An inguinal hernia or groin hernia is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than the left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.[1]
Groin hernias that do not cause symptoms in males do not need to be repaired. Repair, however, is generally recommended in females due to the higher rate of femoral hernias (also a type of groin hernia) which have more complications. If strangulation occurs immediate surgery is required. Repair may be done by open surgery or by laparoscopic surgery. Open surgery has the benefit of possibly being done under local anesthesia rather than general anesthesia. Laparoscopic surgery generally has less pain following the procedure.[1][9]
In 2015 inguinal, femoral and abdominal hernias affected about 18.5 million people.[10] About 27% of males and 3% of females develop a groin hernia at some time in their life.[1] Groin hernias occur most often before the age of one and after the age of fifty.[2] Globally, inguinal, femoral and abdominal hernias resulted in 60,000 deaths in 2015 and 55,000 in 1990.[4][11]
Signs and symptoms
Frontal view of an inguinal hernia (right).
Hernias usually present as bulges in the groin area that can become more prominent when coughing, straining, or standing up. The bulge commonly disappears on lying down. Mild discomfort can develop over time. The inability to "reduce", or place the bulge back into the abdomen usually means the hernia is 'incarcerated' which requires emergency surgery.
Another frontal view of such a hernia, this time without pubic hair.
As the hernia progresses, contents of the abdominal cavity, such as the intestines, can descend into the hernia and run the risk of being pinched within the hernia, causing an intestinal obstruction. Significant pain at the hernia site is suggestive of a more severe course, such as incarceration (the hernia cannot be reduced back into the abdomen) and subsequent ischemia and strangulation (when the hernia becomes deprived of blood supply).[12] If the blood supply of the portion of the intestine caught in the hernia is compromised, the hernia is deemed "strangulated" and gut ischemia and gangrene can result, with potentially fatal consequences. The timing of complications is not predictable.
Pathophysiology
In males, indirect hernias follow the same route as the descending testes, which migrate from the abdomen into the scrotum during the development of the urinary and reproductive organs. The larger size of their inguinal canal, which transmitted the testicle and accommodates the structures of the spermatic cord, might be one reason why men are 25 times more likely to have an inguinal hernia than women. Although several mechanisms such as strength of the posterior wall of the inguinal canal and shutter mechanisms compensating for raised intra-abdominal pressure prevent hernia formation in normal individuals, the exact importance of each factor is still under debate. The physiological school of thought thinks that the risk of hernia is due to a physiological difference between patients who develop a hernia and those who do not, namely the presence of aponeurotic extensions from the transversus abdominis aponeurotic arch.[13]
An incarcerated inguinal hernia as seen on cross sectional CT scanA frontal view of an incarcerated inguinal hernia (on the patient's left side) with dilated loops of bowel above.An inguinal hernia which contains part of the bladder. Bladder cancer also present.
In the case of the female, the opening of the superficial inguinal ring is smaller than that of the male. As a result, the possibility for hernias through the inguinal canal in males is much greater because they have a larger opening and therefore a much weaker wall through which the intestines may protrude.
Protrudes through the inguinal ring and is ultimately the result of the processus vaginalis failing to close after the testicle's passage during the embryonic stage
Lateral
Yes
Congenital / Adult
Inguinal hernias, in turn, belong to groin hernias, which also includes femoral hernias. A femoral hernia is 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.
Clinical classification of hernia is also important according to which hernia is classified into
Reducible hernia: is one which can be pushed back into the abdomen by putting manual pressure to it.
Irreducible/Incarcerated hernia: is one which cannot be pushed back into the abdomen by applying manual pressure.
Irreducible hernias are further classified into
Obstructed hernia: is one in which the lumen of the herniated part of intestine is obstructed.
Strangulated hernia: is one in which the blood supply of the hernia contents is cut off, thus, leading to ischemia. The lumen of the intestine may be patent or not.
Direct inguinal hernia
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 the inferior epigastric vessels. Direct inguinal hernias may occur in males or females, but males are ten times more likely to get a direct inguinal hernia.[15]
When a patient develops a simultaneous direct and indirect hernia on the same side, it is called a pantaloon hernia or saddlebag hernia because it resembles a pair of pants with the epigastric vessels in the crotch, and the defects can be repaired separately or together. Another term for pantaloon hernia is Romberg's hernia.
