Inguinal Hernia

Normal Anatomy

  • Inguinal canal is a 3d cylinder between the deep and superficial inguinal rings
  • Superior Wall – fibres of internal oblique and transversus abdominis
  • Posterior wall – conjoined tendon on internal oblique, transversus abdominis and fascia transversalis
  • Anterior wall – aponeurosis of the external oblique
  • Inferior wall – inguinal ligament, lacunar ligament and the ilio-pubic tract
  • Inguinal Canal
  • Spermatic cord – in men
  • Ilioinguinal nerve
  • Genito-femoral nerve

Pathology

  • A bulge or protrusion of tissue (usually intestine) from the abdominal cavity
  • Tissue may or may not be able to moved back
  • Reducible Hernia
  • hernia sac can be manipulated and tissue moved back in

oIncarcerated/Irreducible

  • the content of the hernia sac cannot be returned to the abdominal cavity
  • can lead to complications
  • Strangulated
  • The blood supply to the entrapped contents is compromised
  • Medical emergency

Mechanism of Injury

Insidious

  • Multifactorial
  • More common in males
  • Pathological changes in the connective tissue of the abdominal wall
  • Chronic coughing and manual labour jobs have NOT been shown to increase risk of intra-abdominal pressure

Classification

Direct Hernia

  • Portion of the intestine protrudes directly outward through a weak point in the abdominal wall
  • Superior to the inguinal ligament
  • Painless
  • Reduces when lying supine
  • Round swelling near pubis area of deep inguinal ring

Indirect Hernia

  • Portion of the intestine pushes downward through the deep inguinal ring into the inguinal canal
  • Through the deep inguinal ring
  • Can pass into the scrotum (men) or labia (women)
  • Pain with straining
  • May decrease when lying supine
  • Swelling that increases with intraabdominal pressure

Examination

Subjective

  • Intermittent or persistent bulge in the groin
  • May report groin pain- can be pain free
  • Pain worse with Valsalva maneuvers
  • Heavy or dragging sensation in the groin
  • Scrotal pain in men
  • Worse at the end of the day or after prolonged activity
  • Activities that increase intra-abdominal pressure worsen symptoms (pain and/or bulging)
  • Coughing
  • Lifting
  • Straining
  • More noticeable following heavy meal or standing for long periods
  • Bulge disappears in a supine position

Objective

  • Swelling in the groin at rest or coughing
  • Bulging in femoral or inguinal areas in standing

Special Testing

  • Internal examination of inguinal ring

Further Investigations

  • Rarely required
  • Ultrasound
  • MRI

Management

  • Surgery considered for symptomatic, large or recurrent hernias
  • Small, minimally symptomatic hernias managed conservatively
  • Physiotherapy post operatively for rehabilitation

Conservative

  • Advised to monitor for symptoms of incarceration or strangulation

Plan B

  • Hernia repair
  • Open
  • Laparoscopic

References

(Irwin and McCoubrey 2012, LeBlanc, LeBlanc et al. 2013, Broadhurst and Wakefield 2015, Fitzgibbons and Forse 2015)

Broadhurst, J. F. and C. Wakefield (2015). "Adult groin hernias: acute and elective." Surgery (Oxford)33(5): 214-219.

Fitzgibbons, R. J., Jr. and R. A. Forse (2015). "Clinical practice. Groin hernias in adults." N Engl J Med372(8): 756-763.

Irwin, T. and A. McCoubrey (2012). "Adult groin hernias." Surgery - Oxford International Edition30(6): 290-295.

LeBlanc, K. E., L. L. LeBlanc and K. A. LeBlanc (2013). "Inguinal hernias: diagnosis and management." Am Fam Physician87(12): 844-848.

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