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Inguinal Hernia

Inguinal Hernia



What is a soft tissue hernia?

A soft tissue hernia is a protrusion in an area of the abdomen. It occurs in places where, for anatomical reasons, gaps in the abdomen exist, as for instance in the groin, at the navel, at the edge of straight strains of abdominal muscles, or at lesions as they occur after abdominal surgery around scars in the abdominal wall. The bulb is caused by an intestinal protrusion, which is enclosed by a hernial sac. It protrudes through a weak spot in the muscles, the hernial gap, and it presses from the abdominal cavity against the abdominal wall. The most frequent place of protrusion in the male body is located in the groin, where the spermatic duct and the vessels, necessary for the blood supply of the testicles, pass within the internal inguinal ring through the abdominal wall into the inguinal canal. With women, the round ligament of uterus passes at the corresponding place from the abdominal cavity into the inguinal canal, and it extends from the uterus to the symphysis. Along there, soft tissue hernias may also occur. In a hernial sac, parts of the intestines could be enclosed as e.g. tips of the greater omentum or parts of the large or small bowel. Without treatment, these ruptures may reach grotesque sizes and look like a second belly in the abdomen.

There are various kinds of soft tissue hernias. The most frequent ones are the inguinal and the femoral hernia. In the following text, the inguinal hernia will be described more specifically.




Inguinal hernia as an especially frequent soft tissue hernia

The medical term for rupture of the groin is inguinal hernia (lat. inguina = groin). Like every soft tissue hernia, the inguinal hernia consists of a protrusion being visible outside the abdominal wall, the hernial sac, its content, and a hernial gap. There are two types of inguinal hernia, which can only be exactly identified during the operation: The more frequent one is called "indirect" and the rarer one is called "direct". The indirect one follows the existing anatomical gaps in the groin, i.e. it follows the spermatic cord that consists of the spermatic duct, the vessels supplying the testicles, and an exomysium. It then leaves the abdominal cavity through the internal inguinal ring (invisible), follows the inguinal canal and leaves through the external inguinal ring (palpable). As soon as it protrudes from the external abdominal ring, it becomes visible and palpable. The direct inguinal hernia protrudes directly through a spot, where the muscles of the abdomen behind the inguinal canal are weak, and may then extend as far as to the external abdominal ring. The difference can only be recognized during the operation. It is important to make this distinction as each of the two types of inguinal hernia needs a special kind of operation. However, the complaints and examinations are the same for both the direct and the indirect inguinal hernia.

The inguinal hernia is above all a male complaint. It affects especially young and sporting men of a delicate figure, but also men who do hard physical work. The reason for the ailment is the stress exerted by great pressure in the abdominal cavity. Pressing during hard work, chronic coughing of smokers, strong pressing in case of prostatauxe as well as a tumour of the colon may be the reasons. Besides, a hernia only rarely occurs due to an accident. Yet once occurred, an inguinal hernia cannot regress. In the course of time, it will enlarge and cause increasing pain. The content of the hernial sac may get incarcerated in the hernial gap and lead to a stoppage of the blood supply. Without treatment, the blood vessels may be blocked and the tissue may necrose.




How do I recognize an inguinal hernia?

"I can say with pride that I am a sporting man. I frequently go in for jogging and regularly for intensive sports. Lately, after jogging, I have had increasing and tearing pains in my right groin. While moving or coughing, the pain intensified. Some days ago, I noticed a small swelling that was as big as a nut in this area and that was painful when I touched it. Now, the pain draws also into the scrotum and along the inside of the thigh. I go to the doctor because I now feel alarmed."

This story was told by one of my patients, and it is quite typical. As a rule, the patients first notice some tearing pain in the groin. Later, they notice a newly occurred protrusion there, but sometimes, the protrusion also forms without pain. It occurs frequently while coughing, laughing, pressing, going in for sports or carrying heavy weights. In the course of time, increasing pain during daily chores may result. Especially endangered are those patients who professionally have to carry heavy loads or who exercise a lot of sports. The protrusion may initially be visible and then disappear again. But normally, it will continually increase until it really becomes a nuisance. If the content of the hernial sac (tips of the greater omentum, bowel) gets jammed, it results in permanent pain at the place of protrusion with some radiation into the scrotum. This is followed by a swelling, reddening, and very intensive pain. The protrusion cannot be pushed back by the doctor any longer. An emergency operation becomes necessary.

On principle, every abnormal protrusion in the groin should be medically examined. As long as no jamming of the hernia occurs, there is no need for an immediate operation. Should the doctor diagnose an inguinal hernia, one can wait without problem for some weeks until the intervention is made.

