Inguinal hernia


Refers to a protrusion of abdominal-cavity contents through the inguinal canal.

Inguinal hernias are the most common of the abdominal hernias.

The inguinal canal allows the spermatic cord and testicle to descend from the abdomen into the scrotum as the fetus develops and matures.

Following testicle descent, the inguinal canal opening is supposed to close completely.

Sometimes, however, the muscles that attach to the pelvis leave a weakened area.

Subsequently, a stress placed on that area of weakened tissues can allow a portion of small bowel or omentum to slide through that opening, producing a bulge.

Inguinal hernias are less likely to occur in women, as there is no opening in the inguinal canal.

Imaging is usually not required with an appropriate clinical history and physical examination.

Imaging is useful in patients who have a suspected hernia by history but lack physical exam defect findings.

Ultrasound is not reliable for hernia detection as it is user dependent.

Noncontrast magnetic resonance imaging or CT with Valsalva the pref2242ed imaging modalities for diagnosing occult hernia.

Lifetime risk 27% for men, and 3% for women.

Surgical correction ranges from 10 per 100,000 in the United Kingdom-28 per 100,000 in the US.

Groin hernia repair annual frequency increases consistently with age from 0.25% at 18 years and 4.2% at 75-80 years of age.

Elective surgery is no longer recommended in minimally symptomatic cases, due to the low risk of incarceration which is <0.2% per year.

Watchful waiting is considered for asymptomatic or mildly symptomatic patients, defined as the absence of hernia related pain or discomfort limiting usual activities or recent difficulties in reducing the hernia.

Randomized clinical trials found no difference in pain or quality of life after 2-3 years for watchful waiting versus patients who underwent surgery.

Surgical repair is necessary for acutely incarcerated hernias with those with significant pain or lifestyle limitations.

Surgery associated with risk of 10–12% for post herniorraphy pain syndrome.

Groin hernias have 3 components: The neck, sac and contents.

The neck is the opening in the abdominal wall, the sac forms by protrusion of the peritoneum int the opening, and the contents refers to a tissue or organ that protrudes through the neck int the hernia sac.

In the groin region the abdominal wall is composed of peritoneum, transversalis fascia, internal and external oblique muscles and their aponeurotic structures, subcutaneous tissues and skin.

The development of all inguinal hernias is due to the failure of the transversalis fascia at the myopectineal orifice of Fruchaud to prevent intrabdominal contents from protruding.

Groin hernias are inguinal or femoral.

Divided into two types of inguinal hernia, direct and indirect, defined by their relationship to the inferior epigastric vessels.

Both direct and indirect hernias protrude above the inguinal ligament

Direct inguinal hernias occur medial to the inferior epigastric vessels, whereas and indirect is lateral.

In direct inguinal hernias abdominal contents herniate through a weak spot in the fascia of the posterior wall of the inguinal canal, which is formed by the transversalis fascia.

Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric vessels.

Indirect inguinal hernias may be caused by failure of embryonic closure of the processus vaginalis.

The opening of the superficial inguinal ring in females is smaller than that of the male and the occurrence of hernias through the inguinal canal in males is much greater due to the larger opening and weaker wall through which the intestines may protrude.

Inguinal hernias belong to groin hernias, which also includes femoral hernias.

A femoral hernia is not via the inguinal canal, but it is through the femoral canal.

A femoral hernia protrudes below the inguinal ligament and ismedial to the femoral vessels

The femoral canal normally allows passage of the common femoral artery and vein from the pelvis to the leg.

Femoral hernias account for less than 5% of inguinal hernias.

Femoral hernias are not diagnosed in 30-40% of cases until patients present with strangulation or bowel obstruction.

Femoral hernia repair mortality is higher in association than with elective repair.

Incidence of femoral hernias increases steadily with age and is higher among patients experiencing recurrent hernias.

Femoral hernias are more common in women.

Women with a groin mass are 5 times will likely to have an inguinal hernia then a femoral hernia.

Inguinal hernias in women are almost always indirect.

Hernia clinical classification:

Reducible hernia: is one which can be pushed back into the abdomen by manual pressure.

Irreducible hernia: is one which cannot be pushed back into the abdomen by manual pressure.

Irreducible hernias are classified:

Obstructed hernia-the lumen of the herniated part of intestine is obstructed but the blood supply to the hernial sac is intact.

