that exerts external compression over the hernia de ect; used only
when surgery cannot be safely performed or when the patient refuses surgery
Dr. Mahmoud W. Qandeel

87. Truss
Dr. Mahmoud W. Qandeel

88. Umbilical hernia
•Occur through the defect where the umbilical structures passed through
the abdominal wall
•Incidence: Occur 10 more often in women than in men.
•The defect is common in children but usually closes by age 2 years, and
less than 5% persist into later childhood and adult life. So ??
•Repair: with small umbilical hernias, consists of a simple transverse repair
of the fascial defect, new?
Dr. Mahmoud W. Qandeel

89. Dr. Mahmoud W. Qandeel

90. Para umbilical hernia
▪Usually above umbilicus
▪Obese middle aged females 5:1
▪Neck is narrow
▪Content omentum,small,large bowel
▪Partial reduction, impulse on cough
Treatment is surgical
Mayo’s repair
Mesh repair
Dr. Mahmoud W. Qandeel

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93. Epigastric hernia
•Epigastric hernias (epiploceles): result from a defect in the lineaalba
above the umbilicus.
•True ??
•Incidence: Occur more commonly in men (3:1 ratio); 20% are multiple at
the time o repair.
•Repair (simple suturing): associated with a recurrence rate as high as 10%
Dr. Mahmoud W. Qandeel

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95. Ventral Hernias
Dr. Mahmoud W. Qandeel

96. Incisional hernia
•Most common type of ventral hernia; results from poor wound healing in a
previous surgical incision and occurs in up to 20% of abdominal incisions
•Common causes: include wound infection, advanced age, obesity, general
debilitation or malnutrition, improper surgical technique, or a postoperative
increase in abdominal pressure (ascites or pulmonary complications)
•Repair: Performed after the patient has recovered from the prior surgical
trauma.
•Requires definition of the adequate fascial edges surrounding the defect,
closure with nonabsorbable sutures, and use of prosthetic mesh when the
defect is too large to be closed primarily.
Dr. Mahmoud W. Qandeel

97. Spigelian hernia
•Spigelian hernias: protrude through the abdominal wall along
the semilunar line (the lateral edge o the rectus muscle) at the
semicircular line o Douglas (below the umbilicus)
Dr. Mahmoud W. Qandeel

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100. Obturator hernia
•Obturator hernias: occur in the pelvis through the obturator foramen and
can cause pain along the obturator nerve (mid-anterior thigh), referred to
as Howship-Romberg sign.
•After significant weight loss
Dr. Mahmoud W. Qandeel

101. Others
•Lumbar hernias: occur on the flank and are seen in the
superior (Grynfeltt) and inferior (Petit) triangles
•Perineal hernias: occur in the pelvic floor usually after surgical
procedures such as an abdominoperineal resection
•Peristomal hernias: develop adjacent to an intestinal ostomy
Dr. Mahmoud W. Qandeel

102. Lumbar hernias:
Dr. Mahmoud W. Qandeel

103. Dr. Mahmoud W. Qandeel
Perineal hernias

104. Parastomal Hernia
Dr. Mahmoud W. Qandeel
“ It doesn’t matter if God Himself made your ostomy. If you have it long enough you
have a 100% risk of a parastomal hernia” J Byron Gathright, 1996

105. All of the following statements are true about inguinal canal
except; (7/2018)
a) Anterior wall is external oblique, internal oblique muscles, and
superficial inguinal ring.
b) Posterior wall is transversalis fascia, conjoint Tendon , and deep
inguinal ring.
c) Inguinal canal transmit the genitofemoral nerve.
d) Superior wall is lacunar ligament and external oblige muscle.
e) Inferior wall is inguinal ligament
Dr. Mahmoud W. Qandeel

106. All of the following statements are true about inguinal canal
except; (7/2018)
a) Anterior wall is external oblique, internal oblique muscles, and
superficial inguinal ring.
b) Posterior wall is transversalis fascia, conjoint Tendon , and deep
inguinal ring.
c) Inguinal canal transmit the genitofemoral nerve.
d) Superior wall is lacunar ligament and external oblige muscle.
e) Inferior wall is inguinal ligament
Dr. Mahmoud W. Qandeel

107. All of the following is differential diagnosis of Femoral hernia
except; (7/2018)
a) Bartholin gland cyst
b) Lipoma
c) Cold abscess
d) Varicose node
e) Inguinal hernia
Dr. Mahmoud W. Qandeel

108. All of the following is differential diagnosis of Femoral hernia
except; (7/2018)
a) Bartholin gland cyst
b) Lipoma
c) Cold abscess
d) Varicose node
e) Inguinal hernia
Dr. Mahmoud W. Qandeel