Since the abdominal walls weaken with age, direct hernias tend to occur in the middle-aged and elderly. This is in contrast to indirect hernias which can occur at any age including the young, since their etiology includes a congenital component where the inguinal canal is left more patent (compared to individuals less susceptible to indirect hernias).[16][17] Additional risk factors include chronic constipation, being overweight or obese, chronic cough, family history and prior episodes of direct inguinal hernias.[15]
Indirect inguinal hernia
Ultrasound of an indirect hernia containing fat, with testicle seen at right.T2 weighted MRI of the same case (done for another purpose), also demonstrating fat content.Ultrasound showing an indirect inguinal hernia[18]Incarcerated inguinal hernia[19]
An indirect inguinal hernia results from the failure of embryonic closure of the deep inguinal ring. In the male it can occur after the testicle has passed through the deep inguinal ring. It is the most common cause of groin hernia. A double indirect inguinal hernia has two sacs.
In the male fetus, the peritoneum gives a coat to the testicle as it passes through this ring, forming a temporary connection called the processus vaginalis. In normal development, the processus is obliterated once the testicle is completely descended. The permanent coat of peritoneum that remains around the testicle is called the tunica vaginalis. The testicle remains connected to its blood vessels and the vas deferens, which make up the spermatic cord and descend through the inguinal canal to the scrotum.
The deep inguinal ring, which is the beginning of the inguinal canal, remains as an opening in the fascia transversalis, which forms the fascial inner wall of the spermatic cord. When the opening is larger than necessary for passage of the spermatic cord, the stage is set for an indirect inguinal hernia. The protrusion of peritoneum through the internal inguinal ring can be considered an incomplete obliteration of the processus.
In an indirect inguinal hernia, the protrusion passes through the deep inguinal ring and is located lateral to the inferior epigastric artery. Hence, the conjoint tendon is not weakened.
There are three main types
Bubonocele: in this case the hernia is limited in inguinal canal.
Funicular: here the processus vaginalis is closed at its lower end just above the epididymis. The content of the hernial sac can be felt separately from the testis which lies below the hernia.
Complete (or scrotal): here the processus vaginalis is patent throughout. The hernial sac is continuous with the tunica vaginalis of the testis. The hernia descends down to the bottom of the scrotum and it is difficult to differentiate the testis from hernia.
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. 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 labium majus on the same side, and hernias can enlarge one labium dramatically if they are allowed to progress. [citation needed]
Medical imaging
A physician may diagnose an inguinal hernia, as well as the type, from medical history and physical examination.[20] For confirmation or in uncertain cases, medical ultrasonography is the first choice of imaging, because it can both detect the hernia and evaluate its changes with for example pressure, standing and Valsalva maneuver.[21]
When assessed by ultrasound or cross sectional imaging with CT or MRI, the major differential in diagnosing indirect inguinal hernias is differentiation from spermatic cordlipomas, as both can contain only fat and extend along the inguinal canal into the scrotum.[22]
On axial CT, lipomas originate inferior or lateral to the cord, and are located inside the cremaster muscle, while inguinal hernias lie anteromedial to the cord and are not intramuscular. Large lipomas may appear nearly indistinguishable as the fat engulfs anatomic boundaries, but they do not change position with coughing or straining.[22]
Differential diagnosis
Differential diagnosis of the symptoms of inguinal hernia mainly includes the following potential conditions:[23]
There is currently no medical recommendation about how to manage an inguinal hernia condition in adults, due to the fact that, until the early 2010s,[24][25]elective surgery used to be recommended. The hernia truss (or hernia belt) is intended to contain a reducible inguinal hernia within the abdomen. It is not considered to provide a cure, and if the pads are hard and intrude into the hernia aperture they may cause scarring and enlargement of the aperture. In addition, most trusses with older designs are not able effectively to contain the hernia at all times, because their pads do not remain permanently in contact with the hernia. The more modern variety of truss is made with non-intrusive flat pads and comes with a guarantee to hold the hernia securely during all activities. They have been described by users as providing greater confidence and comfort when carrying out physically demanding tasks.[citation needed] However, their use is controversial, as data to determine whether they help prevent hernia complications are lacking.[1] A truss also increases the probability of complications, which include strangulation of the hernia, atrophy of the spermatic cord, and atrophy of the fascial margins. This allows the defect to enlarge and makes subsequent repair more difficult.[26] Their popularity is nonetheless likely to increase, as many individuals with small, painless hernias are now delaying hernia surgery due to the risk of post-herniorrhaphy pain syndrome.[27] Elasticated pants[specify] used by athletes may also provide useful support for the smaller hernia.[citation needed]
