What is Inguinal Hernia?
Inguinal hernia repair is a very common surgery. More than 800,000 of these surgeries are done every year. An inguinal hernia is a hole in the muscle layer of the groin area, allowing organs located inside or outside your abdomen to push through. These groin hernias can be grouped into three different types based on their location: indirect, direct, and femoral.
Most people with an inguinal hernia notice a bump or experience pain in their groin area. All hernias that cause symptoms should be fixed to prevent future problems. This can be done using an open surgery or a less invasive approach with small incisions called laparoscopy. The main goal of the surgery is to close the hole and relieve the strain. A special material called a mesh is commonly used to make the repair stronger without putting extra tension on the tissues. However, if using a mesh isn’t recommended for some reason, the surgeon can just use stitches to close the hole.
What Causes Inguinal Hernia?
Inguinal hernias, which are a type of hernia that occur in the groin area, can be both inherited from birth or develop later in life. Most often, they develop in adults. Interestingly, your genes can also affect your chances of getting this type of hernia. If someone in your family has had a hernia, your chances of getting an inguinal hernia are four times higher than someone without such a family history.
Some specific health conditions, like chronic obstructive pulmonary disease (which can block airflow from the lungs), Ehlers-Danlos syndrome (which affects your skin, joints and blood vessels), and Marfan syndrome (which affects the body’s connective tissue), have been found to increase your chances of developing an inguinal hernia.
Similarly, anything that increases pressure in your abdomen can also put you at risk of developing this type of hernia. This includes being overweight, having a persistent cough, lifting heavy objects, or straining because of constipation.
Risk Factors and Frequency for Inguinal Hernia
Inguinal hernia repair is a frequent surgery in the United States, with an estimated 800,000 procedures carried out each year. Inguinal hernias make up about 75% of all hernias in the abdominal wall. These hernias are most common around age 5 and again after age 70. Of these, two-thirds are indirect hernias, the most common type of groin hernia in both men and women. However, men are more likely to have this condition, accounting for about 90% of all inguinal hernias, while women account for only 10%.
- Inguinal hernia repair is a common surgery.
- About 800,000 inguinal hernia surgeries are performed each year in the United States.
- Inguinal hernias make up 75% of all abdominal wall hernias.
- The majority of hernias are seen around age 5 and after 70.
- Two-thirds of these are indirect hernias, the most common type in the groin.
- Men are most likely to have an inguinal hernia, making up 90% of cases.
- Women account for 10% of inguinal hernias.
- Femoral hernias, however, are more common in women and make up 70% of such cases.
- Nearly 25% of men and less than 2% of women will have an inguinal hernia in their lifetime.
- Indirect hernias occur more often on the right side due to the slower closure of a specific part of the body (the patent processus vaginalis).
Signs and Symptoms of Inguinal Hernia
Inguinal hernias can cause different symptoms. Most commonly, people with this condition notice a bulge or feel pain in their groin area. Some people find that this pain or bulge becomes worse when they’re physically active or coughing. Other symptoms can include a burning or pinching feeling in the groin, which can spread to the scrotum or down the leg. Therefore, it’s important to have a detailed health check and share your full medical history to identify other possible causes for this type of pain. Occasionally, an inguinal hernia could lead to severe pain or issues due to the contents of the hernia sac becoming trapped.
When diagnosing an inguinal hernia, a physical examination is essential. The best way to identify this condition is by observing the patient’s groin while they’re standing up, looking closely for any visible lumps or bumps, or one side appearing different from the other. Then, the examiner will gently touch the groin and scrotum areas to see if they can feel a hernia. The last part of the physical examination involves the inguinal canal, located through the scrotum and toward the external inguinal ring. During this part of the examination, patients are asked to cough or perform a Valsalva maneuver (a process that increases pressure in the abdominal area). If a hernia is present, the examiner can feel a bulge moving in and out during these actions. Both sides of the patient’s body are examined, comparing the right and left sides for any differences. It’s unessential to distinguish between an indirect or direct hernia as the surgical treatment for both is the same. For a femoral hernia, it’s usually felt just below the inguinal ligament and a bit to the side of the pubic tubercle. Diagnosing femoral hernias can be challenging, particularly in obese patients, and if suspected but not detected via a physical exam, an imaging test could be necessary to confirm the diagnosis.
Testing for Inguinal Hernia
When it comes to diagnosing inguinal hernias, which are protrusions of abdominal contents through the groin region, a detailed check-up and analysis of your medical history is usually all that’s needed. If your reported symptoms suggest a hernia but the doctor can’t find one during your physical exam or if your body shape makes the physical exam inconclusive, then additional tests using imaging techniques may be needed.
