Inguinal hernia

Added: 2026-05-11

[00:00:00]Heat. Heat.

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[00:03:10]Hello hello hello doctors welcome welcome welcome to the class sorry for the delay please can you hear my voice I want to make sure can you hear my voice I'm very sorry for the delay we had some technical issues and I'm very glad that we are all joining today please can you hear my voice if you can just type yes yes yes yes so that I know you can hear me and then we can go on with the class cuz we have a lot to cover. We have some very important announcements to make as well. So if you can hear me just type yes. Beautiful. Okay. So you can hear me. That's great. I miss you. I didn't see you last week because I had um you know I need to take I needed to take some time off for some personal stuff as well. So I'm very glad that we are meeting today and um very important lessons we need to go through and I'm very glad and excited about that. Okay.

[00:04:07]So let's jump right into the class and get everything going. Today's class is going to be on ingrinal henius. Again, the medical council has these 55 free questions that they have they have um loaded on their website and I want each one of you to do those questions. And while we are going through these questions, a lot of people are getting to realize that look to a Q1 is not just about reading a particular book, but rather understanding how the medical council expects you to think and how the medical council expects you to think. then informs your answer choices. So that is exactly what we are doing today and I have a very important announcement to make about ethics. Many of you have reached out Dr. Brony we want a class on ethics. I promised you that and we're going to have it. It's going to be a six-hour class but I'll announce it as the class goes on. It's for everybody because what I realized was that some people were saying Dr. Bon I'm not a medical cognito student but I have my exam in a month. I have my exam in two months. I want to still participate in some of these unique classes. So we are opening it up. So please if you want to attend it, I need you to stick right here with us because this announcement is for you. So before we waste any further time, I want us to just jump into the first the free question and then we build on it to learn some study tips and things we need to know. So you have a 19-year-old man who presents to your clinic with a 4-hour history of acute scrotal pain.

[00:05:47]On examination, there is a mass in his right groin which extends to the right hemiscro.

[00:05:55]Both testes are non- tender and in a normal position. The skin overlying the mass shows no signs of infection and there's mild tenderness on palpation.

[00:06:08]The question is this, which one of the following is the best next step?

[00:06:16]Remember that's what I always tell candidates that the MCCQE is a bit different from the USMLA. The MCQE is talking about very practical concepts you need to master for your board exam. And so this is something which can happen to any of you when you start practicing right you are in your office someone comes to you 19-year-old male scrotal pain now some features have been given what will you do A sedation and reduction B eent surgical repair C abdominal radiography D eent scuttal ultrasound and E anti-inflammatories and reassurance Anti-inflammatories and reassurance. What is the correct answer?

[00:07:11]Anti-inflammatories and reassurance.

[00:07:13]What's the correct answer, doctors?

[00:07:17]I want to know is the answer A, is it B?

[00:07:20]Is it C? Is it D? Or is it E? What's the correct answer?

[00:07:30]Is it A? Is it B? Is it C? Is it D or is it E? And I see someone going for E.

[00:07:38]Um, someone is going for E. Will someone go for something different? Someone is also going for D. Okay, I like that.

[00:07:46]Some are also going for E. Some are going for E. Anti-inflammatories and reassurance. Okay. Okay. Okay. Okay. A lot of candidates are going for E. And doctors, the correct answer is A.

[00:08:00]The correct answer is A. For those who went for E, I want to know why did you go for E? I really want to know why did you go for E? Why? Why was your answer E? Why did you go for E and not something different? Why did you go for E which is anti-inflammatories and reassurance and not A? And some who also went for D. Why did you go for D? cuz this doctor went for D, right, Dr. Greg?

[00:08:30]And then um the doctor went for E. Why did you go for E and not B or A? But the correct answer is A. And the answer is very simple. Now, this is going to be the basis for what I'm going to teach you today.

[00:08:49]Okay, this is the basis for what I'm going to teach you today. Now you realize that this presentation is suggestive of an incarcerated ingrenal hen. So the whole point is this in your board exam you need to know the differentials and when you know the differentials you need to know how to deal with each of the differentials. Which of them need emergency surgery right now? Which of them need reassurance? Which of them need an intervention for the patient who can go home and have an elective procedure? This is how medical council wants you to think. So this question says this presentation is suggestive of an incarcerated ingral hernia and what are the features which make incarcerated inguinal hernia possible.

[00:09:39]The key findings include number one non-tender testus which is in a normal position because if the question has said the testice was twisted then I'm thinking about testicular torsion right but this patient's testice is normal and it is non- tender and it is in a normal position and there's mouth tenderness over the mass with no signs of infection on the overlying skin.

[00:10:10]Now these findings make testicular torsion less likely. Why? As a torsion typically presents with severe testicular tenderness and abnormal positioning.

[00:10:22]Another thing is emergency scotal ultrasound while it is useful in evaluating testicular torsion is not the next best step given the clinical suspicion of a hernia. So you have this patient who has a hernia which is an incarcerated hernia. Now you also have to ask yourself okay how do I differentiate between incarcerated heria from strangulated heria. These are words which are used in your board exam which you must master very very well. Right now the other option was abdominal radiography. What is abdominal x-ray is not indicated as it would not provide any useful information for this condition. But if for example the patient had a hernia which had caused some form of intestinal obstruction then getting abdominal x-ray will help you to see some air fluid levels. And then anti-inflammatories and reassurance are inappropriate due to the acute nature of the symptoms and the potential for complications if the hernia is not addressed.

[00:11:26]But then the question is this eent surgical repair is necessary if you try to do your manual reduction and that fails but the initial management should focus on attempting sedation and reduction to alleviate the obstruction and potentially to avoid surgery.

[00:11:45]Doctors please I I want to find out if you are all following what we just talked about.

