Inguinal Hernia

Inguinal Hernia

What is inguinal hernia?

An inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also called the small 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. This type of hernia is called inguinal because fat or part of the intestine slides through a weak area at the inguinal ring, the opening to the inguinal canal. An inguinal hernia appears as a bulge on one or both sides of the groin. 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.

An inguinal hernia showing the small intestine descending through the inguinal canal.

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 much more common in males than females because of the way males develop in the womb. In a male fetus, both testicles 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 is caused by the female organs or the small intestine sliding into the groin through a weakness in the abdominal wall.

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 weakening of the muscles during the adult years. Direct inguinal hernias occur only in males. 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.

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

Hernias by themselves may be asymptomatic (produce no symptoms), but nearly all have a potential risk of having their blood supply cut off (becoming strangulated). If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply

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.

When should hernia be treated?

In general, all hernias should be repaired unless severe pre-existing medical conditions make surgery unsafe. Once hernia is detected, it should be treated as early as possible. Surgery is the only cure for majority of hernias. This ensures best results. Moreover, early operation will prevent complications like obstruction and strangulation. Surgical results of large hernias are not as good as the result of an early operation when hernia is small.

How is inguinal hernia treated?

The two main types of surgery for hernias are as follows:

• Open hernia repair. In open hernia repair, also called conventional repair, a person is given  anesthesia and the surgeon makes an incision in the groin, moves the hernia back into the abdomen, and reinforces the muscle wall with stitches called herniorrhaphy. Usually the area of muscle weakness is reinforced with a synthetic mesh or screen to provide additional support—an operation called hernioplasty.
• Laparoscopy/ Endoscopic repair. Laparoscopic surgery is performed using general anesthesia. The surgeon makes three small incisions (5 to 10 mm) 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.

Advantages of Laparoscopic / Endoscopic surgery over conventional / Open  surgery

Endoscopic surgery causes much less pain and patients are mobile within hours after surgery. They are also allowed to resume all activities much earlier and can go back to work within 5-7 days. Another advantage is that both sides can be operated in the same sitting without any extra pain or stay. The procedure is a good choice for people whose hernias recur following traditional hernia surgery because laparoscopic methods allow surgeons to work around scar tissue from earlier repair. The cosmetic results are excellent. Contrary to common belief a mesh can also be placed in laparoscopic procedures

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.