Inguinal Hernia

Medical: inguinal hernia, inguinal hernia, hernia inguinalis

  • Soft bar
  • Sportsmen’s bar
  • Groin pain

The inguinal hernia, like all abdominal wall hernias, is a protrusion of contents from the abdominal cavity through the inner connective tissue sheet that delimits the abdominal cavity. Anatomically, the groin is a place where hernias occur particularly frequently, since this is where natural weak points of the connective tissue are located. The anatomy of the groin is complicated and requires a more detailed explanation.

The abdominal wall consists of (from inside to outside): During the development of the male embryo, the testicles, which are primarily located in the abdominal cavity, are lowered into the scrotum. This leads to the formation of the inguinal canal, in which the spermatic cord and the supply vessels for the testicles lie. This creates a natural gap in the abdominal wall, through which the contents of the abdominal cavity can emerge from the actual abdominal cavity.

Such an inguinal hernia is called direct. The indirect inguinal hernia is caused by a gap that forms closer to the midline of the abdominal wall. If contents from the abdominal cavity enter the muscles or the subcutaneous fatty tissue, an incarceration may occur.

For this reason, inguinal hernias are classified according to this criterion as incarcerated and not incarcerated. Inguinal hernias can also be congenital or acquired since. A special form of inguinal hernia is the so-called scrotum hernia.

It is mainly observed in older men. Via a very large gap in the abdominal wall, parts of the intestine are displaced into the scrotum, which can stretch very far in the course of the hernia. This can make the scrotum hernia extremely large.

In women, a different form of inguinal hernia occurs – the femoral hernia. This is a gap that is created below the inguinal ligament and thus allows the hernia sac to expand into the thigh.

  • Peritoneum
  • Inner connective tissue sheet
  • Muscle
  • Outer connective tissue sheet
  • Subcutaneous fat tissue
  • Skin

Congenital inguinal hernia:In embryos, there is a natural connection between the abdominal cavity and the groin, the processus vaginalis.

If this connection does not close around birth, a congenital inguinal hernia develops. The parents observe a protrusion in the area of the groin(s) (or both), which is more pronounced when crying, due to the increased pressure in the abdominal cavity, and is painless in most cases. Under certain circumstances, however, this protrusion can be painful (due to pressure).

In these cases, at least a beginning incarceration must be assumed. Acquired inguinal hernia:In adulthood, a weaker connective tissue can promote the development of the inguinal hernia. This is often the case in older people.

In young men, an inguinal hernia develops during excessive physical exertion, e.g. during heavy lifting or bodybuilding. The symptoms of inguinal hernia range from painless swelling to intestinal obstruction in the case of an incarcerated hernia. Sometimes there is pain in a circumscribed area without any palpable hernia or swelling.

In these cases, another cause (see below) should be excluded before planning the surgical treatment of the hernia. In case of swelling and/or pain in the groin, a hernia is always considered first, as this is the most common cause. However, these symptoms can also have other causes.

Swelling can be an expression of enlarged lymph nodes in the groin, which in turn are in most cases the result of inflammation. Enlarged lymph nodes require further clarification in any case! After puncturing the groin vein (e.g. with a heart catheter), bruises (haematoma) may also occur, which are also noticeable as swellings.

Such bruises often require surgical treatment. Pain in the groin can be caused by an irritation of the point where the thigh muscles attach to the pelvis. This is often the case after stronger efforts of the leg muscles, e.g. after a soccer match.

Another cause of groin pain are problems of the hip joint. Exploitation symptoms (“hip arthrosis“) but also the femoral neck fracture (femoral neck fracture) are sometimes diagnosed as the sole symptom in groin pain. Inguinal hernias are usually well recognizable even for the layman.

Since in the case of an inguinal hernia the hernia contents, usually a small section of the intestine or the fatty tissue (omentum majus) located in the abdominal cavity and covering the intestine, form a hernia sac through the so-called hernia site, an elevation or swelling of the affected skin area can be observed and palpated.Mostly it is to be found in the groin area as the name suggests, but can also be found in the scrotum or the labia due to the anatomy in this area. The symptoms also depend on the intra-abdominal (inside the abdomen) pressure, which is increased when sneezing, coughing, lifting heavy boxes or lifting shopping bags. In this case, the increased intra-abdominal pressure leads to further pressing of the intestines out into the hernia sac.

In addition, an improvement in the swelling when lying down and at rest points to a hernia, an increase in symptoms when lying down or at night points to other diseases such as certain muscle diseases. Furthermore, a distinction must also be made as to whether the hernia contents are repositionable, i.e. whether the hernia contents are displaceable and can be pushed back into the abdominal cavity by hand. If this is the case, there is usually no or only weak pain, such as a slight pulling in the groin area.

A hardening of the skin over the hernia contents, pain and a non-displaceable hernia contents are typical signs of inflammation or infection, which can also be accompanied by an incarceration of the intestinal segment. This leads to a blockage of the oxygen and nutrient supplying blood supply of the tissue. This is accompanied by the death (necrosis) of the affected tissue, which can lead to further complications.