[00:11:54]So I I think the last point I made answers Dr. Jessica's question. Dr. Jessica's question is why not B which is eent surgery and you realize that this patient's um condition is an incarcerated inguinal hernia. If it's an incarcerated ingralia that means yes think about incarceration the patient if you think about incarceration that means that the person is some way somehow in prison right the patient is in prison I'm trying to explain it I know you've just posted that you've answered it but I want to explain it for other people to to hear so just think about prison right if somebody's in prison the person can still be released that person can still be released right just think about it incarcerated patient incarcerated person if a person is incarcerated the person is in in prison right but then jumping straight to surgery why will you jump straight to surgery I'll discuss that in your in in in the class so you have to know which patient can I reassure like is it every patient who has a hernia who I need to do a reduction no for some people they have a hernia and the hernia can come into the hernia sack and go several times and they've had this for years if that person comes to your clinic you don't go like hey Mr. Smith, I just need to put you down and reduce it. No, because the p the hea comes and goes.

[00:13:20]But this other patient, the hea is incarcerated. If it's incarcerated, that means just think about the the henna is in prison, right? So I have to find a way to release the hea. But if I don't release the hea quickly, then there can be a bigger problem where the incarcerated hea can then lead to strangulation and that is when you want to then go for emergency surgery. So I I hope that answers your question very very well. Okay, thank you very much.

[00:13:50]Okay, so now I want to draw attention to the references again. Since we started, I've been drawing your attention to the references, the references, the references, the references. The medical council has a way they sort the questions. And in these 55 questions, they are giving you indications how they get their questions. And again you realize that this is one of the places PubMed PubMed the resources the the links they gave PubMed PubMed is one of the places they get their questions from that is why I'm saying that for your Q1 please make sure you are also reading broadly you're not just picking some textbook somewhere or some you know I see some things like you know quick points here and there and people are jumping on okay that's fine for me I'll continue doing what I'm doing. I'll continue teaching you what I'm teaching and I know that those who follow what I'm saying are seeing the results. But if you also want a shortcut, that is good. We don't provide any shortcuts in Med Cognito. We will provide you the tools so that you'll be able to go out there and ace the exam because one thing I've realized is that in most of these cases, some of these shortcuts end up hurting you and then you come back saying, "Dr. Bonnie, I didn't do well in the exam. I need to retake the exam. Doctors please you need to read a lot. Q1 is an exam where you need to read a lot.

[00:15:19]Okay. So that is one article they source the question from. This is another article in Guina Henia archive. So it will be on the YouTube channel. After this you can go back and go read it. So now this particular question there are so many traps in the question such that if you are not careful and read the question very well you make huge mistakes huge mistakes and that is why I put this trap there right this trap will break your leg and what's the first trap the first trap is the patient's age and the fact that if you don't take your time to read the question well you make a big mistake because the says 19 year old with acute scrotal pain. So the you know the one who has not been attending medalto classes and these lessons will go like oh 19year-old scrotal pain think about testicular torsion but then if you take your time and read the examination findings which the question the one who wrote the question gave you you realize that this is not a stickler question. So please I beg you number one avoid you know going after people who have written the exam and asking them what did you see in the exam you are setting yourself up for disaster why why I mean is because look number one it's against the rules of the exam and number two if you are not careful and you go into the exam with tunnel vision and you go like oh my friend told me this my friend told me that doctor you hurt yourself 19 year old with acute cotal pain every doctor will think about testicular torsion but until you take your time to read the question very well that is where the problem is that's why I'm saying it is not good for you to go chasing people you know what do you get and it is even against the rules of the exam anyway so please read past the chief complaint number two there's this other distractor they put there oh get an emergency men scuttal ultrasound because scuttal ultrasound can help you to evaluate testicular pathology but this patient's testice is normal. So why are you still focusing on scrotal ultrasound? The problem is that the patient has a mass in the inguinal region which is extending into the scrotum and it is a typical clinical diagnosis.

[00:17:51]You don't even need imaging to make that diagnosis in your clinic there and then so that it can help you to know that okay this is the decision I need to make and you'll see this a lot in Canadian emergency rooms. It's not everybody who comes with a groin mass that you want to get an ultrasound for everybody. No, then your emergency room will be choked.

[00:18:12]Right? So please, these are the things I want you to start paying attention to.

[00:18:17]These are the things I want to start paying attention to. The third trap is like those who went for the e surgical repair.

[00:18:27]So these candidates who went for eent surgical repair they were able to identify that this patient has a ha but the question is is it every case which goes for e surgical repair because remember that in her surgery is the definitive di management plan. Yes, but this patient only has mild tenderness, no strangulation and this been going for 4 hours.

[00:18:55]So the what you need to rather do is to attempt to reduce the hernia. You only go for surgery if reduction fails or if there are signs of strangulation.

[00:19:11]Doctors please are we all tracking together? If you are tracking just type tracking tracking tracking Dr. Bony I'm tracking with you. Just type tracking. I want to know whether you are tracking with me. If you are tracking with me just type Dr. Bony I am tracking. I am tracking. I am tracking. I am tracking.

[00:19:30]I really want to know because this is very important. The medical counselor is testing your knowledge on do you know how to use resources appropriately?

[00:19:39]Which patient should you call the O and call the surgeon to come and see him right away and take to the O and which candidates or which patients can you say hey I know that this patient is not strangulated let me find a way to reduce this mass and then find a way to arrange referral to a general surgeon on outpatient basis.

[00:20:03]This is what you do. This is what you do. So, I want to remind you on May 28th, May 28th, we have a 6-hour class.

[00:20:12]We'll start at 500 a.m. 5:00 a.m.

