Benign Lesions of the Groin and the Canal of Nuck
Hidradenitis and Other Groin Lesions
The most common lesions the gynecologist will encounter in the groin are enlarged lymph nodes, usually secondary to drainage from the inferior extremity or the neighboring vulva. These rarely require surgical treatment. However, an enlarging solitary mass in the groin, particularly without any identifiable cause, requires exploration and possible excisional biopsy. Differential diagnoses include enlarging lymph node(s), myoma, and femoral hernia. Here, knowledge of the precise anatomy of the femoral triangle is essential. Draining sinuses involving the vulva or the groin may be associated with a variety of disorders. Excisional biopsy may be required to make a diagnosis (Fig. 77–1A through D). Clearly, venereal causes should be excluded first by blood tests, smears, and punch biopsy. Disorders such as syphilis, lymphopathia venerea, and lymphogranuloma inguinale may be associated with sinus-like purulent drainage from matter and enlarged groin nodes. Treatment of these conditions is medical. Tuberculosis also may be associated with draining vulvar and inguinal sinuses. Again, this disorder may require that a generous excisional biopsy be performed and a portion of the tissue be sent for culture, while the remainder is sent to pathology for routine and acid-fast stains. Finally, infection of the apocrine sweat glands (hidradenitis) leads to persistent and chronic purulent draining sinuses in the vulva and groin (Fig. 77–2A through C). Additionally, this disorder may be seen in the axilla. These modified sweat glands may penetrate deeply into the underling stroma and typically plunge into the fat. Treatments for this disorder consist of antibiotics, retinoids, and/or surgery. Surgical excision is wide, with deep margins to eliminate the infected vulvar and inguinal tissues (Fig. 77–3A, B). The wounds may be left open after excision. In the latter instance, healing, of course, is by secondary intention (Fig. 77–3C through H). The wound site initially should be covered with wet-to-dry dressings. Longer term, the patient should sit in salt water (Instant Ocean) tub baths 3 times daily and should cover the operative site with silver sulfadiazine (Silvadene) cream. Alternatively, excised sites may be closed if the margins can be mobilized without undue tension (Fig. 77–4A through I). The patient should be placed on antibiotics (after the wound is cultured) and in Instant Ocean tub soaks 2 or 3 times daily.
Lesions of the Canal of Nuck
Unilateral swelling of the labium majus may be due to a variety of nonsurgical disorders. The absence of inflammation and early pain selects out many nonsurgical causes. Several common surgical disorders should be borne in mind: cyst of the canal of Nuck, hernia into the canal of Nuck, myoma, and lipoma originating from structures in and around the canal. Transillumination may aid in the differentiation of a cystic from a solid mass preoperatively. Exploration, removal, and, in the case of hernia, correction are performed by making a vertical incision into the labium majus (Fig. 77–5A). The incision should be made above and to the lateral or medial side of the lesion. Once the subcutaneous tissue has been reached, 0 Vicryl traction sutures or Allis clamps are placed at the upper and lower margins of the mass. The anterior and lateral margins of the mass are completely dissected (Fig. 77–5B). Blood vessels are clamped and suture-ligated with 3-0 or 4-0 Vicryl. Next, the medial, posterior, and inferior margins of the mass are freed. The mass is carefully entered to ensure that no underlying intestine is present. If the mass is solid (e.g., a lipoma), it is simply excised (Fig. 77–5C
