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Inguinal hernia

Inguinal Hernia

What is an inguinal hernia

An inguinal hernia is a protrusion of intra-abdominal contents, usually part of the intestine, through an opening in the groin area. The hernia is caused by the persistence of an open hernia sac that, in contrast to the normal process of development, fails to close completely. The incidence is roughly 3% in males. This condition is much more common in males, occurring about 25 times more often compared to females. This type of hernia may occur at any age and there is sometimes a pre-existing family history of the condition.

Symptoms

Inguinal hernias may not have any symptoms at all. When symptoms do arise, patients usually experience the hernia as a swelling in the groin which may or may not be uncomfortable. The discomfort is usually described as a pressure that may negatively affect the normal activities of daily living, is worse at the end of the day and better at night when the patient reclines. If pain becomes severe and the hernia does not become smaller when lying down or is associated with tenderness, vomiting, fever or perspiration, patients should go to an emergency room to be evaluated for a strangulated hernia. A strangulated hernia occurs when there is ischemia or possible death of cell tissue due to poor circulation.

A strangulated hernia is very uncommon, but it is the most serious complication of the condition.

Risk Factors

As mentioned, inguinal hernias are caused by the persistence of a congenital hernia sac, usually occurring in the right groin area. This genetic predisposition may be aggravated by straining from coughing, constipation or heavy lifting. Inguinal hernias may be single or double and sometimes reoccur after surgical treatment.

How is it diagnosed?

An inguinal hernia is usually easy to diagnose by the examining physician who inserts a gloved finger gently into the scrotal area (in males) and up to the groin where one can feel a palpable impulse when the patient strains or coughs. Often patients are unaware of the hernia's presence and the exam is rarely uncomfortable. Uncomplicated inguinal hernias are easily reduced, meaning THAT WHEN PRESSED BY AN EXAMINER, the bulge disappears as the intra-abdominal contents return to the abdomen. Hernia reductions often occur spontaneously when the patient reclines or with manual pressure by the patient or physician. Rarely a hernia may be difficult to exclude without certain x-ray or CAT scan procedures.

Treatment

Until recently, most patients diagnosed with inguinal hernias were immediately referred to general surgeons for surgical repair. Surgeons were taught that the best way to prevent serious hernia complications such as incarceration, obstruction and strangulation was to repair all hernias. In early 2006, the first randomized trial of male Veteran's Administration patients with inguinal hernias was reported, showing that after a two to four year follow-up, patients with asymptomatic or minimally symptomatic hernias did just as well without surgery compared to those who had surgery. Therefore, doctors can now feel more comfortable recommending watchful waiting instead of immediate surgical repair. The medical treatment of inguinal hernias consist of patient reassurance of long term tolerability, instruction and alertness of warning signs of an impending complication, explanation and demonstration of manual reduction of the hernia, and prescription of a surgical belt or truss to hold the hernia in the abdomen. Surgical treatment traditionally consists of open procedures to close the abdominal defect, often using synthetic surgical mesh to close the opening and done with either local or general anesthesia. More recently, hernias are repaired with a laparoscopic approach where the surgeon operates through scopes entering the abdomen through tiny incisions and closed with synthetic surgical mesh. Laparoscopic procedures are only done with general anesthesia. Complications consist of infection, bleeding, pain and mesh reaction, with both the traditional and laparoscopic approach. Possible bowel injury is more problematic with laparoscopy. Advantages of the open traditional technique include ability in high risk medical patients to operate with local anesthesia and laparoscopic surgery seems to result in somewhat less post-operative pain and quicker recovery to normal activities.

Complications

Inguinal hernia complications consist of:

1. Incarceration or trapping of the intra-abdominal contents in the sac.

2. Obstruction of the bowel which is trapped in the hernia.

3. Strangulation or loss of blood supply to the incarcerated bowel which may progress to life-threatening gangrene, shock or death.

References:

Schwartz, Shires, Spencer. Principles of Surgery. 6th Edition. 1994. 1517-1529.

Fitzgibbons EJ, et al. Watchful waiting vs. repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006; 295: 285-292.