Surgical incision in groin after inguinal hernia operation
Surgical correction of inguinal hernias is called a hernia repair. It is not recommended in minimally symptomatic hernias, for which watchful waiting is advised, due to the risk of post herniorraphy pain syndrome. Surgery is commonly performed as outpatient surgery. There are various surgical strategies which may be considered in the planning of inguinal hernia repair. These include the consideration of mesh use (e.g. synthetic or biologic), open repair, use of laparoscopy, type of anesthesia (general or local), appropriateness of bilateral repair, etc. Mesh or non mesh repairs have both benefits in different areas, but mesh repairs may reduce the rate of hernia reappearance, visceral or neurovascular injuries, length of hospital stay and time to return to activities of daily living.[28] Laparoscopy is most commonly used for non-emergency cases; however, a minimally invasive open repair may have a lower incidence of post-operative nausea and mesh associated pain. During surgery conducted under local anaesthesia, the patient will be asked to cough and strain during the procedure to help in demonstrating that the repair is without tension and sound.[29]
Frank Lamb, a black slave born near Halifax, North Carolina in 1789, affected by a major inguinal hernia since the age of 9 and whom his masters and bosses forced to perform hard labor in spite of it. He was hospitalized in 1867 and underwent a successful surgery. (photo: United States Military Medical Archives) The photograph is blurry as the patient was shaking too much.
Constipation after hernia repair results in strain to evacuate the bowel causing pain, and fear that the sutures may rupture. Opioid analgesia makes constipation worse. Promoting an easy bowel motion is important post-operatively.
Surgical correction is always recommended for inguinal hernias in children.[30]
Emergency surgery for incarceration and strangulation carry much higher risk than planned, "elective" procedures. However, the risk of incarceration is low, evaluated at 0.2% per year.[31] On the other hand, surgery has a risk of inguinodynia (10-12%), and this is why males with minimal symptoms are advised to watchful waiting.[31][32] However, if they experience discomfort while doing physical activities or they routinely avoid them for fear of pain, they should seek surgical evaluation.[33] For female patients, surgery is recommended even for asymptomatic patients.[34]
Epidemiology
A direct inguinal hernia is less common (~25–30% of inguinal hernias) and usually occurs in men over 40 years of age.
Men have an 8 times higher incidence of inguinal hernia than women.[35]
A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 71⁄2 weeks.
Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. The most common symptom in children is sudden, severe testicular pain. The testicle may be higher than usual in the scrotum and vomiting may occur. In newborns, pain is often absent and instead the scrotum may become discolored or the testicle may disappear from its usual place.
The spermatic cord is the cord-like structure in males formed by the vas deferens and surrounding tissue that runs from the deep inguinal ring down to each testicle. Its serosal covering, the tunica vaginalis, is an extension of the peritoneum that passes through the transversalis fascia. Each testicle develops in the lower thoracic and upper lumbar region and migrates into the scrotum. During its descent it carries along with it the vas deferens, its vessels, nerves etc. There is one on each side.
The cremaster muscle is a paired structure made of thin layers of striated and smooth muscle that covers the testicles and the spermatic cords in human males. It consists of the lateral and medial parts. Cremaster is an involuntary muscle, responsible for the cremasteric reflex; a protective and physiologic superficial reflex of the testicles. The reflex raises and lowers the testicles in order to keep them protected. Along with the dartos muscle of the scrotum, it regulates testicular temperature, thus aiding the process of spermatogenesis.
The inguinal canal is a passage in the anterior abdominal wall on each side of the body, which in males, convey the spermatic cords and in females, the round ligament of the uterus. The inguinal canals are larger and more prominent in males.
A hydrocele testis is an accumulation of clear fluid within the cavum vaginale, the potential space between the layers of the tunica vaginalis of the testicle. It is the most common form of hydrocele and is often referred to simply as a "hydrocele". A primary hydrocele testis causes a painless enlargement in the scrotum on the affected side and is thought to be due to the defective absorption of fluid secreted between the two layers of the tunica vaginalis. A secondary hydrocele is secondary to either inflammation or a neoplasm in the testis.