These imaging tests can include an ultrasound, a CT scan or even MRI. An ultrasound is the least invasive of these and essentially uses sound waves to visualize the hernia. However, how accurate it is largely depends on the skill of the person performing the exam. You may be asked to perform a Valsalva maneuver during this, which is basically taking a deep breath and trying to exhale while blocking your nose and mouth to increase the pressure inside your abdomen. Ultrasounds can detect inguinal hernias accurately in about 86% of cases and can correctly identify people without hernias in about 77% of cases.
CT scans, which use a series of x-ray images to create cross-sectional images of your body, are typically used when the diagnosis isn’t clear. They can offer a better view of the groin area and can also be helpful in identifying other possible causes of a groin mass or complicated cases of hernia. It has around an 80% chance of correctly identifying a hernia and a 65% chance of correctly ruling one out.
An MRI, which uses a magnetic field and radio waves to create detailed images of the inside of your body, has the highest accuracy in detecting hernias with a 95% chance and ruling them out with a 96% chance. But, it’s quite costly and not readily accessible, so it’s not commonly used for diagnosing an inguinal hernia. However, when necessary, it can be used to help differentiate between sports-related injuries and inguinal hernias.
Treatment Options for Inguinal Hernia
Inguinal hernia can be treated through surgery. Generally, all hernias that cause noticeable symptoms should be treated with surgery, if possible. For those that don’t show symptoms or only minor symptoms, keeping close observation before taking further actions is sometimes advised. There are many different ways to perform hernia surgery, each with unique risks of complications and recurrence of hernia.
Open Surgery
In some cases, the body’s own tissue is used to close the hernia. This approach uses stitches and doesn’t involve mesh. These are usually performed if the area of surgery is contaminated or if the health of components within the hernia is uncertain. Primary tissue repairs include the Bassini, Shouldice, and McVay methods. For experienced surgeons, the Shouldice method has the lowest risk of the hernia occurring again. McVay is the only method that can be used for femoral hernia repairs. Every surgeon needs to be familiar with the technical details of these methods as they may be the only option in complicated cases. However, implants featuring synthetic mesh are usually preferred over using the body’s own tissues, due to their lower risk of hernia recurrence.
Prosthetic Repairs
Prosthetic repairs are procedures that use synthetic materials, like mesh, to deal with the hernia. These often have a lower rate of hernia coming back as compared to tissue repairs because they don’t put tension on the tissues. The prosthetic methods are the Lichtenstein tension-free repair, plug and patch, and the Prolene Hernia System. The Lichtenstein repair method is the most popular globally. However, these mesh repairs are not suitable in cases where the surgery area is infected, due to high risk of further infection.
Laparoscopic Repairs
There are two techniques of Laparoscopic repairs: the Transabdominal Preperitoneal Procedure (TAPP), and Total Extraperitoneal Procedure (TEP). The TAPP method involves dealing with the hernia through an approach within the abdominal cavity. It can be very helpful especially for treating both sides of hernia, large hernia defects, and for patients who have had a recurrence after an open repair. The mesh placed using this approach covers the direct, indirect and femoral spaces. However, it has a risk of causing injury to intraperitoneal viscera and structures. Patients need to be able to tolerate the gas pumped into the abdominal cavity for this technique.
In the TEP method, hernia repair is done without entering the abdominal cavity, minimizing the risk of injury to organs and structures within the abdomen. This procedure is quicker and easier without previous surgical adhesions. However, surgeons are restricted to limited space and clear viewing of surrounding anatomy is not as easy when compared to TAPP repair.
When compared to open surgery, laparoscopic procedures have a similar risk of hernia recurrence. Laparoscopic procedures have an advantage of causing less postoperative pain and normal activities can also be resumed earlier as compared to open surgery. However, it comes with higher operational costs, and achieving proficiency in performing this type of procedure can be quite difficult. It is suggested that a surgeon might need to perform as many as 250 laparoscopic hernia repairs to become optimally proficient.
What else can Inguinal Hernia be?
