Inguinal Hernia Shohreh Toutounchi Reference Schwartz Principles of

Inguinal Hernia Shohreh Toutounchi Reference: Schwartz Principles of Surgery 2010 Internship: 1391

Anatomy � The inguinal canal is 4 -6 cm long. � The inguinal canal starts in the abdomen from the point that the spermatic cord crosses the internal/deep inguinal ring in the transversalis fascia (in women the Round ligament). � This canal finally ends in the external/surface inguinal ring at the level of the abdominal muscles where the spermatic cord passes from the aponeurosis of the external oblique muscle.

Epidemiology � About 75% of all hernias happen in the inguinal region. � 90% of them are in men and 10% in women. � 70% of femoral hernia repairs occur in women (although the prevalence of inguinal hernia in women is 5 times that of femoral hernia. � The most common inguinal hernia in women and in men is the indirect inguinal hernia. � The prevalence of hernia in men has two peak ages: Under one and above 40.

Epidemiology � About 1/3 of the patients who present with hernia, also develop a contralateral hernia. � Hernia in the right side is more common. � In the laparascopic repair of the hernia, the diagnosis of contralateral hernia can be made. � Femoral hernia in the elderly and in those who had a previous hernia repair is more common. � The prevalence of inguinal hernia increases with age (especially in men). � Inguinal hernia in adults is mainly from an acquired weakness in the abdominal wall (the most important one is a defect in the abdominal muscle).

Etiology � Inguinal hernia has two etiologies: A) Congenital B) Acquired A) Congenital Hernia: i. Congenital hernia consists most of the cases of pediatric hernias ii. In the descent of the testes from the abdomen to the scrotom in the third trimester, a part of the perituneum descends with it which is called the process vaginalis. i. In the weeks 36 -40 of gestation this process vaginalis closes. i. Lack of closure of process vaginalis results in a patent process vaginalis which is a reason for the high prevalence of inguinal hernia in the preterm neonates. i. A lot of the process vaginalises close in a few months after birth and its patency does not necessarily mean that a hernia will be formed.

Etiology B) Acquired Hernia: It seems that most cases of hernia come from an acquired defect in the abdominal wall and the reason for its formation is multifactorial: 1 - Strenuous physical activity can be a factor but it is not known whether the hernia is just from physical activity or in the setting of a patent process vaginalis. 2 - A positive family history which can increase its incidence 8 times. 3 - COPD increases the direct hernia risk. 4 - Collagen deficiency associated diseases like collagen type I deficiency relative to type III. 5 - An association exists between aneurisms and hernias. Being overweight is to some extent protective (maybe it is from the more difficult diagnosis of hernia)

Symptoms � The symptoms are variable from a hernia with no symptoms to one with stangulation. � Asymptomatic hernia is either found in physical exam, or the patient himself realizes the bulging, or it is found during laparascopy. � Symptomatic patients mostly present with inquinal pain. � Sometimes patients present with symptoms outside the inguinal region such as a change in bowel habits, and/or urinary symptoms (in the form of sliding hernia).

Symptoms � With pressure on the nearby nerves, hernia can cause different symptoms such as a general feeling of pressure, localized pain, and referred pain. � The feeling of pressure and weight on the inguinal region especially after a daily activity is common. � Important Point: A sharp pain indicates nerve entrapment and does not have anything to do with physical activity. � Important Point: Neurogenic pains may refer to the scrotom or inside thigh. � Important Point: A change in bowel habits or in the urinary symptoms can indicate involvement of the bladder inside the hernial sac.

Symptoms � Important Point: Pain in the inguinal region without bulging is usually not due to a hernia. � Important Point: The duration and the way the symptoms progress is important � Usually the patient can reduce the hernia but the bigger the hernia, the less likely it is to reduce. � The possibility of the incarceration of the hernia at the beginning of the progress of hernia, for example during the first year , is more likely. � The possibility of incarceration is neonates is more likely than in adults.

Physical Exam � The history is usually indicative of hernia but the physical exam is also an important part of the evaluation. � The examination in obese patients is difficult. � It is best that the patient is examined in an upright position so that the inguinal region and the scrotum is completely exposed.

Physical Exam � A) First we look to see the bulging. If we do not have a bulging, we place a finger inside the scrotum and raise it toward the external ring, and ask the patient to cough or do the Valsalva maneuver until the hernial contents fall. The valsalva maneuver causes an unusual bulging and it is possible to realize if this bulging can be reduced or not. � B) We examine the contralateral side and compare the two sides to each other. The extent of bulging on the two sides can be a criteria for the diagnosis of hernia on one or both sides.

Physical Exam � The differentiation between a direct and an indirect inguinal hernia in the physical exam: There are different techniques for differentiating a direct from an indirect hernia in physical exam. - If the finger is inside the inguinal canal and the patient exerts pressure or coughs and the hernia comes in contact with the tip of the finger it is a direct hernia. - If with closure of the internal ring with the finger while the patient strains (coughs) the hernial sac does not bulge out the hernia is an indirect one, and if the hernial sac bulges the hernia is a direct one.

Physical Exam Important Point: the examination of the femoral hernia is difficult. This hernia presents under the inguinal ligament and the presence of too much or too little fat in the inguinal region cause an error in the diagnosis. (Femoral Psuedohernia) Therefore even the presence of a smallest bulging under the inguinal ligament has to raise the suspicion for a femoral hernia.

