Other structures in the groin each contribute to the harvest of swellings, pains and discomforts patients complain of. These include:
1. Vascular disease: (a) Arterial - aneurysms of the iliac and femoral vessels; these may be complicated by distal embolization or vascular insufficiency which will make the diagnosis easy. Femoral aneurysm as a complication of cardiac catheterization or transluminal angioplasty is a recent arrival in the diagnostic arena. (b) Venous - a saphenovarix could be confused with a femoral hernia. Its anatomical site is the same, but its characteristic blue colour, soft feel, fluid thrill, disappearance when the patient is laid flat and the giveaway associated varicose veins should prevent misdiagnosis. (c) Inguinal venous dilatation secondary to portosystemtic shunting can result in a painful inguinal bulge that can even become incarcerated. Preoperative Doppler ultrasound in cirrhotic patients with suspected inguinal hernias is advised.
2. Lymphadenopathy: Chronic painless lymphadenopathy may occur in lymphoma and a spectrum of infective diseases. Acute painful lymphadenitis can be confused with a tiny strangulated femoral hernia. A lesion in the watershed area, the lower abdomen, inguinoscrotal or perineal region, the distal anal canal or the ipsilateral lower limb quickly resolves the argument.
3. Tumours: Lipomas are very common tumours. The common 'lipoma of the cord', which in reality is an extension of preperitoneal fat is frequently associated with an indirect or direct inguinal hernia. Fawcett and Rooney examined 140 inguinal hernias in 129 patients to study the problem of lipoma. A fatty swelling was deemed significant if it was possible to separate it from the fat accompanying the testicular vessels. The fatty swelling was designated as being a lipoma if there was no connection with extraperitoneal fat and was designated as being a preperitoneal protrusion if it was continuous through the deep ring with extraperitoneal fat. Protrusions of extraperitoneal fat were found in 33% of patients and occurred in association with all varieties of hernia. There was a true lipoma of the cord in only one patient. It was concluded that the forces causing the hernia were also responsible for causing the protrusion of extra-peritoneal fat. Read has commented that occasionally extraperitoneal protrusions of fat may be the only hernia-tion and therefore inguinal hernia classifications need to include not only fatty hernias but sac-less, fatty protrusions. Lipomas also occur in the upper thigh to cause confusion with femoral hernias. A lipoma is rarely tender; it is soft with scalloped edges and can be lifted 'free' of the subjacent fat.
4. Secondary tumours: A lymph node enlarged with metastatic tumour usually lies in a more superficial layer than a femoral hernia. Such lymph nodes are more mobile in every direction than a femoral hernia and are often multiple. A metastatic deposit of a tumour arising from the abdominal cavity such as adenocarcinoma can present as a rock-hard immobile mass that can be confused as either a primary incarcerated inguinal hernia or a postoperative fibrotic reaction following an inguinal hernia repair.
5. Genital anomalies, (a) Ectopic testis in the male - there is no testicle in the scrotum on the same side. Torsion of an ectopic testicle can be confused with a strangulated hernia. (b) Cyst of the canal of Nuck - these cysts extend towards, or into, the labium majorum and are transilluminable.
6. Obturator hernia: An obturator hernia, especially in a female lies in the thigh lateral to the adductor longus muscle. Vaginal examination will resolve the diagnosis. Elective diagnosis is rarely entertained.
7. Rarities. (a) A cystic hygroma is a rare swelling; it is loculated and very soft. Usually the fluid can be pressed from one part of it to another. (b) A psoas abscess is a soft swelling frequently associated with backache. It loses its tension if the patient is laid flat. It is classically lateral to the femoral artery. (c) A hydrocoele of the femoral canal is a rarity reported from West Africa. In reality it is the end stage of an untreated strangulated femoral epiplocoele. The strangulated portion of omentum is slowly reabsorbed, the neck of the femoral sac remains occluded by viable omentum, while the distal sac becomes progressively more and more distended by protein-rich transudate.
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