• Clinical science

Inguinal hernia

Summary

An inguinal hernia is an abnormal protrusion of intra-abdominal contents either through the deep inguinal ring (indirect inguinal hernia; lateral to the inferior epigastric artery) or through the weakened posterior wall of the inguinal canal (direct inguinal hernia; medial to the inferior epigastric artery). Inguinal hernias are often asymptomatic, presenting as a painless swelling in the groin. Pain and features of intestinal obstruction are signs of a complicated inguinal hernia (obstructed/strangulated hernia). Diagnosis is mainly based on clinical findings. Surgical repair is the definitive treatment. Elective open/laparoscopic mesh repair of the inguinal hernia is the standard of care for uncomplicated inguinal hernias. Emergency surgery which may include resection of gangrenous bowel is indicated in patients with complicated inguinal hernias.

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Anatomy

Inguinal canal

Hesselbach triangle borders

References:[3]

Pathophysiology

Direct inguinal hernia

Indirect inguinal hernia

MDs don't Lie: Medial = Direct, Lateral = Indirect

References:[2][1][4][3]

Clinical features

References:[1]

Diagnostics

  • Ultrasound
    • Imaging test of choice
    • Visualization of the hernial orifice and hernial contents may be possible.
  • CT/MRT: to distinguish from differential diagnoses in ambiguous cases

Inguinal hernia diagnosis is typically established based on medical history and physical exam findings!

References:[1]

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Indications for surgery

  • Complicated hernia (see “Complications” below)
  • Uncomplicated hernia + moderate symptoms:
    • Inguinal pain associated with exertion
    • Daily activities are limited due to pain
    • Manual reduction is not possible
  • Uncomplicated hernia + mild symptoms: elective hernia repair

Open vs. laparoscopic hernia repair

  • Indications for open hernia repair
    • Complicated hernias
    • Previous preperitoneal surgeries (e.g., hysterectomy, cesarean section)
    • Presence of ascites
    • Inability to undergo surgery under general anesthesia
    • Recurrent hernia (if the patient initially had a laparoscopic hernia repair)
  • Indications for laparoscopic hernia repair
    • Bilateral hernia
    • Recurrent hernia (if the patient initially had an open hernia repair)

Surgical management

  • Main idea: reinforcement of the posterior wall of the inguinal canal with synthetic mesh or primary tissue approximation
    • Mesh vs. nonmesh repair: Mesh is preferred because of decreased recurrence rates and postoperative pain. It is contraindicated in the case of inguinal infection or contamination.
  • Most common surgical procedures
  • Recurrence after surgical intervention is 0.5–15% depending on the surgical procedure (see “Therapy” above).

Risks of surgery

References:[5][6][7][2]

Complications

References:[1][5]

We list the most important complications. The selection is not exhaustive.

Special patient groups

Inguinal hernia in infants

References:[8][9]

  • 1. Brooks DC, Hawn M. Classification, clinical features and diagnosis of inguinal and femoral hernias in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/classification-clinical-features-and-diagnosis-of-inguinal-and-femoral-hernias-in-adults. Last updated February 4, 2016. Accessed December 12, 2016.
  • 2. Rather AA. Abdominal Hernias. In: Geibel J. Abdominal Hernias. New York, NY: WebMD. http://emedicine.medscape.com/article/189563. Updated December 1, 2015. Accessed December 12, 2016.
  • 3. Le T, Bhushan V, Sochat M, Petersen M, Micevic G, Kallianos K. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.
  • 4. Jiang ZP, Yang B, Wen LQ, et al. The etiology of indirect inguinal hernia in adults: congenital or acquired?. Hernia. 2015; 19(5): pp. :697–701. pmid: 25431254.
  • 5. Brooks DC. Overview of treatment for inguinal and femoral hernia in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-treatment-for-inguinal-and-femoral-hernia-in-adults. Last updated September 1, 2016. Accessed December 12, 2016.
  • 6. Griffen FD. Open surgical repair of inguinal and femoral hernia in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/open-surgical-repair-of-inguinal-and-femoral-hernia-in-adults. Last updated August 3, 2016. Accessed December 12, 2016.
  • 7. Brooks DC. Overview of complications of inguinal and femoral hernia repair. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-complications-of-inguinal-and-femoral-hernia-repair. Last updated January 26, 2016. Accessed December 12, 2016.
  • 8. Ramsook C, Endom EE. Overview of inguinal hernia in children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-inguinal-hernia-in-children. Last updated October 6, 2016. Accessed December 12, 2016.
  • 9. 5MinuteConsult.com. Inguinal Hernia, Pediatric. http://5minuteconsult.com/collectioncontent/1-153411/diseases-and-conditions/inguinal-hernia-pediatric. Accessed December 12, 2016.
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  • Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ. Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. ; 31(2): pp. E1–12. doi: 10.1148/rg.312105129.
  • LeBlanc KE, LeBlanc LL, LeBlanc KA. Inguinal hernias: diagnosis and management. Am Fam Physician. 2013; 87(12): pp. 844–8. pmid: 23939566.
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  • Köckerling F, Schug-Pass C. Diagnostic Laparoscopy as Decision Tool for Re-recurrent Inguinal Hernia Treatment Following Open Anterior and Laparo-Endoscopic Posterior Repair. Frontiers in surgery. 2017; 4: p. 22. doi: 10.3389/fsurg.2017.00022.
  • Kim B, Robinson P, Modi H, Gupta H, Horgan K, Achuthan R. Evaluation of the usage and influence of groin ultrasound in primary and secondary healthcare settings. Hernia. 2015; 19(3): pp. 367–71. doi: 10.1007/s10029-014-1212-1.
  • Piga E, Zetner D, Andresen K, Rosenberg J. Imaging modalities for inguinal hernia diagnosis: a systematic review. Hernia. 2020. doi: 10.1007/s10029-020-02189-4.
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last updated 09/23/2020
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