If you notice a bulge in your groin area, there can be many possible causes. Doctors would look into these potential conditions:
- Hernia
- Lymphadenopathy (swollen lymph nodes)
- Lymphoma (a type of blood cancer)
- Metastatic neoplasm (cancer that has spread from the original site)
- Hydrocele (swelling in the scrotum)
- Epididymitis (inflammation of the tube at the back of the testicle)
- Testicular torsion (twisting of the testicles)
- Abscess (puss-filled pocket due to infection)
- Hematoma (pooling of blood outside of a blood vessel)
- Femoral artery aneurysm (abnormal enlargement of the major artery in the leg)
- Undescended testicle (a testicle that did not move into its proper position before birth)
Remember, every health concern should be discussed with a healthcare provider who can conduct the proper tests and provide an accurate diagnosis.
What to expect with Inguinal Hernia
In general, people with inguinal hernias (protrusion of tissue through a weakened area in the groin) have a good chance of recovery. The common belief used to be that all inguinal hernias should be repaired with surgery. However, that view has been changing recently.
Recent studies suggest that a “watchful waiting” approach – where no immediate action is taken, but the condition is monitored closely – can be a safe and acceptable choice for men who are experiencing no symptoms or only very mild symptoms. This approach is seen as suitable since the risk of the hernia becoming trapped (‘incarceration’) and blood supply being cut off (‘strangulation’) turned out to be quite unlikely in these studies.
However, it’s still universally agreed upon that if you’ve been medically cleared for surgery and your inguinal hernia causes symptoms, you should be given the choice to have elective surgery. As for femoral hernias (protrusion of tissue through the upper thigh or hip), they must always be surgically repaired because they carry a high risk of becoming trapped.
The risk of complications does increase for hernias that have become trapped, had their blood supply cut off, or have occurred again after initial repair (recurrent hernias).
Possible Complications When Diagnosed with Inguinal Hernia
In general, around 10% of people experience complications after an elective inguinal hernia repair. These complications are similar to what can happen after any surgery and often include the build-up of serous fluids or blood in a pocket under the skin, problems with urinating, and infection of the surgical area. The two main complications specifically linked to an inguinal hernia repair are the hernia coming back and long-lasting pain.
- Hernia Recurrence
Normally, inguinal hernia repair has a low rate of the hernia returning. The risk is lower if the hernia is repaired using mesh, only about 3 to 5%. If the surgery is done using sutures, the rate of recurrence can be as high as 10 to 15%. Recurrence can be due to issues with the surgery like using the wrong size mesh, putting too much tension on the repair, missing hernias, or not having enough blood supply to the area. Lifestyle factors and health conditions, like smoking, using steroids, diabetes, poor nourishment, and chronic coughing, can also contribute to the recurrence of hernias. Usually, if a second surgery is needed, doctors will opt for a laparoscopic approach if the first surgery was open, and vice versa. This makes the surgery easier and minimizes the chances of injury to the cord structures and nerves.
- Chronic Pain
Around 10% of people report chronic pain after an inguinal hernia repair. This is a difficult problem and is now considered the main complication. In open surgeries, the surgeon must identify and protect three important nerves in the groin to prevent them from getting trapped. In laparoscopic surgeries, the surgeon has to be careful not to injure these nerves when securing the mesh. If a nerve is damaged, the part that was injured is tied off and cut. The first treatment option for chronic pain is usually anti-inflammatory drugs. If these don’t work, nerve blocks can be used. In some cases, a surgical exploration of the groin may be required, and cutting the damaged nerves might relieve the pain if the other treatments don’t work.
Recovery from Inguinal Hernia
Repairing an inguinal hernia, or a hernia in the groin area, is typically done in a day surgery setting. This means that the patient can go home on the same day as the operation. However, they should be able to use the bathroom on their own before being discharged. Detailed instructions about post-operation care will be given, and it’s important that these are followed closely.
To manage pain after surgery, patients may be given strong pain medicines called narcotics. These can be alternated with less strong medicines called NSAIDs or acetaminophen. It’s crucial to understand how these pain medicines may affect the patient, and what their side-effects are. Narcotics can cause constipation, so a medicine to soften the stool or a laxative might be needed.
Most patients are able to gradually return to their normal diet on the same day as the operation. Patients can usually shower 1-2 days after being discharged, depending on the surgeon’s recommendations. Physical activity should be limited in the weeks following surgery. In the first week, not lifting more than 10 pounds (4.5 kg) is suggested. This limit is raised to 20 pounds (9 kg) in the second week, and after that, lifting can be determined based on how the patient feels.
Activities involving high amounts of physical effort should be avoided for 4 to 6 weeks after the operation. Returning to work normally happens 1 to 2 weeks after surgery, but this can vary depending on the type of work the patient does and how they are managing their pain. Therefore, each return-to-work plan will need to be individually customized.