[00:20:16]Ontario time. 6 hours from 5:00 a.m. to 11:00 a.m. We're going to delve deep into ethics, but I'm going to give you the announcement later in the class. I'm just I'm just priming you up so you know that this thing is about to happen.

[00:20:31]Okay? So what must you watch out for on your board exam about scrotal pain?

[00:20:38]Number one, the medical council wants to know whether you were able to differentiate among the causes of acute scotal pain using the patient's history physical exam and physical exam findings alone.

[00:20:54]So if I give you the history, can you be able to tell me the differentials you're dealing with? Number two, they want to know whether you can prioritize initial management in a logical stepwise manner.

[00:21:07]Right? Where you start from the least invasive to the most invasive management plan.

[00:21:15]And can you identify red flag signs?

[00:21:20]Red flag signs. Every topic you're dealing with, abdominal pain, you must know red flags. Headache, you must know red flags. Back pain, you must know red flags. Leg pain, you must know red flags. Chest pain, you must know red flags. Right? And then applying your clinical reasoning where you are using the key features because the critical decision point where errors lead to patient harm is when you don't apply the clinical features in your management steps. So now that we've dealt with this question and what a medical counselor is looking for, let's delve deeper into the concept of inguinal heers.

[00:22:00]Let's delve deeper.

[00:22:02]Let's delve deeper into the concept of inguinal heas.

[00:22:08]Okay. So I need you to refresh your knowledge and your memory when it comes to her henas for the MCQ1. I need you to just think about three henas. The first one is indirect henas. The second one is direct heas. And the third one is femoral heas. And each of these types of henas have something unique about them.

[00:22:30]Then when you've thought about it anatomically, I need you to also think about incarcerated versus strangulated heas. These are things you need to know. So five things I want you to know so far as heas are concerned. Number one, direct heras.

[00:22:46]Number two, indirect heras. Number three, femoral hernas. Number four, incarcerated heras. Number five, strangulated heras. So far as you know these five things, you should be able to ace every MCQ1 question on heras. And there's a whole objective which focuses on that.

[00:23:05]Okay, there's a whole objective which focuses on that. So let's keep on. I told you the three types of the three hers I want to focus on. the indirect, the direct and the femoral.

[00:23:23]Now, one thing I want you to look at is what we call the epicastric vessels. So, if in your board exam depending on how the hea is described. Is it lateral? Is it medial? Is it below?

[00:23:39]These are the three words I want you to remember. Lateral, median, and below. So what is the relation between indirect hernas and epigastric vessels? You realize that in your board exam if I am testing you on your knowledge of the types of hernas I will say that indirect hernas they are lateral lateral to the epigastric vessels.

[00:24:08]Lateral indirect hemas they are lateral.

[00:24:13]Will indirect henas enter the scrutinum?

[00:24:16]Yes, they can.

[00:24:19]How will the indirect hya be described in the question stem? You'll be told that it is pearshaped.

[00:24:26]Pearshaped.

[00:24:28]Pearshaped.

[00:24:30]Which group of people usually have indirect heras commonly? Young males.

[00:24:36]Why? Because indirect her heas occur as a result of a congenital anormally.

[00:24:44]What is the strangulation risk of indirect heas? Moderate. Moderate. And what is the mechanism of the formation of an indirect hanger? There is a patent process vaginalis.

[00:25:00]Patent processes vaginalis. So please a is the indirect hernia. That is what it goes through. It goes through you know the patent process vaginalis because of that congenital anormally. Doctors please remember two things. Number one remember indirect um inguina in relation to the epigastric vessels and then their mechanism. Okay. So now that we talked about indirect inguina which is lateral to epigastric vessels.

[00:25:33]Now let's talk about direct inguinal heas.

[00:25:37]Direct inguinal heas what is their location in relation to the epigastric vessels? Direct inguinal helas are medial medial.

[00:25:49]Can a direct inguinal hea enter the scrotum? It is very rare.

[00:25:55]So in relation to direct and indirect ingrowners which of them can enter the scrotum easily indirect which of them is medial to the epigastric vessels direct doctors please I I want to know let me know tell me Dr. Brun slow down slow down slow down if you want me to slow down just tell me Dr. bony slow down if not as well let me know that I should continue because doctors that word medial lateral below alone can set you apart in the board exam so far as inguinal structures are concerned so please I want to know should I continue I should go back please let me know should I move on or I should go back I'm okay to go back to explain the concepts deeply Always remember when it comes to direct indirect and femoral hernas the word you're looking for is the pigastric vessels is the pastric vessels. Okay. So, someone says I should go on. All right.

[00:26:57]Let's continue then. Thank you very much. Someone says I should move on. So, let's continue. Okay. So, remember direct inguinal heas they are medial while indirect inguinal heas are lateral to the epigastric vessels. Can indirect inguinal heas get into the scrotum? Yes, of course. Can direct inguinal heas get into the scrotum? It is rare. Right.

[00:27:23]What is the mechanism of the formation of an indirect inguinal hea? Because of a patent process vaginalis. What is the mechanism of the formation of a direct inguinal hea? Because of weakness in the posterior wall.

[00:27:44]Now what about ephemeral hernia? What about ephemeral hea in relation to the epigastric vessels? Ephemeral hea is below below below. So here it is below if you see my mouth it is below the epigastric vessels. So one is medial one is lateral and one is below below. Can femoral heras enter the scrotum? No.

[00:28:12]How will they present? Usually they present as a small firm mass. Which people are usually affected by femoral heers older woman?

[00:28:26]Older woman. And what is the likelihood that a femoral ha can get translated?

[00:28:32]The likelihood is high. And what is the mechanism? The mechanism is that there's protrusion through the femoral ring.

[00:28:44]through the femoral ring. So femoral hernas are coming to the femoral ring.

