- Clinical science
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 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.
- Inguinal hernias are the most common type of hernias (∼ 75% of all cases).
- Responsible for one of the most common general surgical procedures in the United States
- Prevalence: 5–10% in the US
- In both genders, indirect inguinal hernias are more common than direct inguinal hernias.
Epidemiological data refers to the US, unless otherwise specified.
- Direct inguinal hernia
Indirect inguinal hernia
- Congenital or acquired condition
- Due to patent processus vaginalis
Anatomy of the inguinal canal and the inguinal triangle (the Hesselbach triangle)
- Extends between the deep (internal) and superficial (external) ring
- Roof (superior): internal oblique and transversus abdominis muscles
- Floor (inferior): inguinal ligament (shelving edge of external oblique) and lacunar ligament (medially)
- Posterior wall: transversalis fascia laterally; conjoint tendon medially
- Anterior wall: external oblique aponeurosis and internal oblique muscle laterally
- Borders of Hesselbach's triangle
- Medially: rectus abdominis muscle
- Laterally: inferior epigastric vessels
- Inferiorly: inguinal ligament
- Medial to the inferior epigastric blood vessels (within Hesselbach's triangle)
- Hernial sac protrudes directly through the posterior wall of the inguinal canal (without involvement of the spermatic cord or round ligament of the uterus)
- Only herniates through the superficial (external) ring
- Only surrounded by the external spermatic fascia
- Lateral to the inferior epigastric blood vessels (outside Hesselbach's triangle)
- Runs from the deep (internal) inguinal ring through the inguinal canal to the superficial (external) inguinal ring (in men, along with the spermatic cord)
- Surrounded by the external spermatic fascia, cremasteric muscle fibers, and internal spermatic fascia
'MD': medial = direct References:
- Visible, palpable groin protrusion or bulge
- Inguinal pain (does not have to correlate with the size of the hernia)
- Increase of symptoms during physical activity (walking or standing, coughing, sneezing, abdominal pressure)
- Indirect inguinal hernia may be associated with a communicating hydrocele
Palpation of the inguinal canal
- With the patient standing, palpate from the scrotal skin towards the superficial (external) inguinal ring.
Ask the patient to cough or strain and bear down (Valsalva maneuver).
- Bulging can be felt with a fingertip (expansile cough impulse).
- For other possible symptoms, see “Complications” below.
Inguinal hernia diagnosis is typically established based on medical history and physical exam findings!
- 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
Indications for surgery
- Complicated hernia (see “Complications” below)
- Uncomplicated hernia + moderate symptoms:
- Uncomplicated hernia + mild symptoms: elective hernia repair
Open vs. laparoscopic hernia repair
- Indications for open hernia repair
Indications for laparoscopic hernia repair
- Bilateral hernia
- Recurrent hernia (if the patient initially had an open hernia repair)
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
- Conventional (open) surgical procedures
- Lichtenstein repair: reinforcement by implementation of a synthetic mesh between the abdominal internal oblique muscle and the aponeurosis of the abdominal external oblique muscle
- Shouldice repair: doubling of the transverse fascia and fixation of the abdominal internal oblique muscle and transverse muscle at the inguinal ligament by suture (a nonmesh repair)
- Laparoscopic surgical procedures
- The choice of which repair to perform depends on the type of hernia and patient's risk factors.
- Conventional (open) surgical procedures
- Recurrence after surgical intervention is 0.5–15% depending on the surgical procedure (see “Therapy” above).
Risks of surgery
- Vas deferens injury
- Spermatic vessels injury, dissection, or constriction, which may lead to testicular necrosis
- Injury to femoral nerve, artery, or vein
- Chronic inguinal pain
- Bladder injury
- General risks of surgery (see laparoscopic surgery and )
Incarcerated hernia: inability to reduce the hernia back into abdominal cavity; fixation of contents in the hernial sac
- Surgical emergency in case of concurrent bowel obstruction
- Strangulated hernia: tight constriction of hernial contents leading to constriction of blood vessels and bowel ischemia
We list the most important complications. The selection is not exhaustive.
Inguinal hernia in infants
- Incidence: ∼ 1–5% of all children
- ♂ > ♀ (∼ 4:1)
- Occurs more often on the right side
- Etiology and risk factors
- Premature infants with uncomplicated inguinal hernia: Surgery should be performed after discharge from the neonatal intensive care unit (NICU).
- If hernia can be reduced manually: Wait 24–48 hours before performing surgery to allow enough time for edema to decrease.
- If hernia cannot be reduced manually: immediate surgery
- Asymptomatic inguinal hernia: within 14 days of diagnosis