Differential Diagnosis 1 -Malignancy: Lypoma, metastasis, testicular tumory 2 -Testeicular primary conditions : Varicocele, Epididimitis, Testicular torsion, Hydrocele, Ectopic testes, undescended testes 3 - Aneurism or pseudoaneurism of the femoral artery 4 - Lymphadenopathy 5 - Sebacious cyst 6 - Hydroadenitis 7 - Nuck canal cyst (in women) 8 - Varices 9 -Psoas Abcess 10 - Hematoma 11 - Ascites

Diagnosis � The diagnosis is based on history, physical exam and sometimes imaging. Imaging in hernia: � In some conditions physical exam cannot diagnose the hernia: 1 - Overwieght individuals 2 - Recurrent hernia 3 - Hernias that are not found in the physical exam In these conditions imaging is important

Diagnosis � The most common radiologic conditions include sonography, CT, MRI, and each has its own pros. and cons. 1 -Sonography: It is inexpensive and does not have radiation. Important Point: In underweight individuals the movement of the posterior wall and spermatic cord toward the anterior wall of the abdomen can have false positive results (the false positive results of the sonography is more than in the phyisical exam and MRI)

Diagnosis 2 - CT scan: Although it gives more information but the routine use of it is not recommended. Important Point: In one determined evaluation among the imaging techniques, MRI was more truthful, and an accurate physical exam was more truthful than sonography.

Treatment � The final treatment of inguinal hernia is surgery. � Now using a mesh herniorhaphy, hernia repair takes place. � Mesh herniorhaphy is the golden standard because less tension is produced and there is less recurrency. � Because of the very good results of mesh the initial tissue repair is not used any more. � Important Point: Laparascopic surgery is used in bilateral and recurrent conditions or when another surgery like prostate surgery has to take place at the same time. � Important Point: The laparascopic procedure is not different from the open surgery method in the recurrency rate. It has less post-op complications and a sooner return to work. Intestinal obstruction and ileus is seen more often after a laparascopic procedure.

Treatment � Contraindications of laparascopy: 1 - A previous surgery in the area (a surgery that the surgeon entered the abdomen such as prostatectomy) 2 -Primary medical condition Important Point: In recurrent cases, dissection in the scar tissue should not be made (due to inability in exactly differentiating the anatomic parts. Important point: In the treatment of hernia surgery is necessary, since with a conservative method, the wall defect is not removed but has the tendency to enlarge and cause incarceration.

Treatment � Indications of conservative surgery: 1 -Bad coexisting medical condition 2 -A small asymptomatic hernia 3 -An elderly person who is asymptomatic Important Point: Conservative treatment is not used in femoral hernia.

Anesthesia Method � Anterior surgery can be done with, local, regional, or general anesthesia. � Laparascopic surgery has to be done with general anesthesia. � Local anesthesia: Lidocaine, Marcaine with or without epinephrine. � Important Point: The use of epinephrine in people with coronary problems is contraindicated. � Important Point: Before incision or prep inguinal nerve has to be blocked. � Epidural anesthesia is also a proper method.

Emergency Surgery � Incarceration, Sliding, Strangulation Emergencies. �Incarcerated Hernia: Hernia that cannot be reduced for a long time. Three reasons for incarceration 1 - Enlargement of the contents of the hernia 2 - Adhesion of sac contents to the canal wall 3 - Narrow neck of the sac Important Point: Indication for urgent surgery is when the intestines are under pressure and the patient has symptoms of bowel obstruction either in incarceration or in a sliding hernia.

Emergency Surgery Treatment: 1 -Simple Reduction 2 -Taxis 3 -Surgery �Sliding Hernia: In this condition one side of the intestinal wall is trapped but the lumen is not closed. However with the progress of edema, the lumen closes and sometimes in this kind of hernia, the bladder is entrapped.

Emergency Surgery �Strangulated Hernia: NO TAXIS 1 -Fever 2 -Leukocytosis 3 - Hemodynamic instability 4 - Tender and warm hernia contents 5 - Erythema in hernial sac Important Point: Before surgery Antibiotics, and NG Tube Serum and electrolytes, IV

Recurrence � Depends on: 1 -Patient condition: Nutrient deficiency, Immune deficiency, Diabetes, Steroid use, Smoking 2 -Surgical Technique: Inexperienced surgeon, Not fixing the mesh, a Small mesh 3 -Tissue: Infection, Tension, Ischemia To reduce recurrence use a mesh

Diagnosis of Recurrence � Bulging � Important Point: Can have no bulging or mass and still suspect recurrence Sonography, CT, or MRI � DDX of hernia recurrence: 1 -Cord lipoma 2 -Seroma 3 -Weakness of external oblique muscle 4 -Cough

Complications of Hernia Surgery 1 -Pain 2 -Spermatic Cord Damage and Ischemic Orchitis 3 -Vas deferans cut 4 -Wound infection 5 -Seroma 6 -Urinary Retention

Sportsman’s Hernia �Occult hernia, pubic pain in sportsmen, sportsmen’s hernia Due to repetitive movement in lower extremity such as skiing, hockey, or American football, usually hernia is not found in physical exam other than the time of surgery. � Symptoms: Acute or chronic pain that gets worse with movement, coughing or sneezing and can reduce the sportsman’s function. In the physical exam no bulging or evidence of hernia is seen and pain and tenderness in the inguinal canal and the external ring is present. � Diagnosis: Best choice is MRI. � Treatment: Conservative, if after 6 -8 weeks fails inguinal canal repair. surgery

Pediatric Hernia � Prevalence in children 0. 8 -44 % and in 10% bilateral. � Prevalence of hernia is higher in, premature and LBW and on the right side. � Hernia is more likely indirect in children. � Diagnosis: Made by observation and during crying. � DDx: UDT, Testicular Tumor, Hydrocele, Varicocele � Treatment: to some extent emergency even if with no symptoms. In premature neonates inguinal hernia repair before hospital discharge. � Surgery Herniotomy (Cut in the inguinal area) � Important Point: Method of exploring the opposite side is somewhat controversial. Now laparascopy is mostly used. But sonography has also been used.