[00:28:48]Direct heras are coming from the weakness in the posterior wall and indirect heras are coming as a result of a patent processes vaginalis. Indirect heas are lateral direct heras are medial femoral heas are below the epigastric vessels. Doctors if you know this you are good to go. Please I want to know is it now clear if you are sleeping and someone wakes you up please can you tell the person the differences between direct heas indirect heas and femoral heas I want to know yes or no in your board exam can you tell the difference between direct indirect and femoral heas yes or no I want to know yes okay beautiful I'm very happy about that. I'm very happy about that. Now, let's continue to deeper waters because we need to be able to deal with that and then we can go into deeper deeper deeper waters. So, let me quiz you on this. A surgeon is performing an open inguinal heal repair and identifies a heral sack protruding lateral to the inferior epigastric vessels. What type of hena is this? This one you know because I've already taught you. Is it a direct ha?

[00:30:10]Is it an indirect hernia? Is it a femoral hernia? Is it an opterator hea?

[00:30:15]Is it a spyian hernia? What's the correct answer? Tell me what's the correct answer. Is it A, B, C, D, or E?

[00:30:29]All right. A lot of doctors are saying they are going to go for B because of the way Dr. Bronny taught and the correct answer is B. Simple simplicity, right? The inferior epigastric vessels are the single most important landmark for classifying groin hernas. Indirect hernas protrude lateral while direct heras will protrude medial and femoral hernas will proude below below. So please just remember epigastric vessels.

[00:30:59]That is it. Okay. So now let's talk about direct versus indirect versus femoral heas and we're just going to use questions to solve them. You have a 72 year old woman who presents a small firm tender mass just below the inguinal ligament and medial to the femoral pulse. She has nausea and abdominal distension. What's the most likely diagnosis and why is it dangerous? A direct inguinal hernia. It has high recurrence rate. B indirect inguinal hernia risk of testicular eskeeia. C femoral heria risk of strangulation. D optator hernia difficult to diagnose clinically and E incisional hernia risk of evviseration.

[00:31:46]What is the correct answer? Is it A is it B? Is it C? Is it D or is it E? Tell me something good doctors.

[00:31:58]Tell me something good.

[00:32:01]And please kindly share this link with as many friends as possible so they can join this live stream. Kindly share the link with as many friends as possible so they can all join this live stream. I'm really enjoying it. You know, whoever thought that a class on heas will be enjoyable. But hey, this is me cognito for you. So the correct answer is C.

[00:32:22]Femoral hera there's a risk of strangulation. So we have to always remember that femoral hernas protrude below the inguinal ligament through the femoral ring medial to the femoral vessels. So don't forget don't confuse the femoral vessels with the epigastric vessels. Right now they are more common in older women. We learned that and approximately 37% of it can get strangulated. Now that we've talked about femoral direct and indirect ingrown heas, now let's talk about incarceration and strangulation.

[00:33:00]Let's talk about incarceration and strangulation. You realize that when it comes to incarcerated heas, there's a tight healer neck which is causing the incarceration and the bowel may be swollen but there's normal blood flow through the walls of the bowel and the bowel is not at risk of death. But when it comes to strangulated hea that he suck has become very very tight very very tight right and because of that it is cutting of blood supply it is cutting of the blood supply so let's use this question to delve deep into the class you have a 55 year old man with a known inguinal hea who presents with a 6-hour history of a painful irred reducible groin mass. This guy is a fibral, is hemodynamically stable and has mild tenderness over the mass. There are no peronial signs. What is the best description of this hea? A reducible hernia. B incarcerated her hena without strangulation. C strangulated her d rectile hera and e sliding her henia.

[00:34:17]I'm going to get off the video and uh put the question there because I am feeling warm. I want to take off my jacket. Okay, please. So, please solve the question and then All right. So, I've taken off my jacket now. I feel free. So what is the answer here? Is it incapaculated hernia, reducible hernia, strangulated hernia, rectile hernia? And the answer is incarcerated her without strangulation.

[00:34:57]Why this hernia is irreducible?

[00:35:01]But the patient lacks the signs of strangulation.

[00:35:04]What are the signs of strangulation?

[00:35:06]Fever, tachicardia, peronial signs, no sepsis and only mild tenderness.

[00:35:13]Strangulation usually would present with tense exquisitely tender mass and there may be systemic signs of sepsis.

[00:35:24]So this distinction is very critical because incarceration without strangulation allows you to try manual reduction which in surgery we call taxes. Okay. Whereas strangulation will require immediate surgery.

[00:35:43]So please remember the next best step in a patient with incarcerated heria is attempt reduction. The next best step in a patient with strangulated heria is immediate surgery.

[00:35:57]Doctors please let me know is it okay for you? Yes or no?

[00:36:06]The next best step for a patient with incarcerated hea is try to release the hea or reduce it. The next best step for a patient with strangulated heria is surgical management.

[00:36:26]Simple. Okay. Now, next question. Which of the following clinical findings most strongly suggest that an incarcerated ingrown has progressed to strangulation?

[00:36:40]Which of the following clinical findings most strongly suggest that an incarcerated ingrinal hea has progressed to strangulation? A mild tenderness over the hernia mass. B inability to reduce the hernia manually.

[00:36:59]C, fever, tachicardia, a tense, exclusively tender mass. D, a hernia that has been reducible for 2 hours. And E, absence of bowel sounds over the hernia.

[00:37:14]What finding shows that this patient has moved for incarcerated incarceration to strangulation?

[00:37:28]The correct answer is C. So all the doctors who are choosing C you are correct. C see C see C see C see C see C see strangulation will mean that look the blood supply to the heria contents is compromised and that leads to eskeeia and necrosis and the hallmarks are a tense exquisitly tender groin mass and it is combined with systemic signs of sepsis like fever, tachicardia, hypotension, vomiting and confusion.

