What is an Inguinal Hernia?

· December 20, 2017
An inguinal hernia is one of the most common ailments today. Because of that, surgery for a hernia is one of the most common surgical services in the world.

Do you know what an inguinal hernia is?

In general, a hernia is a protrusion that can be found in either the abdomen or the groin. It occurs when there is a weak spot or a hole in the abdominal wall.

Typically, a hernia is a consequence of a problem with your body’s tissue structure and it manifests in the form of a bulge.

It’s known as an “inguinal hernia” when it forms at the exit of an intestinal loop – the jejunum or ileum – through the inguinal canal.

Inguinal hernias can be inherited or acquired. For example, if a young child experiences this type of hernia it’s typically congenital, while when it occurs in an adult it’s usually acquired.

  • Congenital hernias appear in up to 30% of newborns and constitute a surgical emergency. In these cases, they’re usually found in relation to an anomaly in utero.
  • When a hernia returns, 50% of cases are due to an infection.

Acquired hernias typically affect adults. In most cases, they’re usually the result of an increase in pressure from inside the abdomen due to:

  • Pregnancy
  • Work that requires heavy lifting or tightening the abdominal muscles
  • Diseases like COPD
  • Prostatism (the effort required when urinating)
inguinal hernia
In addition, a hernia may be encapsulated or non-encapsulated.

  • Non-encapsulated hernias look like a mass that either appears or increases in size when you exert yourself. Coughing or standing will therefore make it larger, while lying down causes it to shrink.
  • When a hernia is encapsulated, it doesn’t grow or shrink at all.

Why do hernias appear in this location?

All types of hernias are found in areas of “anatomical weakness.

That means any areas where your anatomical walls are the weakest. This is what happens to the anterior abdominal wall, which is much weaker than the posterior wall.

Inguinal hernia epidemiology

  • These are among the most common surgical pathologies. It’s estimated that 1 person in 30 will suffer from it at some point in their life.
  • Surgery for a hernia accounts for 15% of all general surgeries. This makes it the most commonly performed surgery in the world.
  • Inguinal and femoral (crural) hernias are the two most common types of hernia. Inguinal hernias tend to affect men, while femoral hernias are more typical of women. Hernias are the second more common cause of intestinal obstruction of mechanical origin.
  • Recurrence is also relatively common.In half of the cases, it’s related to an infection.

Inguinal hernia classification

An inguinal hernia is classified based on the relationship between your intestine and where it travels through the inguinal canal. They are classified as:

Direct inguinal hernia

The intestinal loop crosses the floor of the inguinal canal, around the Hesselbach triangle.

The hernia can descend to the epigastric artery and won’t pass through the deep orifice of the inguinal canal. It’s located behind the cremaster muscle, but not involved with its fibers.

This type of hernia is commonly seen in elderly people.

Direct inguinal herniaIndirect inguinal hernia (external oblique)

This is the most frequent type of hernia, both in men and women. This hernia appears in the abdominal cavity through the deep inguinal orifice.

In this situation, the intestinal loop is lateral to the epigastric artery and the Hesselbach ligament. It accompanies the structures of the inguinal cord, inside the cremaster muscle.

In some men, the intestinal loop can appear within a testical, which is known as an inguinoscrotal hernia.

Symptoms

Generally, inguinal hernias produce mild symptoms.

In most cases, patients wake up feeling fine. During the day, however, they start to notice discomfort when they exercise, cough, etc.

However, many patients can reduce their hernia on their own.

Complications

  • Incarceration: in these cases, a hernia becomes “trapped.” It cannot be reduced manually, but there is no vascular compromise. The intestinal loop is correctly irrigated.
  • Strangulation: in this case, the irrigation of the herniated loop is compromised. It’s a surgical emergency and the intestine has little resistance to periods of ischemia. There is also the risk of necrosis.

When a hernia is complicated, it is impossible to reduce it. In addition, the pain is usually very intense and may be accompanied by a fever.

Diagnosis

Diagnosis is made through a simple physical exam, along with the patient’s clinical history. In fact, many times the patient arrives knowing that they have a hernia. Even so, for all patients with abdominal pain, it’s important to undergo an exam.

In light of the different diagnoses, it’s important to perform the exam along with tests for other causes of acute abdominal pain.

Treatment

Treatment objectives

Surgical repair of a hernia is based on:

  • Returning the intestinal loop to the abdominal cavity, without opening the peritoneum if possible.
  • Identifying the aponeurotic edges.
  • Closing the hole that caused the hernia.

Surgical treatment

The surgical treatment for an inguinal hernia can be performed either through open surgery or laparoscopy.

The most commonly used open surgery techniques are hemoriography and hemioplasty.

  • Hemoriography is an anatomical repair. In this technique, the patient’s own tissue is used to repair the hernia.
  • Hemioplasty is a prosthetic repair. After the intestinal loop has been returned to the abdomen, a synthetic mesh is put into place to reinforce the wall. Currently, this is the technique of choice due to its high success rate.

The minimally invasive inguinal hernia surgery has advantages and disadvantages compared to traditional techniques.

Surgical treatment
On one hand, it reduces postoperative pain and recovery time, while having a more aesthetically pleasing result.

On the other hand, there’s a higher rate of complications, both intraoperatively and extra-operatively. It can also increase the rate of recurrence, cost more, and have unknown long-term side effects.

For these reasons, it’s still a controversial process with many proponents and detractors.

Recurrence

This is defined as when a hernia reappears in the same area. Depending on how it presents itself, it can be immediate or delayed.

Recurrence depends on a series of factors, some due to the patient and others due to the surgery.

Some dependent factors related to the patient include:

  • Age
  • Hernia type
  • Existence of other diseases

Dependent factors dependent on the surgery are:

  • Inexperience
  • Poor technique
  • Improper diagnosis