Inguinal hernia: How to recognize and treat it? (Know everything)

Share with your concerned loved ones
4.5
(13)

Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine

Have you ever consulted for a problem of inguinal hernia ? Do you know a loved one who was diagnosed with this condition by doctors?

Basically, it is a subcutaneous lump located in the groin. This lump can be congenital or acquired. There inguinal hernia is common in men due to a number of factors that we will identify later.

The objective of this popularized article is to provide detailed information on the definition, causes and symptoms of this pathology. It will also set out the means of diagnosis and the different treatment methods that exist. The article will focus on the surgery, possible complications and recovery after the operation.

Contents

Definition

We speak of an inguinal hernia when structures contained in the belly (abdominal viscera) erupt out of their usual place and come to be found under the skin at the level of the groin. According to the mode of occurrence of the protrusion of the viscera as well as the exact moment and place of the exit, several types of inguinal hernia.

Indirect inguinal hernia

When this exit occurs through the inguinal orifice which becomes too distended, we speak of indirect inguinal hernia. Normally this orifice located at the level of the groin in the abdominal wall, lets pass vessels and ligaments intended for the irrigation of the lower limb. This type of hernia is externalized by an oblique path from outside to inside and from back to front. We therefore use the term external oblique inguinal hernia (HIOE).

Direct inguinal hernia

The protrusion of the abdominal viscera can also be done through the muscles of the abdominal wall. In this case we speak of direct inguinal hernia. The hole created in these muscles occurs when there is a weakness of these muscles often during repeated efforts.

Congenital inguinal hernia

We also distinguish the congenital inguinal hernia when present at birth. In this case, the weakness of the abdominal wall is due to the persistence of the peritoneo-vagina canalI. This channel exists to naturally ensure the migration of the testicles into the bursae in the fetus. Indeed, the testicle is formed near the kidney. When it is going to be placed in the scrotum, it takes the inguinal canal in a passage called the peritoneal-vaginal canal.

Failure to close this canal before birth then leaves a point of weakness from which the abdominal viscera engage as soon as the baby comes out. This condition will get worse over time and could be diagnosed as soon as the child is older.

Acquired inguinal hernia

Furthermore, we will talk about acquired inguinal hernia when its occurrence occurs in adults due to exogenous factors. This article will list some causes of acquired inguinal hernia in the lines to follow. But first doing a little anatomy lesson to better understand the pathology.

Anatomical reminders

The inguinal region

The groin is the anatomical region between the abdomen and the thigh. This region is crossed, among other things, by the iliac vessels which, in the course of their course, become the vessels of the thigh and the leg. In addition, depending on whether we are in men or women, we find other specific anatomical elements. Thus, in men, the inguinal region is crossed by a cord which contains the vascular pedicle of the testicle and the vas deferens which connects the testicles to the prostate. In women, this region is crossed by a ligament called the round ligament which attaches the uterus to the bottom of the labia majora.

The passage of these different elements in this region creates areas of weakness through which the elements of the abdominal cavity can be inserted, thus favoring the development of a hernia.

RECOMMENDED FOR YOU:  Inguinal hernia: When to walk after the operation?

To know 9 causes of groin pain, see the following article.

The inguinal region is separated into two parts by the crural arch. The cutaneous projection of this arch is called the line of Malgaigne. In relation to this arch, two types of hernias are defined at the level of the groin. The inguinal hernia just as the femoral hernia still called crural hernia. Hernias whose neck is located above the crural arch are inguinal hernias and hernias whose neck is located below the crural arch are called crural hernias.

Crural arch inguinal hernia
Source

The different parts of an inguinal hernia

The hernia is composed of a path through an orifice or a canal (here it is the inguinal canal) and an envelope comprising:

  • the hernia sac: it is the portion of peritoneum (membrane covering the abdominal viscera and separating them from the abdominal wall) which comes out of the abdomen and whose base is called Collet (deep orifice of the hernia).
  • the hernial contents (all of the viscera such as fragments of the small intestine of the colon sometimes the ovary in women).

Causes of Inguinal Hernia

The causes of acquired inguinal hernia are mostly pathological conditions that put pressure on the abdomen. These conditions will weaken the muscles of the abdominal wall and promote hernia. These include, among others:

  • Carrying heavy loads 
  • Change in body weight (more or less)
  • A chronic disease of the lungs (acute bronchitis for example) which causes a severe cough mobilizing the abdominal muscles.
  • Ascites (fluid in the abdomen)
  • Intraperitoneal (inside the peritoneum) problems that increase pressure in the abdomen.
  • A colon tumor especially in patients over 45 years old
  • A disease of the prostate because it sometimes requires significant abdominal thrusts to be able to urinate
  • Transient or chronic constipation with significant abdominal thrusts.