[00:37:58]All right so please remember that. Okay, I have another question for you. So, you know, I'm trying to quiz you on all the areas that you can possibly be quizzed in your board exam so that you can go into the board exam with a lot of confidence, right? So, a patient with incarcerated ingrenal hernia has been symptomatic for 36 hours. He now has abdominal distension, vomiting, and a WBC count of 18,000. What's the best next step? A sedation and manual reduction. B. Abdominal CT scan. C.

[00:38:34]Watchful waiting with IV antibiotics. D.

[00:38:37]Eren surgical repair. And E. Nasogastric tube decompression and observation.

[00:38:43]What's the correct answer? What's the correct answer? Now we getting into a little bit of deep waters. What's the correct answer? What's the correct answer? What's the correct answer?

[00:38:50]What's the correct answer? And the correct answer according to many many many doctors right now who are choosing is D. eent surgical repair. So we have to really understand when are we going to observe, when are we going to reduce and when are we going to send the patient to the theater directly. So you realize that this patient has red flags for strangulation and what are they? The patient had prolonged symptom duration.

[00:39:18]There was vomiting. There was abdominal distension, luccoytosis and all of these suggest that the bowel has been compromised. this patient needs to be taken to the O right away where the intestinal you know strangulation can then be dealt with. So next question, next question. You have a 30-year-old man who presents with a 3hour history of painful irreducible right in heria. He's hemodynamically stable with no signs of peritonitis. You decide to attempt manual reduction. Which of the following is the most appropriate sedation regimen? Now we we we we changing the game just a little bit. We we taking it up a little bit. We turning up the heat, right? So general anesthesia in the operating room. B IV morphine and short acting benzoazipin titrate to effect. C local anesthetic injection into the heal sac. D oral aamophen and reassurance. and E spinal anesthesia.

[00:40:26]So this question is basically asking you in your board exam in the Q1 what medication will you give if you have a patient who has an incarcerated heria and you want to reduce it what medication will you give will you give general anesthesia in the theater will you give IV morphin and short actin benzoazipen will you give local anesthesia will you give an oral tylenol and reassure the patient or will you give spinal anesthesia it looks like everybody body is going for B and B is the correct answer. You want to do some form of sedation, some form of sedation. So, you also have to understand in the Q1, you have to know, you know, and these are the things I'm talking about. You need to know some of these things. And this morning, I had a chat with a doctor who was concerned about, you know, how she's going to study. And I was like, you know what?

[00:41:23]first pass the exam then you can use your lifetime to gather medical knowledge because if you want to know everything in medicine you'll never know right even when you start practicing in Canada you need to continue doing continuous professional development so these are the b points or the the the ballpark points I want you to know how what medication regimen will I use if you have a patient who has come in with incarcerated ingrenal heria with no signs of strangulation. I'm going to do conscious sedation and which medications will I use? IV morphine with combined short acting benzoazipin for example midazzol and I will titrate them to their safe effect and the smallest effective dose should be used so that you avoid over sedating the patient. Right? you realize that general anesthesia is unnecessary.

[00:42:18]If you need to just do reduction and we do reductions all the time in the emergency room, you don't need to give general anesthesia. Just give some IV morphin, give some IV midazzylam and the patient will be good. And you can even give midazzylam through other routes, right? And local anesthesia alone does not provide adequate relaxation for you to be able to uh reduce a um an incapacitated hernia. So now the other point is this after successful manual reduction of an incarcerated ingrain her what is the recommended next step you know we started with telling the difference between the types of heras indirect direct femoral and then we looked at how we going to manage each of them we looked at the anatomy how and why are they formed so when you go into the board exam you're looking for critical clues. Is it lateral? Is it medial? Is it below? Now, we've looked at how am I going to manage strangulated heria? How am I going to manage incarcerated hernia? Now, after you've managed an incarcerated heria, this is the next question. What will you do? A discharge with no followup needed. B immediate surgical repair during the same visit. C short period of observation. Then arrange urgent elective repair. D CT CT abdomen to confirm reduction and E repeat reduction attempt to ensure stability.

[00:43:49]What's the correct answer? Is it A? Is it B? Is it C? Is it D or is it E?

[00:43:56]What's the correct answer? Doctors, is it A? Is it B? Is it C or is it D or is it E?

[00:44:09]All right. All right. All right. All right. So, looks like a lot of doctors are going for C short period of observation then arrange agent elective heria repair. Why? Because you want to make sure that the incarcerated her maybe if it comes back it can go back again. Right? If it come back into the heria sack, you want to make sure it can go back again. So, what's the teaching point here? The patient should undergo a short period of observation to ensure no complications happen like reduction in mass and delayed bow eskemia and definitive surgery can then be arranged as an urgent elective repair from the same admission up to several weeks later.

[00:44:52]Why should you do that? because this avoids the higher mobility and mortality associated with emergency surgery while still addressing the underlying defect.

[00:45:02]There's no point rushing a patient whom you've been able to reduce an incarcerated hea rushing the patient to the O. No.

[00:45:11]Right?

[00:45:12]Why would you do that? You can manage it. Send the patient home.

[00:45:18]arrange the surgeons for the P surgeon to see the patient maybe in the course of the week and then arrange surgery for that. So now that we've done all those things you realize that there is another objective about scrotal masses and scrotal pain. So I wanted to fit that as well into the class but I have a quick question doctors how has the class been so far? I'm going to fix that into the class so that we can get some pearls for the board exam. But how has the class been so far? I want to know how has the class been so far. Those who who have my phone number as well, just text me. How has the class been so far? So good, bad?

[00:45:55]Dr. Bern, I don't like it. Dr. B, we don't like your teaching. You know what?

