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inguinal hernia

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Inguinal Hernia

Overview

An inguinal hernia is a protrusion of abdominal contents through the inguinal canal, which is a weakness in the abdominal wall. It is one of the most common surgical conditions.

Types of Inguinal Hernia

Indirect Inguinal Hernia

  • Pathogenesis: Protrusion through the deep inguinal ring, following the path of the spermatic cord (males) or round ligament (females)
  • Location: Lateral to the inferior epigastric vessels
  • Congenital: Due to patent processus vaginalis
  • Age: More common in younger patients
  • Risk of strangulation: Higher

Direct Inguinal Hernia

  • Pathogenesis: Protrusion through a weakness in the posterior wall of the inguinal canal (Hesselbach’s triangle)
  • Location: Medial to the inferior epigastric vessels
  • Acquired: Due to weakened abdominal wall muscles
  • Age: More common in older patients
  • Risk of strangulation: Lower

Clinical Features

Symptoms

  • Bulging or swelling in the groin area
  • Discomfort or pain, especially with:
    • Coughing
    • Heavy lifting
    • Straining
    • Prolonged standing
  • Dragging sensation in the groin
  • May be asymptomatic initially

Physical Examination

Inspection

  • Visible bulge in the groin, may extend to scrotum
  • Increased with coughing or straining
  • May reduce spontaneously when lying down

Palpation

  • Soft, reducible mass (if uncomplicated)
  • Tender, firm mass (if incarcerated/strangulated)
  • Impulse on coughing

Differentiation Points

FeatureIndirectDirect
LocationLateral to inferior epigastricMedial to inferior epigastric
ExtentMay extend into scrotumUsually limited to groin
AgeYounger patientsOlder patients
GenderMore common in malesMore common in males

Differential Diagnosis

Common Mimics

  • Femoral hernia - Below inguinal ligament
  • Hydrocele - Fluid collection in scrotum
  • Lipoma - Fatty tumor
  • Enlarged lymph node
  • Undescended testicle (in infants)
  • Spermatic cord lipoma
  • Psoas abscess

Complications

Incarceration

  • Definition: Hernia cannot be reduced
  • Symptoms: Pain, nausea, vomiting
  • Urgency: Requires immediate attention

Strangulation

  • Definition: Compromised blood supply to herniated contents
  • Symptoms:
    • Severe pain
    • Nausea and vomiting
    • Fever
    • Signs of bowel obstruction
  • Medical emergency: Requires immediate surgical intervention

Obstruction

  • Bowel obstruction from trapped intestine
  • Vomiting, abdominal distension
  • Inability to pass stool or gas

Risk Factors

Increased Abdominal Pressure

  • Chronic cough (COPD, asthma)
  • Heavy lifting or straining
  • Chronic constipation
  • Pregnancy
  • Prostatism (straining to urinate)

Weakened Abdominal Wall

  • Age-related muscle weakness
  • Previous surgery in the area
  • Connective tissue disorders
  • Family history of hernias

Other Factors

  • Male gender (25:1 male:female ratio)
  • Premature birth (increased risk of patent processus vaginalis)
  • Obesity
  • Smoking (impairs collagen metabolism)

Diagnostic Approach

History

  • Onset and duration of symptoms
  • Aggravating factors (coughing, lifting)
  • Reducibility of the hernia
  • Previous similar episodes
  • Risk factors assessment

Physical Examination

  • Examination in standing and supine positions
  • Valsalva maneuver to elicit hernia
  • Assessment of reducibility
  • Check for complications

Imaging Studies

  • Ultrasound: First-line imaging modality
  • CT scan: For complex cases or uncertain diagnosis
  • MRI: Rarely indicated, usually for research

Management

Conservative Management

Indications:

  • Asymptomatic or minimally symptomatic
  • High surgical risk patients
  • Patient preference after informed discussion

Approaches:

  • Watchful waiting
  • Activity modification
  • Supportive truss (temporary measure)

Surgical Management

Indications:

  • Symptomatic hernia
  • Incarcerated or strangulated hernia (emergency)
  • Patient preference

Surgical Approaches:

Open Repair

  • Bassini repair - Traditional technique
  • Shouldice repair - Multi-layered repair
  • Lichtenstein repair - Mesh repair (most common)
  • Advantages: Direct visualization, familiar technique
  • Disadvantages: Longer recovery, more postoperative pain

Laparoscopic Repair

  • TAPP - Transabdominal preperitoneal
  • TEP - Totally extraperitoneal
  • IPOM - Intraperitoneal onlay mesh
  • Advantages: Faster recovery, less pain, bilateral repair possible
  • Disadvantages: Requires general anesthesia, longer operative time, higher cost

Postoperative Care

Immediate Postoperative

  • Pain management
  • Activity restrictions (typically 2-6 weeks for heavy lifting)
  • Wound care
  • Monitoring for complications

Long-term Follow-up

  • Recurrence surveillance
  • Activity guidance
  • Address chronic cough or constipation
  • Lifestyle modifications to reduce recurrence risk

Prognosis

Success Rates

  • Open mesh repair: >95% success rate
  • Laparoscopic repair: >95% success rate
  • Recurrence rate: <5% with modern techniques

Complications

  • Chronic pain (5-10%)
  • Recurrence (<5%)
  • Infection (<2%)
  • Testicular complications (rare)

Graph View

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