An inguinal hernia is a bulging of the contents of the abdomen through a weak area in the lower abdominal wall. Inguinal hernias can occur at either of two passages through the lower abdominal wall, one on each side of the groin. These passages are called inguinal canals. Inguinal hernias can also occur through two deeper passages in the groin called the femoral canals. Hernias through these passages are also known as femoral hernias.
Inguinal hernias typically develop on one side of the groin and form on the right side more often than on the left. Some people who have an inguinal hernia on one side will have or will develop a hernia on the other side.
Inguinal
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A weak area in the muscles and connective tissue of the lower abdominal wall at the inguinal canal allows an inguinal hernia to develop. A hernia can form in different ways, causing two types of hernias.
Most people with inguinal hernias will need surgery to repair the hernia. Several different types of open and laparoscopic hernia surgery are available. The type of surgery your doctor recommends may depend on factors such as the size of the hernia and your age, health, and medical history.
Research suggests that men with inguinal hernias that cause few or no symptoms may be able to safely delay surgery, an approach called watchful waiting.4,5 Men who delay surgery should watch for symptoms and see a doctor regularly. About 70 percent of men who delay surgery will develop new or worsening symptoms and will need surgery within 5 years.4
You can find clinical studies on inguinal hernias at www.ClinicalTrials.gov. In addition to searching for federally funded studies, you can expand or narrow your search to include clinical studies from industry, universities, and individuals; however, the NIH does not review these studies and cannot ensure they are safe. Always talk with your health care provider before you participate in a clinical study.
Inguinal hernia repair is an extremely common operation performed by surgeons. More than 800,000 repairs performed annually. These groin hernias can be divided into indirect, direct, and femoral based on location. Most patients present with a bulge or pain in the groin. Healthcare professionals recommend repairing all symptomatic hernias to avoid complications. An open or laparoscopic approach can be used with the goal of defect closure and a tension-free repair. This activity reviews the pathophysiology of inguinal hernia and highlights the role of the interprofessional team in its management.
Objectives:Describe the presentation of an inguinal hernia.Recall the potential complications of an inguinal hernia.Summarize the treatment of an inguinal hernia.Review the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by an inguinal hernia.Access free multiple choice questions on this topic.
Inguinal hernia repair is an extremely common operation performed by surgeons. More than 800,000 repairs performed annually. An inguinal hernia is an opening in the myofascial plain of the oblique and transversalis muscles that can allow for herniation of intraabdominal or extraperitoneal organs. These groin hernias can be divided into indirect, direct, and femoral based on location. Most patients present with a bulge or pain in the groin. Healthcare professionals recommend repairing all symptomatic hernias to avoid complications. An open or laparoscopic approach can be used with the goal of defect closure and a tension-free repair. A mesh is usually used for a tension-free repair. When the mesh is contraindicated, primary suture repair can be performed.[1][2][3][4][5]
Inguinal hernias are considered to have both a congenital and acquired component. Most adult hernias are considered acquired. However, there is evidence to suggest genetics also play a role. Patients with a known family history of a hernia are at least 4 times more likely to have an inguinal hernia than patients with no known family history. Studies have also shown that certain diseases like chronic obstructive pulmonary disease (COPD), Ehlers-Danlos syndrome and Marfan syndrome contribute to increased incidence of an inguinal hernia. Also, it is believed that increased intra-abdominal pressure, as seen in obesity, chronic cough, heavy lifting, and straining due to constipation, also plays a role in the development of an inguinal hernia.
Inguinal hernia repair is a common surgery in the United States. It is estimated that about 800,000 inguinal hernias are performed annually. Inguinal hernias account for 75% of all abdominal wall hernias. The incidence of inguinal hernias has a bimodal distribution, with peaks around age 5 and after age 70. Two-thirds of these hernias are indirect, making an indirect hernia the most common groin hernia in both males and females. Males account for about 90% of all inguinal hernias and females about 10%. Femoral hernias account for only 3% of all inguinal hernias and are more commonly seen in women with females accounting for about 70% of all femoral hernias. An inguinal hernia will affect nearly 25% of men and less than 2% of women over their lifetime. An indirect hernia occurs more often on the right. This is believed to be attributed to the slower closure of a patent processus vaginalis on the right side compared to the left.