109. Which artery is considered to be differentiate between site of
origin in inguinal hernia; (7/2018)
a) Cremastricartery
b) Superior epigastric artery
c) Inferior epigastric artery
d) Femoral artery
e) Superficial circumflex iliac artery
Dr. Mahmoud W. Qandeel

110. Which artery is considered to be differentiate between site of
origin in inguinal hernia; (7/2018)
a) Cremastricartery
b) Superior epigastric artery
c) Inferior epigastric artery
d) Femoral artery
e) Superficial circumflex iliac artery
Dr. Mahmoud W. Qandeel

111. All are true about femoral hernia except; (7/2018)
a) Most common groin hernia in women
b) It goes into femoral canal
c) It goes below inguinal ligament
d) It lies medial to femoral vein
e) It is high risk for strangulation
Dr. Mahmoud W. Qandeel

112. The most common injured nerve with inguinal hernia repair;
(4/2018)
a) Ilioinguinal hernia repair
b) Genitofemoral nerve
c) Sciatic nerve
d) Lumbosacral nerve
e) Femoral nerve
Dr. Mahmoud W. Qandeel

113. The most common injured nerve with inguinal hernia repair;
(4/2018)
a) Ilioinguinal hernia repair
b) Genitofemoral nerve
c) Sciatic nerve
d) Lumbosacral nerve
e) Femoral nerve
Dr. Mahmoud W. Qandeel

114. A 65 years old woman presents with a tender medial thigh mass
the pain increases with internalrotation of the thigh the most
likely Dx: (4/2018)
a) Inguinal hernia
b) Obturator hernia
c) Ventral hernia
d) Femoral hernia
e) Howship–Romberg hernia
Dr. Mahmoud W. Qandeel

115. A 65 years old woman presents with a tender medial thigh mass
the pain increases with internalrotation of the thigh the most
likely Dx: (4/2018)
a) Inguinal hernia
b) Obturator hernia
c) Ventral hernia
d) Femoral hernia
e) Howship–Romberg hernia
Dr. Mahmoud W. Qandeel

116. A 2 year old is brought into your office for an umbilical hernia.
All of the following are trueexcept; (4/2018)
a) Patient should have surgery at about age 5 year if it fails to
close
b) Patient is at high risk for incarceration
c) This hernia is increased in African patients.
d) This hernia is increased in premature patients.
e) Associated with congenital Hypothyroidism
Dr. Mahmoud W. Qandeel

117. A 2 year old is brought into your office for an umbilical hernia.
All of the following are trueexcept; (4/2018)
a) Patient should have surgery at about age 5 year if it fails to
close
b) Patient is at high risk for incarceration
c) This hernia is increased in African patients.
d) This hernia is increased in premature patients.
e) Associated with congenital Hypothyroidism
Dr. Mahmoud W. Qandeel

118. A 50 year old male felt a pain in his groin after lifting a heavy box.
He was advised on operation during the surgery a hernial sac with a
small knuckle of intestine was found protruding just below the
inguinal ligament the hernia was diagnosed as; (12/2017)
a) Congenital inguinal hernia
b) Direct inguinal hernia
c) Femoral hernia
d) Incisional hernia
e) Indirect inguinal hernia
Dr. Mahmoud W. Qandeel

119. A 50 year old male felt a pain in his groin after lifting a heavy box.
He was advised on operation during the surgery a hernial sac with a
small knuckle of intestine was found protruding just below the
inguinal ligament the hernia was diagnosed as; (12/2017)
a) Congenital inguinal hernia
b) Direct inguinal hernia
c) Femoral hernia
d) Incisional hernia
e) Indirect inguinal hernia
Dr. Mahmoud W. Qandeel

120. All the following sentences about hernia are true accepted; (12/2017)
a)Inguinal hernia is the most common in both females and males
b)Incisional hernia is more common after open compared with
laparoscopic operation
c)Open is always better and safer than laparoscopic approach for
hernia repair
d) Divarication of rectus abdominis muscles in elderly does not
necssionatesurgical repair
e)Morbidity is increased after emergency compared with elective
repair of hernia.
Dr. Mahmoud W. Qandeel

121. All the following sentences about hernia are true accepted; (12/2017)
a)Inguinal hernia is the most common in both females and males
b)Incisional hernia is more common after open compared with
laparoscopic operation
c)Open is always better and safer than laparoscopic approach for
hernia repair
d) Divarication of rectus abdominis muscles in elderly does not
necssionatesurgical repair
e)Morbidity is increased after emergency compared with elective
repair of hernia.
Dr. Mahmoud W. Qandeel

