medicnotes.org.uk :: Inguinal hernia

Inguinal hernia

Epidemiology:

Account for 80% of all external abdominal hernias
Most common in infants and the elderly
Inguinal hernias are 20x more common in men than in women
Occur most frequently on the right-hand side

Classification:

Indirect inguinal hernia:

This passes through the internal ring lateral to the inferior epigastric artery and along the canal to emerge at the external ring above the pubic crest and tubercle
Its coverings are the attenuated layers of the cord

Direct inguinal hernia:

This hernia bulges out through the posterior wall of the canal medial to the inferior epigastric artery
Is, therefore, not covered by the layers of the cord

Pantaloon hernia:

This is a combination of both an indirect and a direct inguinal hernia

Aetiology:

Indirect hernia:

There is a congenital sac or potential sac which is the remnant of the processus vaginalis
If the processus does not close, then an indirect hernia occurs in early life, but other factors may lead to it reopening at any age
Indirect hernias are 20x more common in men than in women
60% occur on the right side (possibly contributed to by damage to the motor nerves of the abdominal muscles at open appendicectomy)
40% on the left
20% are bilateral

Direct hernia:

This is an acquired lesion
For reasons unknown, the posterior wall of the inguinal canal becomes attenuated
Direct hernia is, therefore, a condition of later life and is rarely seen under the age of 40 years

Differences between an indirect and a direct inguinal hernia:

Indirect Direct

Patient’s age Usually young Older

Cause May be congenital Acquired

Bilateral 20% 50%

Protrusion on coughing Oblique Straight

Appearance on standing Full size delay Full size immediately

Reduction on lying Not immediate Immediate

Descent into scrotum Common Rare

Occlusion of internal ring Controls Does not control

Neck of sac Narrow Wide

Strangulation Not uncommon Unusual

Relation to inferior Lateral Medial

epigastric vessels

Clinical findings:

If it is impossible to get above a groin swelling, it is most likely to be an inguinal hernia
In addition to the features listed above, an indirect hernia that extends beyond the external ring appears above and medial to the pubic tubercle (in contrast to a femoral hernia, which is below and lateral)

Other causes of groin swelling:

Femoral hernia
Hydrocele
Undescended or ectopic testis
Lipoma of the cord
Epididymal cyst

Management:

Most adult inguinal hernias are repaired by open operation under local or general anaesthesia as a day case procedure
Open operation usually means:

A layered suture technique (Shouldice), or
Insertion of a non-absorbable prosthetic mesh (Lichtenstein)

Alternatively, mesh repair may be done laparoscopically

Specific complications:

Urinary retention:

Because of the proximity of the inguinal region to urine excretion in the male, temporary problems may be encountered
Rare with modern techniques (unless BPH has been overlooked in the preoperative evaluation)

Scrotal haematoma:

May follow extensive dissection

Damage to the ilio-inguinal nerve:

Produces an area of anaesthesia over the:

Pubic tubercle
Scrotum/labia

Outcome:

Recurrence rates for groin hernias should be <1%
It is more widely quoted as 3% for primary hernias and up to 30% in the management of recurrence

Recurrent inguinal hernia:

Factors involved in the recurrence include:

Inadequate preoperative selection:

Those with unforgettable precipitating factors or high-dose steroid therapy which interferes with healing

Type of hernia:

Indirect hernias: 1-7% recurrence rate
Direct hernias: 4-10% recurrence rate

Type of operation:

Repairs under tension do not heal with adequate protection against recurrence

Postoperative wound infection

Management of recurrence:

Recurrent inguinal hernias should be repaired in order to avoid the same complications that occur in primary hernias, which are even more likely when recurrence has taken place
Because of scarring, the dissection can be difficult and, in the male, orchidectomy is sometimes performed to allow closure of the deep ring


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	Inguinal hernia Epidemiology: Account for 80% of all external abdominal hernias Most common in infants and the elderly Inguinal hernias are 20x more common in men than in women Occur most frequently on the right-hand side Classification: Indirect inguinal hernia: This passes through the internal ring lateral to the inferior epigastric artery and along the canal to emerge at the external ring above the pubic crest and tubercle Its coverings are the attenuated layers of the cord Direct inguinal hernia: This hernia bulges out through the posterior wall of the canal medial to the inferior epigastric artery Is, therefore, not covered by the layers of the cord Pantaloon hernia: This is a combination of both an indirect and a direct inguinal hernia Aetiology: Indirect hernia: There is a congenital sac or potential sac which is the remnant of the processus vaginalis If the processus does not close, then an indirect hernia occurs in early life, but other factors may lead to it reopening at any age Indirect hernias are 20x more common in men than in women 60% occur on the right side (possibly contributed to by damage to the motor nerves of the abdominal muscles at open appendicectomy) 40% on the left 20% are bilateral Direct hernia: This is an acquired lesion For reasons unknown, the posterior wall of the inguinal canal becomes attenuated Direct hernia is, therefore, a condition of later life and is rarely seen under the age of 40 years Differences between an indirect and a direct inguinal hernia: Indirect Direct Patient’s age Usually young Older Cause May be congenital Acquired Bilateral 20% 50% Protrusion on coughing Oblique Straight Appearance on standing Full size delay Full size immediately Reduction on lying Not immediate Immediate Descent into scrotum Common Rare Occlusion of internal ring Controls Does not control Neck of sac Narrow Wide Strangulation Not uncommon Unusual Relation to inferior Lateral Medial epigastric vessels Clinical findings: If it is impossible to get above a groin swelling, it is most likely to be an inguinal hernia In addition to the features listed above, an indirect hernia that extends beyond the external ring appears above and medial to the pubic tubercle (in contrast to a femoral hernia, which is below and lateral) Other causes of groin swelling: Femoral hernia Hydrocele Undescended or ectopic testis Lipoma of the cord Epididymal cyst Management: Most adult inguinal hernias are repaired by open operation under local or general anaesthesia as a day case procedure Open operation usually means: A layered suture technique (Shouldice), or Insertion of a non-absorbable prosthetic mesh (Lichtenstein) Alternatively, mesh repair may be done laparoscopically Specific complications: Urinary retention: Because of the proximity of the inguinal region to urine excretion in the male, temporary problems may be encountered Rare with modern techniques (unless BPH has been overlooked in the preoperative evaluation) Scrotal haematoma: May follow extensive dissection Damage to the ilio-inguinal nerve: Produces an area of anaesthesia over the: Pubic tubercle Scrotum/labia Outcome: Recurrence rates for groin hernias should be <1% It is more widely quoted as 3% for primary hernias and up to 30% in the management of recurrence Recurrent inguinal hernia: Factors involved in the recurrence include: Inadequate preoperative selection: Those with unforgettable precipitating factors or high-dose steroid therapy which interferes with healing Type of hernia: Indirect hernias: 1-7% recurrence rate Direct hernias: 4-10% recurrence rate Type of operation: Repairs under tension do not heal with adequate protection against recurrence Postoperative wound infection Management of recurrence: Recurrent inguinal hernias should be repaired in order to avoid the same complications that occur in primary hernias, which are even more likely when recurrence has taken place Because of scarring, the dissection can be difficult and, in the male, orchidectomy is sometimes performed to allow closure of the deep ring
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