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Inguinal hernias are protrusions of abdominal cavity contents through an area of the abdominal wall, commonly referred to as the groin, and known in anatomic language as the inguinal area or the myopectineal orifice. They are very common and their repair is one of the most frequently performed surgical operations. There are two types of inguinal hernia, direct and indirect. Femoral hernias occur within the same "myopectineal orifice," but are usually classed as separate from the "inguinal" hernias. Image File history File links Gray1084. ...
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Origin Inguinal hernias usually arise as a consequence of the descent of the testis from the abdomen into the scrotum during early fetal life. They are more commonly seen in men due to larger size of their inguinal canal, which transmitted the testicle and accomodates the structures of the spermatic cord. Men are 25 times more likely to have a groin hernia than women, but since this is such a common problem in the general population (it is estimated that 5% of the population will develop an abdominal wall hernia), inguinal hernia is not extremely uncommon in women. Direct hernias however are very uncommon in women.
Clinical presentation Hernias present as painless bulges in the groin area that can become more prominent when coughing, straining, or standing up. The bulge commonly disappears on lying down. The presence of pain, or the inability to "reduce" the bulge back into the abdomen, usually indicates the onset of complications.
As the hernia progresses, contents of the abdominal cavity, such as the intestine, can descend into the hernia and run the risk of being strangulated within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine that is caught in the hernia is compromised, gut ischemia and gangrene can result, with serious consequences. The time of occurrence of complications is not predictable; some hernias can remain static for years, others can progress rapidly from the time of onset. Therefore, provided there are no serious co-existing medical problems, patients are advised to get the hernia repaired surgically at the earliest convenience after a diagnosis is made. Emergency surgery for complications such as obstruction and strangulation carry much higher risk than planned, "elective" procedures.
Diagnosis Despite the profusion of medical technology, the diagnosis of inguinal hernia rests on the history given by the patient and the physician's examination of the groin. Further tests are rarely needed to confirm the diagnosis. However, in unclear cases an ultrasound scan or a CT scan might be of help, especially to rule out a hydrocele. Medical ultrasonography (sonography) is an ultrasound-based diagnostic imaging technique used to visualize internal organs, their size, structure and any pathological lesions. ...
CAT apparatus in a hospital Computed axial tomography (CAT), computer-assisted tomography, computed tomography, CT, or body section roentgenography is the process of using digital processing to generate a three-dimensional image of the internals of an object from a large series of two-dimensional X-ray images taken around...
A hydrocele denotes a pathological accumulation of serous fluid in a bodily cavity. ...
Surgical treatment Surgical correction of inguinal hernias, called a herniorraphy or hernioplasty, is now often performed as an ambulatory, or "day surgery," procedure. A workable technique of repairing hernias was first described by Bassini in the 1800s; the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis. Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the Cooper's Ligament/McVay repair. In a 'herniotomy', the hernia sac is removed and ligated to prevent future herniation of abdominal contents. In newborns this procedure is performed alone, without additional herniorraphy repair. it is a procedure or rather an operation for correcting the hernia as its medical name implies --rrhaphy (which means strengthening something), it is an operation for strengthening the muscles of the abdomen around the inguinal canal. ...
Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). This operation is called a 'hernioplasty'. The meshes used are typically made from polypropylene or polyester, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, with pain control using only mild oral narcotics such as Vicodin or Percocet. Patients are encouraged to walk and move around immediately post-operatively, and can usually resume all their normal activities within a week or two of operation. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair. Polypropylene lid of a Tic Tacs box, with a living hinge and the resin identification code under its flap Polypropylene or polypropene (PP) is a thermoplastic polymer, used in a wide variety of applications, including food packaging, textiles, laboratory equipment, automotive components, and polymer banknotes. ...
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In recent years, as in other areas of surgery, laparoscopic repair of inguinal hernia has emerged as an option. "Lap" repairs are also tension-free, although the mesh is placed within the preperitoneal space behind the defect as opposed to in or over it. It has no proven superiority to the open method other than a slightly lower post-operative pain score. Unlike the open method, laparoscopic surgery requires general anesthesia. It is usually more expensive and consumes more O.R. time than open repair, carries a higher risk of complications, and has equivalent or higher rates of recurrence compared to the open tension-free repairs. Laparoscopic surgery, also called keyhole surgery (when natural body openings are not used), bandaid surgery, or minimally invasive surgery (MIS), is a surgical technique. ...