Symptoms of the disease

An inguinal hernia can be asymptomatic if it is small. However, when it grows, symptoms appear. The patient then feels heaviness and discomfort (sometimes even pain) in the lower abdomen. He may also simply notice the presence of a lump in his groin.

The inguinal hernia is usually absent in the morning on waking and appears as the day progresses. The symptoms intensify when the patient adopts a long standing position, or when he makes efforts (cough, heavy lifting).

It can happen in humans that the viscera of the inguinal hernia descend into a bursa. We speak in this case of hernia inguino-scrotal.

In children, inguinal hernia is discovered by parents when bathing or changing clothes. It will then be a lump that appears or increases in size when the child cries or has a bowel movement. This lump will usually go away when the child becomes calm again.

On examination, an uncomplicated hernia is painless, coughing impulsively (increases in volume when the patient coughs) and reducible (the pressure exerted causes the viscera to return to the abdomen, reducing the size).

Complicated hernias

In the absence of support, an inguinal hernia can become complicated. It can grow and become so large that it is no longer possible to reintegrate it into the abdominal cavity. The hernia can also become strangled and cause a acute intestinal obstruction.

Strangulation is the complication of external oblique inguinal hernias of congenital origin. It constitutes a surgical emergency and is marked by the sudden onset of paroxysmal pain (severe acute pain). Vomiting appears and intestinal transit stops (no more gas or stools).

On examination, the swelling is painful, non-expanding to coughing and non-reducible.

Strangulated hernia inguinal hernia
Source

Diagnosis of inguinal hernia

The positive diagnosis of inguinal hernia is made in the clinic. The doctor objects a spontaneous tumefaction on a standing patient or possibly after making him cough or walk. The doctor passes his index finger through the skin of the scrotum, enters the superficial orifice of the inguinal canal and travels up, back and out into the inguinal canal. It encounters the tumefaction which is painless, impulsive (on coughing) and whose collar is located above the line of Malgaigne.

The continuation of the clinical examination of the doctor must take into account all the abdominal wall in search of a contralateral hernia and another type of hernia. He scrupulously examines the condition of the skin next to the inguinal hernia and assesses the elements of the hernial content.

If it is an acquired inguinal hernia, the doctor must look for the contributing factors by doing a careful questioning and a more thorough examination.

Treatment

The different surgical techniques for an inguinal hernia

Herniorraphy (direct surgical repair of an inguinal hernia)

1. Positioning the patient

The operation can be performed under local, locoregional or general anesthesia. The patient is installed in the supine position (lying on the back).

2. Cut

A 2 cm incision is made on the lower abdominal skin fold opposite the superficial inguinal orifice. It is located 1 cm outside the pubic spine.

3. Dissection of the hernial sac

The dissection of the underlying adipose tissue is carried out with an electric scalpel up to the fascia superficialis (membrane located under the skin which envelops our entire body). The latter is opened with fine scissors.

The practitioner then uses Faraboeuf retractors (instruments to spread and keep the two parts of an incision in place) to highlight the superficial inguinal orifice from which the hernia sac emerges.

Exposure of the sac can be facilitated by opening the superficial inguinal orifice in the direction of the muscle fibers of the external oblique muscle, taking care not to injure the genital branch of the genito-femoral nerve.

RECOMMENDED FOR YOU:  Inguinal hernia: Recovery after surgery (tips)

The dissection of the bag is done using Christophe forceps along the internal face of the crural arch under the superficial inguinal orifice for its lower edge and under the joint tendon for its upper edge. It is performed slightly below the plane of the superficial inguinal orifice, which allows in the event of perforation of the bag to resume the dissection higher up.

4. Identification of the spermatic cord

After dissection of the hernial sac, the elements of the spermatic cord are identified. The cord is separated from the bag and stretched over an atraumatic clamp.

5. Dissection of cord and sac elements

The dissection of the hernial sac is continued by freeing it from the spermatic cord. This dissection must be meticulous, the bag must be freed without damaging the elements of the cord and without being opened. The cremasteric fibers which surround the sac can be separated in their axis at the upper surface of the cord.

This allows the sac to be better exposed, which is then caught using dissecting forceps. The external side of the bag is in slight tension and the elements are lowered using another dissecting forceps.