Studies have shown that inguinal hernia patients have demonstrated higher proportions of type III collagen as compared to type I. Type I collagen is associated with better tensile strength than type III. Studies have also shown that a patent processus vaginalis predisposes to the development of an inguinal hernia in adulthood. The majority of pediatric inguinal hernias are thought to be congenital due to a patent processus vaginalis. During normal development, the testes descend from the abdomen into the scrotum leaving behind a diverticulum that protrudes through the inguinal canal and becomes the processus vaginalis. In normal development, the processus vaginalis closes around 40 weeks of gestation eliminating the peritoneal opening at the internal ring. Failure of this closure can lead to an indirect hernia in the pediatric population. A patent processus vaginalis does not always lead to an inguinal hernia.
Inguinal hernias can present with an array of different symptoms. Most patients present with a bulge in the groin area, or pain in the groin. Some will describe the pain or bulge that gets worse with physical activity or coughing. Symptoms may include a burning or pinching sensation in the groin. These sensations can radiate into the scrotum or down the leg. It is important to perform a thorough physical and history to rule out other causes of groin pain. At times an inguinal hernia can present with severe pain or obstructive symptoms caused by incarceration or strangulation of the hernia sac contents.[6][7][8][9]
A proper physical exam is essential in the diagnosis of an inguinal hernia. Physical examination is the best way to diagnose a hernia. The exam is best performed with the patient standing. Visual inspection of the inguinal area is conducted first to rule out obvious bulges or asymmetry in groin or scrotum. Next, the examiner palpates over the groin and scrotum to detect the presence of a hernia. The palpation of the inguinal canal is completed last. The examiner palpates through the scrotum and towards the external inguinal ring. The patient is then instructed to cough or perform a Valsalva maneuver. If a hernia is present, the examiner will be able to palpate a bulge that moves in and out as the patient increases intraabdominal pressure through coughing or Valsalva. Examination of the contralateral side is essential as this allows the clinician to compare right versus left for symmetry and/or abnormalities. It is not essential to differentiate an indirect from a direct hernia on the exam as the surgical repair is the same for both. A femoral hernia should be palpable below the inguinal ligament and just lateral to the pubic tubercle. Femoral hernias can easily be missed in an obese patient. In cases when there is high suspicion but no hernia can be detected on physical exam, a radiologic investigation may be warranted to elicit the diagnosis.
Most inguinal hernias are diagnosed with a thorough history and physical examination. When history strongly suggests a hernia, but none can be elicited on an exam or in situations where body habitus makes physical examination limited, then a radiologic investigation may be warranted. Radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). An ultrasound is the least invasive modality, but it is largely dependent on the skill of the examiner. The examination should be conducted with a Valsalva maneuver to increase intra-abdominal pressure. An ultrasound can detect an inguinal hernia with a sensitivity of 86% and a specificity of 77%. CT imaging is beneficial when the diagnosis is obscure. CT scan can better delineate groin anatomy and help to detect other etiologies of groin mass or in cases of complicated hernias. CT scan can detect inguinal hernias with a sensitivity of 80% and specificity of 65%. MRI has a sensitivity of 95% and specificity of 96% in the detection of an inguinal hernia. However, MRI is costly and rarely used for diagnosis of an inguinal hernia due to its limited access. When indicated, MRI can be used to assist in the differentiation of sports-related injuries versus inguinal hernias.
Surgical repair is the definitive treatment for an inguinal hernia. As a general rule, all symptomatic inguinal hernias should be repaired when possible. In some asymptomatic or minimally bothersome hernias, watchful waiting can be an option. There is a multitude of different techniques for hernia repair with different complication and recurrence profiles.
There are several classifications for inguinal hernias. Currently, there is no universal classification system for inguinal hernias. One simple and widely used classification is the Nyhus classification which categories hernia defects by size, location, and type. ff782bc1db