Incarcerated hernia-is one in which adhesions develop between the wall of hernial sac and the wall of intestine.

Strangulated hernia- the blood supply of the sac is cut off, leading to ischemia: the lumen of the intestine may be patent.

Hernias present as bulges in the groin area.

Hernias becomes more prominent when coughing, straining, or standing.

Hernias are rarely painful, and commonly disappear on lying down.

Many men are asymptomatic.

Inguinal hernias are more common on the right side than left.

Inguinal hernias are 10 times more common in men and women.

Indirect hernias twice as common as direct hernias.

Groin hernias most commonly diagnosed at the extremes of life.

Major risk factor is family history, associated with an 8 times increased risk.

Risks are increased with COPD, smoking, lower body mass index, increased abdominal pressure, collagen vascular diseases, thoracic or abdominal aneurysm, patent processes vaginalis, open appendectomy history and peritoneal dialysis.

A history of matrix metalloprotease abnormalities such as exists in Ehlers-Danlos syndrome, Marfan’s syndrome, Hurler’s syndrone, and Hunter’s syndrome have increased risk.

Associated with an increased connected tissue homeostasis markers including increased type I:type III collagen ratio and increased metalloproteinase activity.

Heavy lifting may be a risk factor, but remains controversial as weight lifters do not have an increased incidence of inguinal hernias.

The inability to reduce the hernia back into the abdomen usually means the hernia is incarcerated which requires emergency surgery.

Significant pain is suggestive of an incarcerated indirect inguinal hernia.

Hernia progression leads to intestinal descending into the hernia, risking intestinal obstruction.

If the blood supply is compromised, the hernia becomes strangulated with ischemia and gangrene that can have fatal consequences.

Emergency surgery for incarceration and strangulation associated with higher risk than planned hernia procedures.

The risk of incarceration is low, at 0.2% per year.

Indirect hernias follow the same route as the descending testes, migrating from the abdomen into the scrotum during the development of the urinary and reproductive organs.

Because of the larger size of their inguinal canal in men, they are 25 times more likely to have an inguinal hernia than women.

Factors preventing hernia formation in normal people include the strength of the posterior wall of the inguinal canal and shutter mechanisms that compensate for raised intra-abdominal pressure.

There is currently no medical recommendation about how to manage an inguinal hernia.

Surgical correction of inguinal hernias is currently not recommended in minimally symptomatic hernias.

Watchful waiting is advised in minimally symptomatic hernias due to the risk of post herniorraphy pain syndrome.

Surgery is commonly performed as outpatient surgery.

Surgical options include: open repair, laparoscopic repair, use of mesh, and type of anesthesia.

There are various surgical strategies which may be considered in the planning of inguinal hernia repair. These include the consideration of mesh use (e.g. synthetic or biologic), open repair, use of laparoscopy, type of anesthesia (general or local), appropriateness of bilateral repair, etc.

Preventing constipation is important postoperatively.

A direct inguinal hernia is less common, making up 25%. of inguinal hernias, and usually occurs in men over 40 years of age.

Natural history of untreated hernia is not known.

Complications include incarceration with bowel, intestinal obstruction or strangulation of intra-abdominal contents all of which are rare events.

Commonly held estimated 4-6% lifetime risk for strangulation is probably a gross exaggeration.

Lifetime risk for strangulation for an 18 year old estimated to be 0.27% and for a 72 year old man 0.034% based on sparse studies.

700,000 procedures done in 2001.

Following repair 10% have a hematoma or wound infection complications.

Surgeons are taught that inguinal hernias should be repaired at the time of diagnosis, even if the patient is asymptomatic to prevent strangulation.

Recent study of 720 men comparing watchful waiting or standard open tension free repair with mesh in patients with minimally symptomatic disease revealed that at 2 years watchful waiting is a reasonable approach.

In the above study at two years after randomization similar numbers of patients in a watchful waiting group or in a surgical repair group had pain that limited activities and physical functions were similar.

In a VA database the mean age of patients having hernia emergencies was 77 years with a death rate after repair of only 2.2% and a low accident rate of 1.8 per 1000 patients also indicates def2242ing surgery is a reasonable option.

Cancer found in 0.4% of examined hernia specimens.

Three types of hernia tumors: primary, within a herniated viscus or metastatic.

Most cases of inguinal hernia with malignant tumors are colorectal in origin but rarely can be secondary to sarcomas, gastric or thymus tumors.

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