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What Is an Inguinal Hernia?

   
 

An inguinal hernia occurs in the groin area when fatty or intestinal tissues push through the inguinal canal. The inguinal canal resides at the base of the abdomen. Both men and woman have an inguinal canal. In men, the testes usually descend through this canal shortly before birth. In women, the canal is the location for the uterine ligament. If you have a hernia in this passage, it results in a protruding bulge that may be painful during movement.

   
 
   
 

Many people don’t seek treatment for this type of hernia because it may not cause any symptoms. Prompt medical treatment can help prevent further protrusion and discomfort.

 
  Symptoms of Inguinal Hernia
  These types of hernias are most noticeable by their appearance. They cause bulges along the pubic or groin areas that can increase in size when you stand up or cough. This type of hernia may be painful or sensitive to the touch.
 

Other symptoms may include:

  • pain when coughing, exercising, or bending over
  • burning sensations
  • sharp pain
  • a heavy or full sensation in the groin
  • swelling of the scrotum in men
   
  Causes and Risk Factors of Inguinal Hernia
 

There isn’t one cause for this type of hernia, but weak spots within the abdominal and groin muscles are thought to be a major contributor. Extra pressure on this area of the body can eventually cause a hernia.

Risk factors can increase your chances of this condition. Examples of risk factors include:

 
  • heredity
  • personal history of hernias
  • being male
  • premature birth
  • being overweight or obese
  • pregnancy
  • cystic fibrosis
  • chronic cough
  • frequent constipation
  • frequently standing for long periods of time
   
  Types of Inguinal Hernias
  Inguinal hernias can be either indirect or direct. An indirect inguinal hernia is the most common type. It often occurs in premature births, before the inguinal canal can fully develop. However, this type of hernia can occur at any time during your life. This condition is most common in males.

A direct inguinal hernia most often occurs in adults. The popular belief is that weakening muscles during adulthood lead to a direct inguinal hernia. Inguinal hernias can also be incarcerated or strangulated. An incarcerated inguinal hernia happens when tissue becomes stuck in the groin and can’t go back. Strangulated versions are more serious medical conditions that restrict blood flow to the small intestine. Strangulated hernias are life-threatening and require emergency medical care.
   
  Diagnosis of an Inguinal Hernia
  A doctor can easily push these hernias back into your abdomen when you are lying down. However, if this is unsuccessful, you may have a strangulated inguinal hernia. Your doctor can make this determination during a physical exam. During the exam, your doctor will ask you to cough while standing so they can check the hernia when it’s at its largest.
   
  Treating Inguinal Hernias
 

Surgery is the primary treatment for inguinal hernias. It's a very common operation and a highly successful procedure when done by a well-trained surgeon. Your doctor will recommend either herniorrhaphy ("open" repair) or laparoscopic surgery (done through a small scope).

Open repair involves making an incision into the groin and returning the abdominal tissues to the abdomen and repairing the abdominal wall defect. Laparoscopy uses several short incisions rather than a single, longer incision. This surgery may be preferable if you want a shorter stay and fast recovery.

Laparoscopic inguinal hernia repair originated in the early 1990s as laparoscopy gained a foothold in general surgery. Inguinal hernias account for 75% of all abdominal wall hernias, and with a lifetime risk of 27% in men and 3% in women. Repair of these hernias is one of the most commonly performed surgical procedures in the world. In the United States, approximately 800,000 inguinal herniorrhaphies are performed annually

Although open, mesh-based, tension-free repair remains the criterion standard, laparoscopic herniorrhaphy, in the hands of adequately trained surgeons, produces excellent results comparable to those of open repair .In a comparison between open repair and laparoscopic repair, It is found that 5 years after operation, 1.9% of patients who had undergone laparoscopic repair continued to report moderate or severe pain, compared with 3.5% of those who had undergone open repair.

