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INGUINAL HERNIA

What is inguinal hernia?

An abdominal wall  hernia is a condition in which intra-abdominal fat or portions of the bowel bulges through a weak area in the lower abdominal muscles. An inguinal hernia occurs in the groin—the area between the abdomen and thigh. An inguinal hernia appears as a bulge on one or both sides of the groin. The bulge is more obvious when staining occurs. This type of hernia is called inguinal because fat or part of the intestine slides through a weak area called the inguinal canal. Blood vessels, nerves and the vas deferens traverse this canal traveling back and for the between the abdomen and the testicles. Compression of these structures by the hernia contribute they pain associated with this condition.  An inguinal hernia can occur any time from infancy to adulthood and is much more common in males than females. Inguinal hernias tend to become larger with time.


What are the types and causes of inguinal hernia?


The two types of inguinal hernia have different causes.

Indirect inguinal hernia. Indirect inguinal hernias are congenital hernias and are much more common in males than females because of the way males develop in the womb. In a male fetus, the spermatic cord and both testicles—starting from an intra-abdominal location—normally descend through the inguinal canal into the scrotum, the sac that holds the testicles.

Sometimes the entrance of the inguinal canal at the inguinal ring does not close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the small intestine slides through the weakness into the inguinal canal, causing a hernia. In females, an indirect inguinal hernia occurs in the same location as men but only the round ligament is traveling in the female inguinal canal so the pain pattern tends to be different.

Indirect hernias are the most common type of inguinal hernia. Premature infants are especially at risk for indirect inguinal hernias because there is less time for the inguinal canal to close.

Direct inguinal hernia. Direct inguinal hernias are caused by connective tissue degeneration of the abdominal muscles, which causes weakening of the muscles during the adult years.  The hernia involves fat or the small intestine sliding through the weak muscles into the groin. A direct hernia develops gradually because of continuous stress on the muscles. One or more of the following factors can cause pressure on the abdominal muscles and may worsen the hernia:

  • sudden twists, pulls, or muscle strains
  • lifting heavy objects
  • straining on the toilet because of constipation
  • weight gain
  • chronic coughing

Indirect and direct inguinal hernias usually slide back and forth spontaneously through the inguinal canal and can often be moved back into the abdomen with gentle massage. Over time the tissues sliding back and forth may actually start to get stuck in the “out” position. This is called “incarceration” and typically presents as a bulge that never goes away. If bowel is involved in the incarceration it can occasionally become twisted or obstructed and this is considered a surgical emergency. Severe pain and vomiting are associated with this situation.


What are the symptoms of inguinal hernia?


Symptoms of inguinal hernia include

  • a small bulge in one or both sides of the groin that may increase in size and disappear when lying down; in males, it can present as a swollen or enlarged scrotum
  • discomfort or sharp pain—especially when straining, lifting, or exercising—that improves when resting
  • a feeling of weakness or pressure in the groin
  • a burning, gurgling, or aching feeling at the bulge

What are “incarcerated” and “strangulated” inguinal hernias?

An incarcerated inguinal hernia is a hernia that becomes stuck in the groin or scrotum and cannot be massaged back into the abdomen. An incarcerated hernia is caused by swelling and can lead to a strangulated hernia, in which the blood supply to the incarcerated small intestine is jeopardized. A strangulated hernia is a serious condition and requires immediate medical attention. Symptoms of a strangulated hernia include

  • extreme tenderness and redness in the area of the bulge
  • sudden pain that worsens in a short period of time
  • fever
  • rapid heart rate

Left untreated, nausea, vomiting, and severe infection can occur. If surgery is not performed right away, the condition can become life threatening, and the affected intestine may die. Then that portion of the intestine must be removed.


How is inguinal hernia diagnosed?

To diagnose inguinal hernia, the doctor takes a thorough medical history and conducts a physical examination. The person may be asked to stand and cough so the doctor can feel the hernia as it moves into the groin or scrotum. The doctor checks to see if the hernia can be gently massaged back into its proper position in the abdomen.


How is inguinal hernia treated?