Orchiopexy is a surgery to move and/or permanently fix a testicle into the scrotum. While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve testicular torsion.
A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the testicle, called the tunica vaginalis, which is derived from peritoneum. Provided there is no hernia present, it goes away without treatment in the first year. Although hydroceles usually develop in males, rare instances have been described in females in the canal of Nuck.
A hematocele is a collections of blood in a body cavity or potential space. The term most commonly refers to the collection of blood in the tunica vaginalis around the testes, known as a scrotal hematocele. Hematoceles can also occur in the abdominal cavity and other body cavities. Hematoceles are rare, making them harder to diagnose and treat. They are very common especially as slowly growing masses in the scrotum usually in men older than 50 years.
An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards—the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine. The bulge can often be pressed back through the hole in the abdominal wall, and may "pop out" when coughing or otherwise acting to increase intra-abdominal pressure. Treatment is surgical, and surgery may be performed for cosmetic as well as health-related reasons.
In human anatomy, the inferior epigastric artery is an artery that arises from the external iliac artery. It is accompanied by the inferior epigastric vein; inferiorly, these two inferior epigastric vessels together travel within the lateral umbilical fold The inferior epigastric artery then traverses the arcuate line of rectus sheath to enter the rectus sheath, then anastomoses with the superior epigastric artery within the rectus sheath.
In human anatomy, the inguinal region refers to either the groin or the lower lateral regions of the abdomen. It may also refer to:
Femoral hernias are hernias which occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness in the abdominal wall called the femoral canal. Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, almost all develop in women due to the increased width of the female pelvis. Femoral hernias are more common in adults than in children. Those that do occur in children are more likely to be associated with a connective tissue disorder or with conditions that increase intra-abdominal pressure. Seventy percent of pediatric cases of femoral hernias occur in infants under the age of one.
The testicular artery is a branch of the abdominal aorta that supplies blood to the testicle. It is a paired artery, with one for each of the testicles.
Post herniorrhaphy pain syndrome, or inguinodynia is pain or discomfort lasting greater than 3 months after surgery of inguinal hernia. Randomized trials of laparoscopic vs open inguinal hernia repair have demonstrated similar recurrence rates with the use of mesh and have identified that chronic groin pain (>10%) surpasses recurrence (<2%) and is an important measure of success.
The pampiniform plexus is a venous plexus – a network of many small veins found in the human male spermatic cord, and the suspensory ligament of the ovary. In the male, it is formed by the union of multiple testicular veins from the back of the testis and tributaries from the epididymis.
Amyand's hernia is a rare form of an inguinal hernia which occurs when the appendix is included in the hernial sac and becomes incarcerated. The condition is an eponymous disease named after a French surgeon, Claudius Amyand (1660–1740), who performed the first successful appendectomy in 1735.
The development of the gonads is part of the prenatal development of the reproductive system and ultimately forms the testicles in males and the ovaries in females. The immature ova originate from cells from the dorsal endoderm of the yolk sac. Once they have reached the gonadal ridge they are called oogonia. Development proceeds and the oogonia become fully surrounded by a layer of connective tissue cells. In this way, the rudiments of the ovarian follicles are formed.
Scrotalultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses.
Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the inguinal canal in the groin region.
↑ Neutra R, Velez A, Ferrada R, Galan R (January 1981). "Risk of incarceration of inguinal hernia in Cali, Colombia". Journal of Chronic Diseases. 34 (11): 561–564. doi:10.1016/0021-9681(81)90018-7. PMID7287860.
1 2 Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ (March 2011). "Diagnosis of Inguinal Region Hernias with Axial CT: The Lateral Crescent Sign and Other Key Findings". RadioGraphics. 31 (2): E1–E12. doi:10.1148/rg.312105129. PMID21415178.
↑ Klingensmith ME, Chen LE, Glasgow SC, Goers TA, Melby SJ (2008). The Washington manual of surgery. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN978-0-7817-7447-5.
↑ Rosenberg J, Bisgaard T, Kehlet H, Wara P, Asmussen T, Juul P, etal. (February 2011). "Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults". Dan Med Bull. 58 (2): C4243. PMID21299930.
1 2 Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M, etal. (18 January 2006). "Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men". JAMA. 295 (3): 285–92. doi:10.1001/jama.295.3.285. PMID16418463.
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