A different kind of soft tissue hernia can easily be overlooked - the femoral hernia. It is rare and it is found at the inside of the thigh, directly below the groin. It emerges through a gap left open in the lower abdominal wall, which allows the big artery of the leg and the corresponding vein to pass from the leg into the abdominal cavity.




How is an inguinal hernia clarified?

The medical interrogation is especially directed to the kind, duration, and place of the pain. It is important to know whether the patient himself has noticed a protrusion in the groin or not. It is further important to know whether he suffers from a chronic lung disease with an intensive cough, from problems with the release of urine, or from severe constipation. Generally, the clarification is simple and consists of an inspection of the groin and a palpitation of the area. It is necessary to examine both groins while the patient is in a standing as well as in a lying position. Often, the finding is clearly visible if the hernia protrudes as far as into the scrotum. Additional examinations are rarely necessary. In the case of male patients, the doctor uses his forefinger for the examination. The skin of the scrotum is partly pushed against the inguinal canal with the fingertip. Through the skin, it reaches the external inguinal ring. Its size, form, diameter, and pain caused by the examination are important indicators. The protrusion of the hernia, the hernial sac, can thus often be felt. Sometimes, the hernia only becomes apparent when the patient presses or coughs, and often, only its tip becomes palpable when it touches the fingertip while the patient coughs. This is called a positive cough impact. Further, it has to be considered whether the testicles are of the same size and whether they are in the correct position in the scrotum. Additional technical or radiological examinations are normally not necessary for experienced surgeons. If a male patient is over 40 years old, a rectal examination should be made in order to find out whether the prostrate is possibly enlarged.

Women do not have an external abdominal ring. A gap in the internal abdominal ring is not palpable as it is situated below the tight external fascia of the belly. Below, it also extends the round ligament of the uterus from the internal inguinal ring to the symphysis. If the findings in relation to a female patient are not clear enough, an ultrasound examination of the groin should be made. The ultrasound can show the different layers of the inguinal canal and also a possible gap.




How can an inguinal hernia be treated?

Principally, all diagnosed and painful hernias should be surgically treated. As soft tissue hernias cannot naturally regress, they get bigger in the course of time. If a safe diagnosis of a hernia has been made and the patient is in an operable condition, surgery is indicated. Depending on the intensity of the complaints, the date of the operation can be fixed. Only if patients are in an inoperable condition or if they refuse to be operated upon, the use of a truss should be tried. A truss is actually a very cumbersome device. It consists of a padded elastic metal clasp, which is applied around the hip, and a small leather ball, which exerts pressure against the hernial gap. As inguinal hernias can be easily operated under general anaesthesia, epidural block, or local anaesthesia, the truss has more or less come out of use today.

Nowadays, different surgical techniques are used, depending on the diagnosis of the hernia. There are open and minimally invasive methods as well as methods with or without the use of plastic nets.




Open Surgical Interventions

The two most important methods of today's open surgical intervention are the Shouldice technique (named after the Shouldice Clinic in Canada) and the transversal plastic, the technique introduced by Liechtenstein, in which a plastic net is implanted. By means of a transversal incision in the groin, the skin and the subcutaneous fat tissue are split. After dissecting the external abdominal ring, the surgeon splits the fascia and the funicle (comprising the vessels of the testicles, the spermatic cord, and the exomysium) is exposed. An indirect hernial sac is separated from the funicle. It is ablated at its place of entrance into the abdominal cavity and then sutured. A direct hernial sac is simply pushed back into the abdominal cavity. The most important step now is to split the so-called transverse fascia (a tense, flat band located in front of the abdominal membrane) and to suture it to the inguinal ligament with a running suture. The diameter of the internal abdominal ring must be left very small in the process, but big enough that the blood-supply of the testicles is not impaired. With women, the same procedure is employed, but the broad ligament of uterus is joined into the suture. After closing the outer fascia and the subcutaneous fat tissue, the skin is sutured.

In the method according to Liechtenstein, a small plastic net (made of polyethylene) is implanted. It is placed over the hernial gap and fixed to the inguinal ligament as well to the abdominal muscles in such a way that the gap is closed without exerting any tension. With men, a small passage must also be left for the passage of the spermatic chord.