[00:46:00]What what what how has the class been so far?

[00:46:07]How's the class been so far? Okay, so somebody's asking what is reduction and mass? So reduction in mass is basically you know maybe the patient has the beginnings of um um strangulation and then you force you know where you force uh the reduction and even cause some uh some content which should not be forced back into the abdominal mass back into it. You know that is a big big big problem. So reduction in mass that is something because that can lead to um um strangulation as well. It will give you the feeling that it's been reduced but in reality you just pushed all the structures backward. Mhm. Okay. So someone is saying good. Let's continue then. Let's continue. Let's continue.

[00:46:54]Let's continue. Let's continue. Let's continue. Let's continue the class.

[00:46:58]Okay. All right. So now this question is very important. Remember we are we are we are now adding another layer. We've looked at the various types of hernas and we've gone through it and then now we are here scuttal masses in general.

[00:47:14]You have a 14-year-old boy who presents with sudden onset of severe left scal pain nausea and vomiting. On examination the left testus is high riding and is a and a traverse lie. The creamic reflex is absent to the left. What's the most likely diagnosis and the best next step?

[00:47:32]A epidmitis prescribed antibiotics. B tossing of the appendex testers supportive care. C testicular torsion emerent surgical exploration. D incarcerated ingrenal hernia attempt manual reduction. And E testicular torsion obtain scal ultrasound first.

[00:47:57]What's the correct answer? Are you going to go for A? Are you going to go for B?

[00:48:01]Are you going to go for C? Are you going to go for D? Or you going to go for E?

[00:48:05]And I see a lot of doctors going for C and C is the correct answer. Testicular torsion emergent surgical exploration should be your next best step. Okay. Now why is it so? This is a typical textbook presentation of testicular torsion where the patient presents with sudden severe pain, nausea, vomiting, high riding testus in a transverse lie and absent cremaster reflex. Now the absent cremaster reflex has an ratio of 47.6 for diagnosing torsion in one study. And there's what we call the twist score, but I didn't want to waste your time on it. And the components of the twist score are like a high riding testice, absent cremaster reflex, nausea, vomiting, testicular um swelling and this patient has a high risk and should proceed directly to surgical exploration without imaging. So the twist score helps you to know um when you should send the patient directly to the O or when you should maybe look for getting an ultrasound before you do what you need to do. Okay. Now delaying for ultrasound risks losing the testice and the salvage rate is approximately 90% within 6 hours but after that it drops precipitously. So that is why you don't want to delay so much. This patient has had the scal pain for quite some time.

[00:49:32]Okay. Next question.

[00:49:35]Yep. A 10-year-old boy who presents with gradual onset of scuttal pain localized to the upper pole of the left testus.

[00:49:46]Gradual upper pole. On examination, there's a small tender noodle at the upper pole with a bluish discoloration visible through the scrutal skin. The creamic reflex is intact.

[00:50:02]Now, what's the most likely diagnosis? A testicular torsion, B torsion of the appendix testus, C epidemitis, D testicular tumor and E incarcerated in granal hen. What's the correct answer?

[00:50:16]Are you going to go for A, B, C, D, or E? What's the correct answer? Tell me what's the correct answer.

[00:50:30]I going to go for A. Are you going to go for B, C, D, or E?

[00:50:48]So, we've now moved from the realms of heria to testicular masses. I just wanted to drop that so that you can have an idea when you're preparing for your board exam, know which areas to focus on, right? Okay, good. So the correct answer is torsion of the appendix testus.

[00:51:06]Torsion of the appendix testus that is B. Torsion of the appendix testice. Not C. Torsion of the appendix testice. And some people will say Dr. Brony what is that? This is how a torsion of the appendix testice looks like. So I think almost everyone got it wrong. Everyone went for C. Okay. This is what we call the blue dot sign. The blue dot sign.

[00:51:33]It's a bluish discoloration which is visible through the scrutal skin.

[00:51:37]Especially the patient is like you know Caucasian right for blacks like Dr. Brun you not see you not see the blue dot skin you not see the blue dot sign right at the upper pole and is pagnommonic for tossion of the appendix testus which we call the hydided of moagnney.

[00:51:57]Uhhuh. the hydide of mognney. Now the key differential features include the fact that it was gradual.

[00:52:05]It was not sudden and the tenderness is localized at the upper pole not the entire testice and then there's also intact creastic reflex because when it comes to testicular torsion the creastic reflex will be absent.

[00:52:24]Okay, cream reflex will be absent. That is textbook stuff. But when you see the blue dot sign, think about what we call you know um um twisting or torsion of the appendix testice. It's just a little tiny thing which sits on top of the testice and this condition is managed conservatively.

[00:52:47]So you need to know while you're managing epidmitis with antibiotics and testicular torsion with surgery when it comes to a patient with the blue dot sign you're managing that patient conservatively no surgery is needed doctors this is very important which one are you going to give antibiotics which one are you going to send to the theater which one are you going to manage consecutively there's is a point.

[00:53:19]So doctors, are we all on the same page? Did Did that Did that ring a bell? Did that ring a bell? Did that ring a bell? So I see a lot of people went for C and that was unfortunately wrong.

[00:53:34]That was unfortunately wrong.

[00:53:37]Okay. So please, as I said, I need you to mark your calendars.

[00:53:43]May 28th, 6 hours with me.

[00:53:48]Remember, this is on top of the regular classes you have. And tonight, if you're in ME Cognito program, you have a class.

[00:53:55]But on May 28th, I'm giving you this special special invitation.

[00:54:02]Just click on the link and register after the class. I'll put the link in the YouTube the YouTube link. But what is this about?

[00:54:13]What is this about?

