Inguinal Hernia

Juan D. Rico, MD
The Operative Review of Surgery. 2023; 1:302-309.

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Table of Contents

Definitions and Descriptors
Presentation and Diagnosis
Treatment

Recurrent Inguinal Hernia

Mnemonics
References

Definitions and Descriptors

Definitions 1,2 Mn
  • Indirect Inguinal Hernia: Hernia Through the Processus Vaginalis
    • The Most Common Inguinal Hernia
    • Lateral to Inferior Epigastric Vessels
    • Sac Protrudes Through the Inguinal Ring Anterior and Medial to the Cord Structures
  • Direct Inguinal Hernia: Hernia Through Hasselbach’s Triangle
    • Due to a Weakness in the Transversalis Fascia
    • Medial to Inferior Epigastric Vessels
    • Sac Protrudes Through the Posterior Wall of the Inguinal Canal
    • Lower Risk of Incarceration but Higher Risk of Recurrence
  • Pantaloon Hernia: Hernia with Both Direct and Indirect Components
Sex Differences
  • Lifetime Prevalence: 3
    • Males: 27-43%
    • Females: 3-6%
  • Anatomic Differences in Females: 4
    • Greater Distance Between Pubic Tubercle and Internal Ring
    • Wider Rectus Muscle
    • Narrower Internal Ring
Basic Hernia Descriptors
  • Reducible: Able to Reduce/Push the Hernia Contents Back into the Abdominal Cavity
  • Incarcerated: Unable to Reduce/Push the Hernia Contents Back into the Abdominal Cavity
    • Causes a Risk of Strangulation
  • Strangulated: Hernia Blood Supply is Obstructed
    • Causes a Risk of Ischemia and Necrosis (Surgical Emergency)

Indirect Inguinal Hernia 12

Direct Inguinal Hernia 13

Additional Descriptors Mn
  • Reduction en Masse: Hernia Sac is Reduced but the Bowel is Still Incarcerated within the Reduced Sac 5
    • Causes a Risk of Progression to Ischemia and Necrosis Despite Reduction
    • “Classically” Describing an Inguinal Hernia 5
  • Richter Hernia: Only the Antimesenteric Border of the Bowel Wall is Herniated 6
    • Also Described as a “Partial Enterocele” 6
    • May Not Cause Obstruction as Bowel Contents Can Pass Through the Intraperitoneal Portion of the Bowel
    • High Risk of Incarceration and Strangulation of the Herniated Portion
  • Littre Hernia: Hernia Contains a Meckel Diverticulum 7
  • Amyand Hernia: Hernia Contains the Appendix 8
    • “Classically” Describing an Inguinal Hernia
  • Sliding Hernia: A Retroperitoneal Organ is Included as Part of the Hernia Sac 9
    • Most Common Organs:
      • Males: Sigmoid Colon and Cecum
      • Females: Ovary and Fallopian Tube (Ligate the Round Ligament and Return the Ovary at Surgery)

Reduction en Masse 5

Richter Hernia 14

Amyand Hernia 15

Other Groin Hernias

Presentation and Diagnosis

Presentation

  • Groin Bulge
  • Groin Pain and Discomfort
    • May be Worsened by Coughing or Straining
  • Symptoms of Bowel Obstruction
    • Nausea and Vomiting
    • Constipation
  • Risk for Bowel Incarceration, Strangulation, and Necrosis
  • Overlying Skin Can Develop Erythema, Ischemia, or Ulceration Due to Excessive Pressure

Diagnosis

  • Generally a Clinical Diagnosis
    • 75% Sensitivity, 96% Specificity by Physical Exam 16
    • Small Hernias May Be Difficult to Palpate
    • More Difficult to Diagnose in Females and Obese
  • Imaging May Be Required if Uncertain
    • US – More Cost Effective and Allows Dynamic Assessment with Valsalva (Operator Dependent)
    • CT – Allows Better Evaluation of Large and Complex Defects

Inguinal Hernia on CT 17

Treatment

Treatment

  • Asymptomatic or Minimal Symptoms: Watchful Waiting vs Surgical Repair
    • Choice Based on Patient Preference
    • No Evidence that Physical Activity Can Cause Incarceration or Clinical Worsening of Existing Hernias – Exercise and Beneficial Physical Activity Should Not Be Avoided 18
  • Symptomatic: Surgical Repair
  • Necrotic Bowel: Open Repair with Small Bowel Resection
    • Avoid Permanent Mesh with Bowel Necrosis – Historically Did a Tissue Repair but Now Able to Use Absorbable or Biologic Mesh