In the UK a government committee called NICE re-examined the data on laparoscopic and open repair (2004). They concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical. They found that laparoscopic repair results in a more rapid recovery and less pain in the first few days. They found that lap repair has less risk of wound infection, less bleeding and less swelling after surgery (seroma). They also reported less chronic pain, which can last for years and in one in 30 patients can be severe. A recent, large American study found that recurrence within two years of operation after lap repair was 10% compared with 4% after open surgery. Both of these results however are considered poor by international standards and suggest that the surgeons were inexperienced, particularly in lap repair.
Groin Herinias The most common groin hernia, the indirect inguinal hernia protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure of the internal inguinal ring after passage through it of the testicle and the trailing supply of blood vessels and nerves, and the vas deferens, which make up the spermatic cord. The internal ring, which is the beginning of the inguinal canal, was initially formed by the processus vaginalis, a fold of peritoneum which breaches the abdominal wall to make way for the descending testicle. In normal development, this processus is obliterated once the testicle is completely descended. When it remains open, a situation known as patent processus vaginalis, the stage is set for an indirect hernia. Human male anatomy The testicles, known medically as testes (singular testis), are the male generative glands in animals. ...
Male Anatomy The spermatic cord is the name given to the cord-like structure formed by the vas deferens and surrounding tissue (veins, arteries, nerves, and lymphatic vessels) that run from the abdomen down to each testicle. ...
An indirect hernia occurs when intra-abdominal contents, commonly including preperitoneal fatty tissues and intestines, traverse the ring to enter the inguinal canal. As time passes, the hernia contents may enlarge, extend the length of the canal, and even exit the canal through the external inguinal ring into the scrotum.
In the female, groin hernias are only 4% as common as in males. Indirect inguinal hernia is still the most common groin hernia for females, however. If a woman has an indirect inguinal hernia, her internal inguinal ring is patent, which is abnormal for females. The protrusion of peritoneum is not called "processus vaginalis" in women, as this structure is related to the migration of the testicle to the scrotum. It is simply a hernia sac. The eventual destination of the hernia contents for a woman is the vulva majoris on the same side, and hernias can enlarge one vulva dramatcially if they are allowed to progress.
During herinorraphy, the surgeon recognizes the "indirect" hernia by noting that the hernia sac begins lateral to the inferior epigastric vessels, indicating that it arose at the top of the inguinal canal. Conversely, the "direct" inguinal hernia enters through a weak point in the fascia of the abdominal wall, and its sac is noted to be medial to these vessels. Direct inguinal hernias are the same in men and women.
A third type of groin hernia, the "femoral hernia" is rare in men (but still #3, even in women). This hernia exits not via the inguinal canal, but via the femoral canal, which normally allows passage of the common femoral artery and vein from the pelvis to the leg. The most common repair for this type of hernia is the McVay repair, which approximates Cooper's ligament to the inguinal ligament to narrow the femoral canal. Mesh is used less often, partly because the femoral hernia repair is more often emergent, and due to an incarcerated hernia, which raises infection risk
Direct inguinal hernias A direct inguinal hernia protrudes through a weakened area in the transversalis fascia within an anatomic region known as the medial or Hesselbach's triangle, an area defined by the edge of the rectus abdominis muscle, the inguinal ligament and the inferior epigastric artery. While these hernias do not involve the inguinal canal directly, they do compromise the structures of the inguinal region. When a patient suffers a simultaneous direct and indirect hernia on the same side, the result is called a "pantaloon" hernia, and the defects can be repaired separately or together. Hesselbachs triangle (not labeled) is defined by the inferior epigastric vessels, inguinal ligament and rectus abdominis muscle. ...
The rectus abdominis muscle is a paired muscle running vertically on each side of the anterior wall of the human abdomen (and in some animals). ...
The inguinal ligament is a band running from the pubic tubercle to the anterior superior iliac spine. ...
Right inferior epigastric artery - view from inside of abdomen. ...
Theories of hernia formation It was previously thought that hernias arose as the result of abnormal stress on the abdominal wall; this theory persists in the belief that hernias are caused by coughing too much or lifting heavy objects. Most researchers still point to a patent processus vaginalis or a failure of the abdominal wall "shutter" (an involuntary movement of the abdominal muscles that closes off the inguinal canal during increased intra-abdominal pressure) as the root cause of indirect hernias. Current research indicates that patients with direct inguinal hernias are heavily predisposed to herniate elsewhere, and that both direct and indirect hernias tend to run in families. As a result of these and other findings, a few researchers now believe that all direct hernias and many indirect hernias are a symptom of a congenital deficiency of collagen, the major structural fiber in connective tissue. Lack of collagen, according to this theory, results in weakened, attenuated connective tissue that cannot withstand the stresses of normal activity, and hence a hernia forms at the area of greatest weakness. |
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