[00:54:16]Oh, somebody says, "Happy Mother's Day to your wife, brother." Sure, I'll tell her. Thank you so much, Dr. Greg. Okay, so what is this about? Someone say, "Hey, but Dr. Bon, I'm a medal student.

[00:54:28]If you're med student, we are spending the six hours together free like what we did with the ECG class." So if you're a medcognito student on the 28th of uh of May that day you don't need to pay anything because you're a metcognito student you it will be in your portal the link will be there just click on it and join it will be from 5:00 a.m.

[00:54:50]Ontario time to 11:00 a.m. and remember you will also get a replay but someone will say hey Dr. Bonnie what about if I'm not a metcognito student. So if you're a Medco student, it's free. If you're not a Medco student, in fact, there are three options. The first option is for you to enroll in the Medco 6 month program, right? Which I highly recommend. But some will also say, "Okay, Dr. Bonnet, I really want to see how your program actually is at a lower price." Okay, that's good. So then you can just do $450 onetime payment and it will give you access to everything in metcognito our question bank our knowledge checks the live classes replay of every live class. So if you want to use the one month to review everything in Medco Cognito including our notes which you can read including our lectures which you can watch as videos including our flash cards including med bullets is just $450. And someone will also say Dr. Bonnie I'm solid on my content but I just want ethics because ethics is a very tough thing for me and I confuse it. When am I calling the police? When am I reporting to the head of department? blah blah blah blah blah.

[00:56:04]Okay, that's also fine. For the six hours only 400, only $200. You get access to a portal, but that will be for ethics only.

[00:56:14]You will get access to the live class and even after the class, you will still get access to replay of that particular class and mock exams and other resources will put there on ethics alone for one whole month. So, let me say it again. If you met Cognito students at that time on the 28th of May, if you are still in the program, it's free because the link will come up in your portal right away like the way we put the link in your portal all the time. If you're not a Medco student and you still want access to everything in Medco, then you have two options. Number one, to enroll in a six months program, which is only $420 every month for 6 months. Or if you want a discount, it's only $2,199 for 6 months. Or you also say that I just want one month. Just one month. Dr. Brony, just give me one month. And that is also fine. That's only $450. Remember that one. You will add it to our WhatsApp page. We'll add you to you can attend all the metcognito classes within that one month which we are running. You will also get access to this free class for all metcognito students. And then someone will also say, Dr. Bon, I'm not a metcognito student. I don't want access to everything. I want access to only that class on ethics, 6 hours with you from 5:00 a.m. dawn to 11:00 a.m.

[00:57:36]Sure, doctor. You're also welcome. It's only $200, you know. Just click I'll put the link in the in the in the in the the YouTube uh link as as soon as we are done or you can send me a WhatsApp right now. So that after this class, I'll send you that link. It's only $200. You get access to that class. You get access to mock exams in ethics only. You'll also get access to even review that class one month after the class is done. So this is my special special special announcement for you. The best is for you to become a medcognito student. But someone wants to say, "Hey, I want to dip my foot to know what Medco is all about." Just $450 you get access to everything.

[00:58:20]Notes, med bullets, med drills, you know, um, Meduddy, which is our AI generated flashcards, notes in Medco Cognito live classes, everything. And someone also says, Dr. Bon, I don't want all that. I just want that ethics class because I've learned my cardiology. I've learned my respirology. I've learned my general surgery. I just want a brush up on ethics. but six hours with you. Welcome.

[00:58:48]Let's go. Let's do it. So, doctors, that is it. Every concept in medical ethics will be covered. That is why I'm giving my time to redesign the notes. We are going to cover more than 2,000 PowerPoint slides and it will be you know that the way we do it in this class is the same way we do it. We'll pick the concepts confidentiality, substitute decision making, interacting with the police, how to treat a a fellow colleague, who do you report to, you know, um how do you deal with abuse of minors, what do you do with an emancipated minor, and we are going to use the resources the medical council itself has said we should use choosing um no um doing right CMPA, right? All the materials the medical council wants us to use. That is what we are going to review. It will be more than 2,000 slides. Please when you're coming, make sure you come with water, get some orange juice, get some biscuits, get some cookies because it will be 6 hours of everything you need to know for ethics for your Q1 exam. If you're med student, it's free like the ECG class. Now, let's go on. Do you have any questions? I want to know if you have any questions about this. If you have any questions, let me know before we before we go to the active recall. If you have any questions about what I just said or if you want to reach out to me, it is at plus one 3068915649.

[01:00:17]I'll wish that just after this class, reach out to me and ask your questions.

[01:00:20]Dr. Bon, I want to enroll in the class or I want to be part of this ethics class or I want one month access.

[01:00:26]Whatever you want, let me know. Boom.

[01:00:28]We'll give you access. Okay, good. Now, let's go on. Let's go on. Let's go on.

[01:00:33]So let's do active recall right away.

[01:00:36]Active recall. What single anatomical landmark classifies ingenia as direct versus indirect? And let me even say plas femoral doctors. Listen to what this doctor says. Says what?

[01:00:59]First time joining the live class and must say you're a fantastic teacher.

[01:01:07]At Medco we will help you to understand the concepts. You will understand the concepts. You need to understand the concepts. So what single anatomic landmark classifies inguinal hemas as direct versus indirect?

[01:01:22]Okay. Okay. Okay. Someone says epigastric vessels. epigastric vessels.

[01:01:30]By the epigastric vessels, we are dealing with the inferior epigastric vessels. Inferior epigastric vessels. So in your board exam, if you are told the ha is lateral lateral to the inferior pigastric vessels, think about an indirect ingral hera which is going to the internal ring through as a result of a patent processes vaginalis. Right? If it is medial medial to the infraastic vessels, then think about a direct ingral hernia which is going through the box triangle, hustlebox triangle and if it is below the inguinal ligament then think about a femoral hernia and it is more common in older women and the risk of strangulation in femoral heas is through the roof is high. Okay, good.