Asymptomatic Prognosis

  • Low-Risk of Incarceration (0.3-3% Per Year) 19-22
  • 30-70% Eventually Become Symptomatic and Require Repair 23-26

Surgical Technique

  • Open Inguinal Hernia Repair
  • Minimally Invasive (Laparoscopic/Robotic) Inguinal Hernia Repair
  • Open vs Minimally Invasive Comparisons: 27-30
    • Similar Recurrence Rates
    • Laparoscopic Benefits:
      • Faster Return to Work/Activity
      • Less Postoperative Pain
      • Lower Rates of Chronic Pain
      • Better Choice for Bilateral Hernias – Repair Both Through the Same Incisions
    • Open Benefits:
      • Shorter Learning Curve
      • Shorter Operative Time
      • Decreased Cost
      • Can Possibly Perform Under Local Anesthetic and Avoid General Anesthesia if Severe Comorbidities Preclude

Hernia in Pediatrics

Recurrent Inguinal Hernia

Definitions

  • Primary Hernia – The Initial Hernia, Not Previously Repaired
  • Recurrent Hernia – Hernia that Develops After it was Initially Repair
  • Re-recurrent Hernia – Hernia that Develops After At Least Two Prior Repairs
  • Neglected Hernia – Hernia That was Missed During Repair of Another Hernia

Rates of Recurrence 11,31,32

  • Tissue Repair: 10-30%
    • *Shouldice Repair Specifically Has Been Reported to Have Significantly Lower Risk of Recurrence than Other Tissue Repairs (2.2%)
  • Mesh Repair: 3-4%
    • No Difference Based on Type of Mesh Used
    • No Difference Between Open or Minimally Invasive 27-30

Timing vs Etiology 33

  • Early Recurrence (< 3-6 Months) – Generally the Result of Technical Error
    • Immediate Recurrence May Be Due to Neglected/Missed Hernia
  • Late Recurrence (> 6-12 Months) – Generally from Patient Factors

Risk Factors 11,33-35

  • Technical Factors:
    • Violent Extubation
    • Coughing Attack in the First Few Weeks of Repair
    • Incomplete Dissection of the Myopectineal Orifice
    • Incomplete Reduction of Hernia Sac
    • Mesh of Insufficient Size
    • Mesh Migration
    • Mesh Shrinking
    • Mesh Folding/“Clam-Shelling”
    • Unresected Cord Lipoma Can Cause a “Pseudo-Recurrence”
  • Patient Factors:
    • Diabetes
    • Obesity
    • Smoking
    • Immunosuppression
    • Steroid Therapy
    • Chemotherapy
    • Direct Hernia – Inherent Tissue Weakness

Most Common Site

  • Open Repair – Direct Hernia 34,36
  • Laparoscopic Repair – Indirect Hernia 37,38

Approach Definitions

  • Anterior Approach: Traditional Open Repairs (Mesh or Tissue)
  • Posterior Approach: Preperitoneal Repair
    • Minimally Invasive (Laparoscopic/Robotic) or a Trans-Inguinal Preperitoneal (TIPP) Repair

Treatment

  • Asymptomatic or Minimal Symptoms: Watchful Waiting vs Surgical Repair
    • Choice Based on Patient Preference
  • Symptomatic: Surgical Repair
    • Previous Tissue Repair: Any Approach
    • Previous Mesh Repair: Approach Through Unviolated Tissue Planes
      • Failed Anterior Repair: Posterior Approach
      • Failed Posterior Repair: Anterior Approach
    • Leave a New Mesh, Even if Mesh Was Already Used Previously
      • Do Not Remove Old Mesh

Mnemonics

Inguinal Hernia Relationship to Epigastric Vessels

  • “M.D.s don’t LIe”
  • MD: Medial to Epigastrics – Direct
  • LI: Lateral to Epigastrics – Indirect

Pantaloon Hernia

  • Pantaloon – A Type of Old Time Baggy Pants
  • Think of Pant Legs Going Down Both Sides

Hernia Descriptors

  • Littre-Little: “Little” Ones Have Meckel’s (Most Common Before Age 2)
  • A-A: Amyand-Appendix

References

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