6. Closure of the peritoneal-vaginal canal

Care should be taken during this stage to always control the distance from the spermatic cord. The isolated hernia sac will be closed using Christophe forceps after having checked its emptiness (absence of digestive contents). The peritoneal sac is cut with scissors.

A stitch with an absorbable thread (sterile thread mounted on a needle) is made at the base of the sac as close as possible to the superficial inguinal orifice, in order to prevent a recurrence (hernia in the sac).

And for the parietal closure, we use a single strand thread with slow resorption.

7. Parietal closure

The surgeon closes the superficial inguinal orifice lengthwise with an absorbable suture, avoiding taking the genital branch of the genito-femoral nerve and the spermatic cord.

The fascia superficialis is closed with separate stitches of the same thread.

Finally, skin closure can be achieved by an intradermal overlock with resorbable thread. A waterproof dry dressing is then applied. Finally, the position of the testicle in the homolateral purse is checked.

8. Prosthetic plasties

These techniques consist of implement a prosthesis of non-absorbable tissue covering the orifice of weakness in the hernial region.

There are 2 types of approaches first.

  • Classic approach (inguinal incision).
  • Laparoscopic route.

These prostheses cover the areas of dehiscence or traction on the muscular or aponeurotic structures.

Hernia repair by laparoscopy

It's about a surgical technique thanks to which the surgeon operates "with a closed stomach". He uses instruments and a camera which are introduced through small skin incisions in the abdomen. The intervention consists of placing a prosthesis. It requires general anesthesia with an approach by camera in the preperitoneal space.

It can be done in 2 ways.

1. Extraperitoneally 

This is done by direct access to the preperitoneal space. We do not go into the abdominal cavity. The operation takes place in the space between the muscles and the peritoneum.

2. By trans-abdominal preperitoneal route

In this case, the (peritoneal) incision begins outside the anterosuperior iliac spine and extends medially to the homolateral umbilical ligament, remaining close to the deep inguinal orifice.

The posterior peritoneal flap is dissected first with the peritoneal sac. Then, the (peritoneal) sac is completely freed from the inguinal canal, cord elements and iliac vessels. A prosthesis is placed, which covers the transversalis fascia, the transverse arch and the inguinal orifice. The prosthesis may not be fixed. But if it is, it is fixed with staples to the Cooper's ligament, to the rectus, just inside the internal orifice. Once the prosthesis is correctly in place, the posterior peritoneal flap is closed.

Peroperative complications (during the operation)

They arise due to the wealth of anatomical structures that are superficial in the inguinal region.

  • Damage to the nerves at this location may be responsible for loss of sensitivity not only of the inguinal region but also of the hemi scrotum, the base of the penis and the upper part of the thigh. These sensory disturbances are generally transient.
  • The nerve damage by cutting or strangulation of a nerve in a suture may be responsible for chronic pain postoperative.
  • A femoral nerve injury, with motor consequences on the quadriceps, can occur when fixing prostheses on the psoas muscle.
  • The bleeding complications concern the lesions of the various vessels, the most serious of which is the lesion of the external iliac vein.
  • The wounds bladder, colon and vas deferens are possible.

Postoperative complications

  • The infection is the most dreaded postoperative complication. The risk of infection does not seem to be higher if a prosthesis is used, however prophylactic (preventive) antibiotic therapy is very often used when it comes to hernia repair with prosthesis fitting. Studies have shown that patients over the age of 60 have a higher risk of infections, justifying systematic prophylactic antibiotic therapy in them.
  • We can have a acute suppuration of the surgical wound occurring in the first days after the operation. The solution will be to proceed with an evacuation of the pus, a washing, a drainage and a directed healing. Removal of the prosthesis is most often not necessary.
  • In the presence of a non-absorbable prosthetic material, a chronic suppuration may persist or occur years after surgery. Definitive healing will then only pass through a resumption of the intervention. The latter will aim to extract all the prosthetic material that has not been properly invaded by the healing tissue.
  • You can also see a collection of fluid under the skin in the blood type groin called hematoma or another yellow colored liquid called seroma. The absorption of seroma usually happens spontaneously in 2 to 3 weeks, but can sometimes take several months. L'hematoma on the other hand, will require immediate evacuation to the operating room.
RECOMMENDED FOR YOU:  Inguinal hernia: Recovery after surgery (tips)

Convalescence

It will most often be marked by the management of pain.