Minimally Invasive Surgery

Minimally invasive surgery can be carried out by using different techniques. Most often used is a method, in which, behind the fascia of the abdominal wall but in front of the muscles of the abdomen, the soft tissue hernia can be closed without opening the abdominal membrane. Through a small incision below the navel, a trocar is pushed between the fascia of the abdominal wall and in front of the muscles of the abdomen. It is connected to a laparoscopic pump blowing CO2 gas into the layer of tissue, forcing it apart. Through the first trocar, a fiberoptic camera is inserted, and a first survey is made. The next step is to install two more trocars right and left in the lower abdomen, through which the tools, small forceps, can be inserted. With the forceps, the hernial sac is pulled back behind the inguinal ring. After a careful preparation of the hernial gap, a sufficiently large plastic net is spread over it and fixed with two clamps.




Which operation is suitable for me?

This question cannot be generally answered. Today, surgeons have a large choice of techniques at their disposal for the operation of hernia. According to the studies available today, it cannot be finally decided which of the methods is best. But one can be quite sure that the appropriate method will be used, depending on the diagnosis and on the patient. One should also consider with which method your surgeon has made the best experience. Generally, it might be safe to assume that in case of recurrence after open surgery, the implantation of a net seems to be more indicated. For an operation of both sides, a minimally invasive method seems to be preferable.

Your surgeon will certainly be ready to explain the advantages or disadvantages of the method proposed for your individual case. For open operations, with or without net, either local anaesthesia, epidural block, or general anaesthesia is used. Minimally invasive operations are only possible under general anaesthesia.




What happens after the treatment?

The patients can already get up from bed and eat shortly after the operation. Analgesics are administered to fight pain as well as decongestive medicine. Some patients prefer an ambulant operation; others want to stay a few days in hospital. On the day of the operation and due to the introduction of gas, a swelling of the scrotum or the lips of pudendum may occur and last for a few days.

Problems after these operations are rare. Infections of the wound and haemorrhagia may occur, but both of them can easily be treated. Very rarely, more serious problems occur: the spermatic duct, the vessels of the testicles, or nerves in the groin can be damaged or irritated by a natural formation of scars. If nerves in the area of the operation are bruised or cut, it may lead to a passing disturbance of sensitivity in the thigh or in the groin. If the vessels of the testicles are damaged, it may lead to a shrinking of the testicles in 1% of the cases. If this occurs on both sides, the generative capability might be impaired. Passing disturbances of sensitivity may occur around the wound and on the skin of the thigh. Infections around the net or its shifting, accompanied by a penetration into the spermatic duct or the bladder, are also quite rare. The danger of a reoccurrence of a hernia is at about 2-4%.




What are the necessary precautions for the time after an operation?

The carrying of loads heavier than 3 kg should be avoided for six weeks after an open operation. Unfitness for work therefore varies from a few days to six weeks. After two months, the healing is complete and there are no further restrictions.




History

Soft tissue hernias were already known in old Egypt. As early as about 3'500 years ago, an old papyrus described the frequent soft tissue hernias. Because of the resulting protrusions which increase in the course of time, the old Greek called them "Hernios", which means something like "bud". The medical term today is therefore still hernia. In ancient days, the soft tissue hernias could only be treated with pressure bandages. In the Middle Ages, hernias were operated upon by so-called groin-cutters during the fairs. The protrusion was removed, and the bowel was pushed back into the abdominal cavity, without narcosis or concern about sterility. The consequences for the pitiable patients were terrible. Most of them already died during the operation or within a few days because of peritonitis. And the few, who survived the operation, suffered again from the protrusion because the rupture had not been sutured.

As late as 1890, Edoardo Bassini (1844-1924) introduced a surgical technique at the Royal University of Padua, in which the back part of the inguinal canal was tightly sutured. Until a few years ago, this technique was looked upon as being the standard in the whole world. It was only during the last decades that improvements of this technique as well as new methods were developed. Since 1883, Bassini was at the same time professor of Pathological Anatomy and Surgery at the University Hospital of Padua and devoted years working upon the problems of hernia which, at that time, could not be treated successfully. In 1890, he published a report about 262 operations (with his new method) in the Archive of Clinical Surgery. The Bassini method was then already a modern and safe method, which had been successfully used for about 100 years.

It was only during the last decades and years that new methods have been developed. A very successful variant of the Bassini method was developed and successfully introduced in the Shouldice Clinic in Canada . This was followed by entirely new surgical methods developed by the surgeon Liechtenstein, in which plastic nets are sewed over the gap into the tissue. If minimally invasive methods are used, these nets are placed behind the muscular system and in front of the abdominal cavity. So today, there are some quite different surgical methods available for a safe treatment of inguinal hernia.