For this reason, a physician should also be consulted in the case of a non-painful hernia. lThe hernia is clinically diagnosed. The doctor will try to palpate the gap and, if necessary, move the hernia sac into the abdominal cavity.

This is particularly important in order to prevent the hernia from becoming trapped. With very small fractures, the hernia gap cannot always be palpated. In some cases, an additional ultrasound examination can provide the necessary certainty about the diagnosis in these cases.

However, sonography (ultrasound) is also used to distinguish trapped inguinal hernias from enlarged lymph nodes, although this can often be difficult. Not every inguinal hernia has to be treated surgically. However, as soon as one or more sections of the intestine within the hernia sac are pinched off, surgery is the only therapeutic option.

In such a case, the affected patient usually feels severe pain in the groin area. A hernia associated with pain should be surgically treated immediately, within the shortest possible time. Only the prompt performance of an inguinal hernia operation can prevent parts of the disconnected intestine from dying off.

There are different techniques and procedures for the surgical correction of inguinal hernias. With the conventional method, an access in the groin area is usually chosen. The necessary skin incisions are kept relatively small and heal well.

Visible scars are rather rare. Furthermore, a minimally invasive, laparoscopic approach is also possible in conventional hernia surgery. The following surgical methods are used: One of the most frequently chosen procedures is the so-called surgical method according to Shouldice.

During this operation a transverse skin incision is made above the inguinal ligament. Starting from this skin incision, the preparation can be carried out up to the hernia sac. Once the hernial sac is completely exposed, it is opened and its contents are transferred back into the abdominal cavity.

To prevent a new inguinal hernia from occurring at the same site (recurrence), parts of the large abdominal fascia (fascia transversalis) are then pulled over the hernial orifice. Afterwards the tensed fascia is double sutured and the inner inguinal ring is constricted in this way. A further advantage of this procedure is the fact that the posterior wall of the inguinal canal is tightened and strengthened during the operation.

Recurrences are very rarely observed after using this surgical method. Another inguinal hernia operation, which is used relatively frequently nowadays, is the so-called Lichtenstein procedure. In this operation, an approximately 6 cm long skin incision is made directly above the inguinal hernia.

Through this surgical access, the hernia sac and its contents can be immediately transferred back into the abdominal cavity. In contrast to the operation according to Shouldice, however, the hernial orifice is closed by the insertion of a plastic mesh in this procedure. The recurrence rate is also very low with this operation.

However, the disadvantage of the surgical hernia correction according to Lichtenstein is the fact that foreign material is introduced into the body with the plastic mesh. The so-called surgical procedure according to Rutkow is also one of the most common surgical correction methods in the presence of a hernia.In this operation the skin incision is much smaller than in the methods just described. Also in the hernia operation according to Rutkow, the surgeon makes the incision directly above the hernia sac.

In addition, this procedure also involves the weak point in the area of the abdominal wall being reinforced by foreign material. Depending on the extent of the hernia, the surgeon chooses a plastic umbrella or a small net. In addition, a painful inguinal hernia can also be treated by means of a laparoscopy from the inside (so-called “keyhole surgery”, for example: method according to Meyer).

In these minimally invasive procedures, a small skin incision is made inside or just below the navel. Subsequently, carbon dioxide is introduced into the abdomen and the surgical field is examined with an optical device (light source and small camera). In addition, two further small skin incisions must be made in the right and left groin region.

Each of these incisions is usually no larger than about 10 mm and for this reason is hardly visible after the wound has healed. Through the accesses in the right and left groin region, the required surgical devices can be introduced during the operation. During the actual operation, the peritoneum in the area of the inguinal hernia is opened from the inside, the hernia sac is pushed back into the abdominal cavity and the peritoneum is closed again.

In this procedure, too, the weak point is secured with a small plastic net, thus effectively preventing recurrences. Depending on the chosen procedure and the severity of the inguinal hernia, the pure surgery time (without induction and discharge of anesthesia) is between 20 minutes and half an hour. In most cases, the hernia operation is performed under general anesthesia, but it is also possible to perform the surgical procedure under local anesthesia.

In general, inguinal hernias are not always operated on. A closure of the hernia is not possible without surgery. However, there are cases where surgery does not really seem to be appropriate.

In very old people or patients who can no longer be operated due to their health condition, the hernia is treated conservatively. For this purpose a so-called hernia band is used. The hernia band resembles a kind of corsage.

It is a leather belt with a metal plate, which is placed on the hernia sac. This metal plate is intended to force the contents of the hernia sac back into the abdominal cavity and stabilize the unstable abdominal wall. A healing of the hernia cannot be achieved in this way.

However, there is a risk of entrapment of the intestines. In men, testicular atrophy (tissue loss) can occur. In general, the constant pressure can cause so-called skin ulcerations (skin defects), which can ultimately cause the hernia to break through the skin.

It is therefore obvious that a hernia band can sometimes cause great damage. Therefore it is no longer used for general therapy. As already mentioned, it is only used for patients who can no longer be operated on to relieve their symptoms.