Four types of neuralgia after hernia repair:

  • type pains hyperesthesia (exaggeration of the painful sensation)
  • paroxysmal burning pain and dysaesthesia or allodynia (abnormal sensitivity);
  • so-called reported pain with pain in the skin area without severity;
  • so-called referred pain due to distant lesions of the nerve which are expressed by the relay of the same spinal nerve root.

Recurrences are also possible. It is estimated that 50% of recurrences occur within 5 years of surgery, including 25% in the first year. In the other cases, the recurrence occurs beyond 5 years, and approximately 90% of recurrences have occurred at 10 years.

Inguinal hernia and diet

Pathologies that include strong abdominal pressure, namely obesityConstipation chronic are major risk factors. It is these two reasons that make the link between diet and inguinal hernia.

inguinal hernia
Source

How can we avoid as much as possible the risk factors that promote or aggravate the disease?

  • La weight gain, obesity: the consumption of excessively fatty and sugary foods promotes the accumulation of fatty mass in the abdominal area, which contributes to increasing the pressure exerted on the viscera. This promotes the appearance of hernia at the level of oldest boy.
  • La weakness of the abdominal muscles, in part, because of a poor diet.
  • La Constipation : the effort made during the evacuation of the stool considerably increases the pressure abdominal. This promotes the exit of the viscera out of their usual location. In addition, the accumulation of excrement that is difficult to evacuate could aggravate the hernia, by disrupting blood circulation.

What foods should you avoid with an inguinal hernia?

Here is a small list of foods to avoid or at least to minimize during this disease:

  • excessive carbohydrate foods: sugar, sweets, pasta, pastries;
  • industrialized foods: sugary and carbonated drinks, condiments, sauces and synthetic flavor enhancers, snacks;
  • foods that are too fatty: bacon, margarine, cheeses, fried foods, meats, etc.
  • junk foods: hamburgers, kebabs, sandwiches… which increase the risk of obesity;
  • alcoholic beverages;
  • stimulants: tobacco, coffee, etc.;
  • foods that constipate: chocolate, unripe fruits especially guava and banana, white rice, red meat;
  • the fruits dry and nuts that are difficult to digest;
  • those rich in gluten, who ignite the intestines. They are therefore bad for people with inguinal hernias. Examples include wheat, cold meats, chocolate, beers, etc.

After the operation, doctors always recommend eating foods that are easily digestible and light and above all not too hard. For example, we can cite broths that are not too greasy, very ripe fruit, compotes, etc. Laxatives like most vegetables are recommended to fight against constipation. And above all, don't forget to stay hydrated by drinking enough water.

Conclusion

Inguinal hernia is the exit of the abdominal viscera outside the abdominal cavity. Depending on the mechanism of occurrence of the hernia, it can be indirect or direct. Depending on the time and the cause, it can be congenital or acquired.

On the clinical and diagnostic level, we retain that an uncomplicated hernia is painless, coughing impulsively et reducible. The complication to be feared is the hernia strangulation which is a therapeutic emergency in order to avoid the worst which is theacute intestinal obstruction.

The treatment for inguinal hernia is surgery. Several techniques exist ranging from simple raphies to hernial cures with prosthesis placement. The convalescence will be marked by possible pain of nervous origin. We must not forget that a recurrence of the inguinal hernia is possible in some patients in the long term.

References

  1. https://www.sante-sur-le-net.com/maladies/hepato-gastro/hernie-inguinale/
  2. http://chirurgie-digestive-sat.aphp.fr/pathologies/hernie-inguinale/
  3. http://campus.cerimes.fr/hepato-gastro-enterologie/enseignement/item245/site/html/1.html
  4. Palot J, Flament J, Avisse C, Greffier D, Burde A. Use of prostheses in the conditions of emergency surgery. Surgery 1996; 121: 48-50
  5. Gatt M, Chevrel J. Treatment of neuralgia after inguinal hernia repair. Ann Chir 1984; 117: 96-104
  6. Hay JM, Boudet MJ, Fingerhut A, Poucher J, Hennet H, Habib E et al. Shouldice inguinal hernia repair in the adult male: the gold standard. Ann Surg 1995; 222: 719-727
  7. Izard G, Gailleton R, Randrianasolo S, Houry R. Treatment of groin hernias using the McVay technique. About 1 cases. Ann Chir 332; 1996: 50-755

Was this article helpful to you?

Indicate your appreciation of the article

Readers rating 4.5 / 5. Number of votes 13

If you have benefited from this article

Please share it with your loved ones

thank you for your comeback

How can we improve the article?

Back to top