[01:02:18]What is the difference between incarceration and strangulation of hernas?

[01:02:22]What's the difference between incarceration and strangulation of hernas? What is the difference between incarceration and strangulation of hernas? Doctors remember if you want us to have a conversation right after this class 1 3068915649 + 1 3068915649 that is my personal phone number. I will respond to you personally. If you want me to send you a video video message I will do that. If you want me to send you a voice note, I will do that. If you want us to have a conversation, we will have the conversation. So please, how would you differentiate between incarcerated strangulation in incarcerated heria and strangulation hernia or strangulated heria? Okay, let me see. Blood supply compromised in strangulation. Okay, blood supply is affected in strangulation but not affected in castration. Beautiful, beautiful, beautiful, beautiful, beautiful. Thank you for the word. So sweet. Let me put this way. Incar castration hernia contents are trapped.

[01:03:28]They irreducible but blood supply is intact. Right? That's what the doctor said. There's mouth tenderness. No systemic signs. But when it comes to strangulation, blood supply is compromised.

[01:03:39]There's tension, right? And it's exclusively tender. The patient may have fever, tachicardia and sepsis. For incarceration, please try to reduce it. For strangulation, do immediate surgery. No reduction attempt.

[01:03:59]For incarceration, attempt reduction.

[01:04:02]For strangulation, immediate surgery, no reduction attempt. Okay. No. Next one.

[01:04:09]What should happen after successful manual reduction of an incarcerated hernia? Next best step after successful manual reduction of an incarcerated her.

[01:04:20]Next best step after successful manual reduction of an incarcerated heria.

[01:04:27]Ladies and gentlemen of the noble profession, what should happen after successful manual reduction of an incarcerated her? What should you do next? What's the next best step? You know in the med the the the medical council's free questions, those are the expressions they use. Next best step. Next best step. Next best step.

[01:04:49]The next best step is very simple. You need to observe. You need to observe brief observation. Rule out complications.

[01:04:59]For example, reduction and mass. Arrange urgent elective repair days to weeks.

[01:05:05]And this converts an emergency surgery to elective surgery. Right. But remember in Canada never ever ever ever discharge a patient with an incarcerated inguinal hea whom you've reduced without followup cuz that will definitely recur to definitely recur. Okay. Now what are the key physical exam findings that differentiate testicular torsion from epiditis?

[01:05:37]Hey, what are the key physical exam findings that differentiate testicular torsion from epidmitis?

[01:05:47]Tell me something sweet. What are the key physical exam findings that differentiates testicular torsion from epidmitis?

[01:05:56]Tell me something. Tell me something.

[01:05:58]Tell me something. Tell me something.

[01:06:01]Key key key physical exam findings that differentiate testicular torsion from epi deitis. Beautiful, beautiful, beautiful, beautiful. Someone is already talking about creamic reflex. Let's go through it quickly. Testicular torsion.

[01:06:18]There's sudden onset high riding testers with a transverse lie and there's absent cream mastic reflex. The patient may have nausea or vomiting. Meanwhile in epidemitis gradual gradual it may be going on for days this ura may be present the patient may even have discharge there's a positive friend sign and what is that a positive friend sign is basically you lift the testice up towards the rest of the body and the pain is relieved but with torsion there's a negative friend sign what's that when you put that so just think about this the screw to I lift it up when I lift it up it is still painful in testicular torsion but it is it improves with epidmitis secondly testicular torsion there's absent creastic reflex but in epidmitis there is present and intouch creastic reflex testicular torsion emergency surgical management epidmitis antibiotics what about what about tossing of the testicular appendix? What how will you manage the patient? Someone should tell me. We learned it. How will you manage a patient with a tossing of the testicular appendix? How will you manage that patient with? We learned that testicular torsion going to go for surgery epidmitis antibiotics. But what about the patient with a tossed testicular appendix with the blue dot sign? Blue dot sign. What will you do? What will you do? Beautiful. You manage that patient consecutively.

[01:08:06]You manage that patient conseively.

[01:08:10]You manage that patient consecutively.

[01:08:13]Okay. Good. So doctors today is happy mother's day but thank you very much for spending your time with me and this announcement is very very important. Which option do you want? 6 months access which I will highly recommend. One time payment of $2,199 gives you access for 6 months and you save $350.

[01:08:35]Someone also say Dr. Bern I want just one month but I want one month with everything in metcognito. Sure that's good. We'll provide it for you. That's only for $450. Someone also says, "Dr. Bonnie, hey, I just want to attend the ethics class and spend some time with you while I'm drinking my orange juice and my water and chewing on my biscuit and walking on my treadmill and listening to you teach ethics so that I have everything in ethics covered."

[01:09:00]Doctors, send me a message right now.

[01:09:03]Right now. Right now. Plus 1 3068915649.

[01:09:07]Plus 1 3068915649.

[01:09:11]Thank you very much for spending your time with me. As usual, this is your brother, your guide, your teacher in this your MCC journey. So you become a doctor in Canada. It's my pleasure serving you. Send this video to as many friends as possible. Let me hear from you on the phone. See you in class tonight. See you in class on Thursday.

[01:09:34]See you in class every Sunday. See you in class on May 28th. Go look at the face of the mother, the wife, if you have a wife, an auntie, a grandmother, and say happy mother's day. Go out there, go to the restaurants, go get something to eat. And don't forget to take care of yourself as you prepare for this MCQE exam, doctors. It's always a pleasure. God bless you. All the best.

[01:09:56]Bye-bye. Bye-bye. Bye-bye. Bye-bye.

[01:10:04]Heat. Heat.