A number of studies have shown laparoscopic repair of inguinal hernias to have advantages over conventional repair, including the following

• Reduced postoperative pain
• Diminished requirement for narcotics
• Earlier return to work

Laparoscopic repair has some disadvantages as well, including the following:


• Increased cost
• Lengthier operation
• Steeper learning curve
• Higher recurrence and complication rates early in a surgeon's experience
The term laparoscopic inguinal herniorrhaphy can refer to any of the following 3 techniques:
• Totally extraperitoneal (TEP) repair
• Transabdominal preperitoneal (TAPP) repair
• Intraperitoneal onlay mesh (IPOM) repair

 
  The IPOM repair has largely fallen from favor, and currently, the most commonly performed laparoscopic techniques are the TEP and TAPP repairs. Although many facets of laparoscopic inguinal hernia repair continue to be debated - such as the possible superiority of one laparoscopic approach to another, comparisons between laparoscopic and open surgery, the learning curve and training issues, and the socioeconomic implications - both TAPP and TEP have been shown to be acceptable and safe for repair of inguinal hernias.
   
  Indications
  The general indications for laparoscopic inguinal hernia repair as opposed to watchful waiting are the same as those for open inguinal hernia repair.

Classically, the existence of an inguinal hernia has been considered sufficient reason for operative intervention. However, studies have shown that the presence of a reducible hernia is not, in itself, an indication for surgery and that the risk of incarceration is less than 1%.

Symptomatic patients (with pain or discomfort) should undergo repair; however, as many as one third of patients with inguinal hernias are asymptomatic. The issue of observation versus surgical intervention in this asymptomatic or minimally symptomatic population was addressed in two randomized clinical trials, both of which found that there were no significant differences in hernia-related symptoms after long-term follow-up and that watchful waiting did not increase the complication rate

In one study, the substantial patient crossover from the observation group to the surgery arm led the authors to conclude that observation may delay but not prevent surgeryThis reasoning holds particularly true for younger patients. Thus, even an asymptomatic patient, if medically fit, should be offered surgical repair. In another study, the authors determined that most patients with a painless inguinal hernia will develop symptoms over time and that surgery is therefore recommended for medically fit patients.

Some reports have listed specific indications for laparoscopy over open repair, including recurrent hernias, bilateral hernias, and the need for earlier return to full activities

Several studies have demonstrated salutary outcomes for laparoscopic repair of recurrent hernias. Re-recurrence rates may decline to 5% or lower with laparoscopic repair, compared with rates as high as 20% for anterior repair.
The reduced pain after laparoscopic inguinal hernia repair as compared with conventional anterior repair makes laparoscopy the approach of choice for bilateral hernias .A particular advantage of TAPP repair in a patient with bilateral inguinal hernias is that both sides can be repaired via the same laparoscopic port sites.

The choice of repair for primary unilateral inguinal hernias is controversial. A large Veterans Affairs cooperative study reported a 10% recurrence rate for laparoscopic inguinal hernia repair, compared with a 5% rate for anterior repair ; however, multiple authors have identified flaws with this study. Other studies from experienced hernia surgeons have reported recurrence rates for laparoscopic repair that range from 1% to 3%.

Although the actual hospital costs of laparoscopic repairs are higher than those of open repairs, the increased cost may be offset by the societal benefits of earlier return to full activities.

Patient preference plays perhaps the greatest role in the choice of one type of repair over another; however, surgical expertise plays a key part as well. Data show that the recurrence rate drops significantly as surgeons gain experience with the laparoscopic technique. Some studies suggest that the learning curve for TEP laparoscopic herniorrhaphy may be as high as 250 cases (as opposed to 25 for open repair). TAPP repair has a learning curve closer to that of the open technique.

A Cochrane database meta-analysis comparing TEP with TAPP found no significant difference in recurrence rates but did find that TAPP was associated with a higher risk of intra-abdominal injury. The authors concluded that further randomized controlled trials are needed for definitive comparison of these 2 techniques.

Conclusions about inguinal hernias in female patients are difficult to draw because most of the literature involves male patients. Koch et al found that recurrence rates were higher in women and that recurrence was 10 times more likely to be femoral in women than in men. This has led some to conclude that approaches that cover the femoral space (eg, laparoscopic repair) at the time of initial operation are better suited for primary repair in women. Further studies will be needed to resolve this question.

The IPOM technique has fallen out of favor because of reports of unacceptably high rates of organ injury, nerve injury, and hernia recurrence.
   
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