In adults, inguinal hernias that enlarge, cause symptoms, or become incarcerated are treated surgically. In infants and children, inguinal hernias are always operated on to prevent incarceration from occurring. Surgery is usually done on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient. The two main types of surgery for hernias are as follows:

  • “Open” hernia repair. In open hernia repair, also called herniorrhaphy, a person is given local anesthesia in the abdomen or spine to numb the area, general anesthesia to sedate or help the person sleep, or a combination of the two. Then the surgeon makes an incision in the groin, moves the herniated tissues back into the abdomen, and reinforces the muscle wall with stitches. Usually the area of muscle weakness is reinforced with a synthetic mesh or screen to provide additional support—an operation called hernioplasty. Modern versions of this type of repair are called “plug and patch” and the “Lichtenstein” type repair. Recovery times are variable for patients depending on the amount of tissue being repaired.  Typically several weeks of recovery are required and full activities are limited in the first four to six weeks to allow for the best results.
    Conventional Tissue-to-Tissue Technique
    To repair a hernia using the conventional tissue-to-tissue method, an incision is made over the hernia site and the hernia is returned to the abdomen. The surgeon repairs the hole by pulling the surrounding tissue and muscle over the defect. Several sutures are used to hold the muscle in place. No mesh is used in this repair. A classic version of this procedure is called the “Bassini” repair. This is method is “conventional” is it reflects how hernias were initially repaired. This repair is common in children because they are constantly growing and mesh would not grow with them. It is rare to see a adult inguinal hernia repaired this way today due to the higher recurrent hernia rates associated with failures of this type of repair.  If there is some contraindication to mesh placement in a patient ( active infection) then this technique is used.
    Operating time and typical recovery periods are longer than the other methods mentioned, and return to normal activities is approximately four to six weeks after surgery.
  • Laparoscopy. Laparoscopic surgery is performed using general anesthesia. The surgeon makes several small incisions in the lower abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached to one end. The camera sends a magnified image from inside the body to a monitor, giving the surgeon a close-up view of the hernia and surrounding tissue. While viewing the monitor, the surgeon uses instruments to carefully repair the hernia using synthetic mesh.

People who undergo laparoscopic surgery generally experience a somewhat shorter recovery time. However, the doctor may determine laparoscopic surgery is not the best option if the hernia is very large or the person has had pelvic surgery.

Most adults experience discomfort after surgery and require pain medication. Vigorous activity and heavy lifting are restricted for several weeks. The doctor will discuss when a person may safely return to work. Infants and children also experience some discomfort but usually resume normal activities after several days.


What are the complications of surgery for inguinal hernia?

Surgery to repair an inguinal hernia is quite safe and complications are uncommon. Knowing possible risks allows patients to report postoperative symptoms to their doctor as soon as they occur.

  • Risk of general anesthesia. Before surgery, the anesthesiologist—a doctor who administers anesthesia—reviews the risks of anesthesia with the patient and asks about medical history and allergies to medications. Complications most likely occur in older people and those with other medical conditions. Common complications include nausea, vomiting, urinary retention, sore throat, and headache. More serious problems include heart attack, stroke, pneumonia, and blood clots in the legs.
    Getting out of bed after surgery and moving as soon as the doctor allows will help reduce the risk of complications such as pneumonia and blood clots.
  • Hernia recurrence. A hernia can recur up to several years after repair. Recurrence is the most common complication of inguinal hernia repair, causing patients to undergo a second operation. Hernia recurrence occurs less often when mesh is utilized.
  • Bleeding. Bleeding inside the incision is another complication of inguinal hernia repair. The most typical finding is some bruising around the pubic bone, scrotum and penis that shows up two or three days after the operation.  In rare cases severe swelling and bluish discoloration of the skin around the incision.   This is more typically associated with open or non-laparosocpic repairs. Surgery may be necessary to open the incision and stop the bleeding. Bleeding is unusual and occurs in less than 2 percent of patients.1
  • Wound infection. The risk of wound infection is small—less than 2 percent—and is more likely to occur in older adults and people who undergo more complex hernia repair.2 The person may experience a fever, discharge from the incision, and redness, swelling, or tenderness around the incision. Postoperative infection requires antibiotics and, occasionally, another procedure requiring local anesthesia to make a small opening in the incision and drain the infection.
  • Painful scar. Sometimes people experience sharp, tingling pain in a specific area near the incision after it has healed. The pain usually resolves with time. Medicine may be injected in the area if the pain continues. This is more associated with the “open” type repairs.
  • Injury to internal organs. Although extremely rare, injury to the intestine, bladder, kidneys, nerves and blood vessels leading to the legs, internal female organs, and vas deferens—the tube that carries sperm—can occur during hernia surgery and may lead to more operations.

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