Inguinal Hernia

An inguinal hernia is an abnormal protrusion of abdominal contents through the inguinal canal. Symptoms include pain while coughing, with bowel movements and during exercise.

The disease tends to get worse during the day and improve on lying down. They are more common on the right than left. One should be careful of the terrible consequence of strangulation that is believed to be a late sequela of hernias in which blood supply to a part of bowel becomes cut off presenting with pain and tenderness of the area.

There are two types of inguinal hernias, direct and indirect. Certain factors predispose the likelihood of getting hernias. They include smoking, obesity, pregnancy, COPD, collagen vascular disease, previous surgical procedures like appendectomy, etc.

The disease is confirmed on the basis of signs and symptoms and occasionally on the basis of imaging techniques. Asymptomatic hernias in a male are left alone. However, repair is a rule in femoral hernias as there are more chances of complications in femoral hernias.

Two reparative measures are suggested: open and laparoscopic. However, laparoscopy is generally the favored choice.

Signs and symptoms of inguinal hernia include:

• A bulge in the area on either side of your pubic bone, which becomes more obvious when you're upright, especially if you cough or strain
• A burning or aching sensation at the bulge
• Pain or discomfort in your groin, especially when bending over, coughing or lifting
• A heavy or dragging sensation in your groin
• Weakness or pressure in your groin
• Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

Usually, the hernia reduces on lying down.

The inability to reduce a hernia on lying down suggests incarceration and is a surgical emergency. Significant pain is suggestive of the strangulated bowel.

As a hernia progresses, the intestinal contents pass into a hernia causing risk of intestinal obstruction. In the worst case, if the blood supply of a hernia is compromised also, then there is a risk of gangrene and infarction called as strangulation of a hernia.

It is a surgical emergency requiring immediate resuscitation of the damaged bowel. However, the risk of strangulation is low. On the other hand, surgical intervention has a significant risk of causing inguinodynia, and this is why minimally symptomatic patients are advised to watchful waiting.

A defect in the abdominal wall at birth causes an indirect inguinal hernia. Due the foetal development, lining of abdominal cavity forms and extends into the inguinal canal. This serves in male as a path for spermatic cord and testicles to descend into the inguinal canal.

This opening near the inguinal canal of abdominal wall usually closes before birth. In those cases, in which the defect persists, it gives rise to an inguinal hernia. However, in females there is no such arrangement and the defect is already closed before birth.

Indirect hernias are the most common type of a hernia and are present in 2-3% of the population and are seen mostly in a male population.

• Direct inguinal hernias usually occur only in male adults as aging and stress or strain to weaken the abdominal muscles around the inguinal canal. Previous surgery in the lower abdomen can also weaken the abdominal muscles. Females rarely have this hernia as broad ligament acts as an additional barrier to prevent abdominal contents from the abnormal protrusion.
• Premature infants have a higher chance of developing an indirect inguinal hernia. Direct hernias, which usually only occur in male adults, are much more common in men older than age 40 because the muscles of the abdominal wall weaken with age.
• People with a family history of inguinal hernias are more likely to develop inguinal hernias. Studies also suggest that people who smoke have an increased risk of inguinal hernias.

Your doctor will diagnose inguinal hernia on the basis of:

• Medical and family history.
• Physical examination.
• Imaging modalities like x-ray and USG.

A direct and indirect hernia is defined on the basis of their relation to inferior epigastric vessels. Direct hernias occur medial to the inferior epigastric vessels whereas indirect occur when abdominal contents protrude through the deep inguinal ring later to the inferior epigastric vessels. In females, the aperture of a superficial inguinal ring is narrower; as a result, there are fewer chances of a hernia in females. Direct hernias occur through Hesselbach triangle. There are various varieties of a hernia based on their contents like in case the content is a vermiform appendix, it is Amyaundshernia and if the content is Meckel”s diverticulum, it is called Littre’s hernia.

Clinically, hernias are classified as reducible and irreducible based on whether they can be reduced manually or not. Irreducible hernias are further classified as obstructed in which lumen of the intestine is obstructed and strangulated in which blood supply to the intestine is compromised.

When a patient suffers a simultaneous direct and indirect hernia on the same side, the result is called a pantaloon hernia.

Direct hernias tend to be more common in middle age and elderly as abdominal walls tend to weaken over time. On the other hand, indirect hernias tend to occur at any age.

After the diagnosis is suspected, it is often confirmed by imaging. When assessed by ultrasound or cross-sectional imaging with CT or MRI, the major differential in diagnosing indirect inguinal hernias is differentiation from spermatic cord lipomas, as both can contain only fat and extend along the inguinal canal into the scrotum.

On axial CT, lipomas originate posterolateral to the cord and are located inside the cremaster muscle, while inguinal hernias lay 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.

It’s important to note that inguinal hernias won’t resolve without treatment.

Management includes conservative and surgical approach.

• In conservative management, hernia truss is used to contain a reducible inguinal hernia inside the abdomen. Although no firm evidence exists for the use of truss, they are believed to contain a hernia and make life more comfortable for the patients. However, truss increases the risk of complications including atrophy of the cord and strangulation. Their popularity is likely to increase, as many individuals with small, painless hernias are now delaying hernia surgery due to the risk of post-herniorrhaphy pain syndrome. The elasticised pants used by athletes also provide useful support for the smaller hernia.
• Surgical corrective techniques are not used in asymptomatic small hernias as the risks associated with and after surgery is greater. Surgeries are commonly performed on outpatient basis. There are various options available including use of mesh, laparoscopic, open repair, or under general or local anaesthesia.
• Laparascopy 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. Constipation is strongly discouraged in the post-operative period due to risks associated with suture rupture.

People cannot prevent the weakness in the abdominal wall that causes indirect inguinal hernias. However, people may be able to prevent direct inguinal hernias by maintaining a healthy weight and not smoking.

People can keep inguinal hernias from getting worse or keep inguinal hernias from recurring after surgery by:

• Avoiding heavy lifting
• Using the legs, not the back, when lifting objects
• Preventing constipation and straining during bowel movements
• Maintaining a healthy weight
• Not smoking.
• Eating a high fiber diet and diets rich in nutrients like fruits and vegetables.

To adapt your lifestyle in coping with inguinal hernia, you must be completely aware of any health changes.

Instruct parents and caretakers on the signs and symptoms of inguinal hernia incarceration.

Delayed recognition of incarceration is likely to result in significant morbidity and mortality for the child.

Complications of an inguinal hernia include:

• Pressure on surrounding tissues. Most inguinal hernias enlarge over time if they're not repaired surgically. Large hernias can put pressure on surrounding tissues. In men, large hernias may extend into the scrotum, causing pain and swelling.
• Incarcerated hernia. If the omentum or a loop of intestine becomes trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas.
• Strangulation. An incarcerated hernia may cut off blood flow to part of your intestine. This condition is called strangulation, and it can lead to the death of the affected bowel tissue. A strangulated hernia is life-threatening and requires immediate surgery.

People who have symptoms of an incarcerated or a strangulated hernia should seek emergency medical help immediately. A strangulated hernia is a life-threatening condition.

Symptoms of an incarcerated or a strangulated hernia include:

• Extreme tenderness or painful redness in the area of the bulge in the groin
• Sudden pain that worsens quickly and does not go away
• The inability to have a bowel movement and pass gas
• Nausea and vomiting
• Fever