122. The commonest hernia type that can been strangulated is;
(12/2017)
a) Incisional
b) Inguinal
c) Para-umbilical
d) Femoral
e) Linea alba
Dr. Mahmoud W. Qandeel

123. All sentences about abdominal hernias are true except ? (7/2017)
a)Most umbilical hernias in adult are acquired .
b)Incisional hernia results from a failure of fascial tissue to heal and
close after surgery .
c) Incisional hernia is more common after open compared with
laparoscopic operation .
d) Lumbar hernia is not common hernia .
e) Divarication of rectus abdominis muscles in elderly necessities
surgical repair .
Dr. Mahmoud W. Qandeel

124. All sentences about abdominal hernias are true except ? (7/2017)
a)Most umbilical hernias in adult are acquired .
b)Incisional hernia results from a failure of fascial tissue to heal and
close after surgery .
c) Incisional hernia is more common after open compared with
laparoscopic operation .
d) Lumbar hernia is not common hernia .
e) Divarication of rectus abdominis muscles in elderly necessities
surgical repair .
Dr. Mahmoud W. Qandeel

125. All of the following sentences about hernia are true except ? (7/2017)
a)Inguinal hernia is the most common hernia in both females and
male's .
b)Femoral hernias are most common in females than male's .
c)Morbidity is increased after emergency compared with elective
repair of hernia .
d) Urinary hesitancy and straining increase the risk for hernia
formation .
e) Open is always better and safer than laparoscopic approach for
hernia repair .
Dr. Mahmoud W. Qandeel

126. All of the following sentences about hernia are true except ? (7/2017)
a)Inguinal hernia is the most common hernia in both females and
male's .
b)Femoral hernias are most common in females than male's .
c)Morbidity is increased after emergency compared with elective
repair of hernia .
d) Urinary hesitancy and straining increase the risk for hernia
formation .
e) Open is always better and safer than laparoscopic approach for
hernia repair .
Dr. Mahmoud W. Qandeel

127. All of the following is true regarding the femoral triangle except ?
(4/2017)
a)The inguinal ligament forms the base .
b)The medial border is formed by the lateral border of the adductor
longus .
c)The lateral border is formed by the medial border of the Sartorius .
d)The floor is formed by the adductor longus and pectineus muscle
medially .
e) The floor is formed by the Iliopsoas muscle laterally
Dr. Mahmoud W. Qandeel

128. Most common hernia in females is ? (1/2017)
a)Femoral hernia
b) Umbilical hernia
c) Obturator hernia
d) Direct inguinal hernia
e) Indirect inguinal hernia
Dr. Mahmoud W. Qandeel

129. Most common hernia in females is ? (1/2017)
a)Femoral hernia
b) Umbilical hernia
c) Obturator hernia
d) Direct inguinal hernia
e) Indirect inguinal hernia
Dr. Mahmoud W. Qandeel

130. One is false? (1/2017)
a)Femoral artery is lateral to femoral vein in the inguinal area .
b)Femoral nerve is present within the femoral sheath .
c)Femoral triangle is bounding by Sartorius muscle laterally .
d) Siaticnerve injury can be avoided by giving iminjection on
the upper lateral quadrant on the gluteal area .
e) Great saphenous vein drain to femoral vein below the
inguinal ligament .
Dr. Mahmoud W. Qandeel

131. A hernia sac containing a Meckelsdiverticulum is called :
(10/2016)
a) Petit hernia
b) Littre hernia
c) Spiglianhernia
d) Richter hernia
e) Grynfeltthernia
Dr. Mahmoud W. Qandeel

132. A hernia sac containing a Meckelsdiverticulum is called :
(10/2016)
a) Petit hernia
b) Littre hernia
c) Spiglianhernia
d) Richter hernia
e) Grynfeltthernia
Dr. Mahmoud W. Qandeel

133. A 30-year-old man presents with a mass in his right groin. It is
not tender and is a bulge that is more prominent on standing
and with exercise. On examination, you noted a 3-cm
protrusion into the right scrotum that completely resolves with
gentle pressure. The most appropriate management is:
A. Broad-spectrum antibiotics
B. Tumor markers, including alpha-fetoprotein
C. Elective surgical repair
D. Observation only
E. CT scan of the abdomen and pelvis
Dr. Mahmoud W. Qandeel

134. A 30-year-old man presents with a mass in his right groin. It is
not tender and is a bulge that is more prominent on standing
and with exercise. On examination, you noted a 3-cm
protrusion into the right scrotum that completely resolves with
gentle pressure. The most appropriate management is:
A. Broad-spectrum antibiotics
B. Tumor markers, including alpha-fetoprotein
C. Elective surgical repair
D. Observation only
E. CT scan of the abdomen and pelvis
Dr. Mahmoud W. Qandeel