Chapter 114

### Introduction

He has a rupture, he has sprung a leake.

Ben Jonson (1573–1637), The Staple of News

Lumps in the groin are common to both sexes but males are likely to have a greater variety of swellings in this area and several may be associated with scrotal lumps.

### Lumps in the groin

The commonest swellings encountered in the groin or inguinal area are hernias and enlarged lymph nodes. The diagnosis of a hernia is usually straightforward but it must be differentiated from other swellings, including Malgaigne bulgings—these are not true hernias but diffuse swellings in both inguinal regions seen in people with poor lower abdominal musculature.1 Table 114.1 lists the differential diagnoses of groin lumps.

Table 114.1

Differential diagnoses of a groin mass

##### Hernias

The commonest types of hernias in the groin are inguinal, femoral and a combination of the two. Rare hernias in the region are obturator, Spigelian (low abdominal), preperitoneal inguinal and prevascular femoral. The basic parts of a hernia are shown in FIGURE 114.1 and important anatomical landmarks in FIGURE 114.2. An indirect inguinal hernia is a hernia emerging through the deep inguinal ring, originating lateral to the inferior epigastric vessels, following the path of the spermatic cord, and which can traverse the whole length of the inguinal canal (see FIG. 114.3). It may also pass through the superficial inguinal ring into the scrotum—an inguinoscrotal hernia.

###### FIGURE 114.1

Basic components of a hernia

###### FIGURE 114.2

Key landmarks in the left inguinal region: the deep inguinal ring lies above the mid-inguinal point (between the ASIS and the pubic tubercle); the femoral artery lies below this point

###### FIGURE 114.3

Left indirect inguinal hernia: it emerges lateral to the inferior epigastric artery and passes into the scrotum medial to the pubic tubercle

Because of their narrow neck and oblique path in the inguinal canal, such hernias are often irreducible and can occasionally lead to strangulation of entrapped bowel.

A direct inguinal hernia originates medial to the inferior epigastric vessels and protrudes through the posterior wall of the inguinal canal, and is therefore separate from the spermatic cord (see FIG. 114.4). It is almost always seen in men and rarely ...

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