Inguinal (groin) hernia

 

Inguinal hernias are common, especially in men, but can also occur in females. An inguinal hernia is a hernia of the groin. In men it is a natural weak spot as this is where the spermatic cord (structures going to the testicle) goes through the abdominal wall. It travels through the inguinal canal, which is the space between the layers of the abdominal wall that have offset openings. A hernia happens here when these tissues weaken and the openings get dilated. This allows the lining of the abdomen to be pushed though the opening, creating a hernia sac. This hernia sac can contain fat from inside the abdomen, or intestine.

Hernias manifest usually as a bulge in the groin and sometimes with pain. In rare cases the hernia can become incarcerated (cannot be pushed back in), and can strangulate (restrict blood flow to) the contents. If that is intestine, it becomes an emergency. If you have a hernia that becomes painful and appears stuck out, lie down flat, relax and apply gentle steady pressure on the hernia. If you still cannot get it to reduce, then you should go to the ER. For reducible hernias, we generally recommend surgical repair, unless the patient has very serious and prohibitive medical problems. Although there have been some studies that have demonstrated the safety of observing asymptomatic hernias, in otherwise healthy patients, I don’t recommend it.

Hernias are treated by surgical repair of the defect. This is in most cases performed with the use of hernia mesh. While they lawyers on television have done a good job of scaring people about the use of mesh, it has been utilized for decades with low risks. In fact the use of mesh has resulted in much fewer hernia recurrences, and less post-operative pain and that has been well documented.

There are many variations of inguinal hernia repair, but generally break down into the open approach and the laparoscopic approach.

I use the laparoscopic approach in most cases, and while this can be hotly debated among surgeons, I have found that my patients that have a laparoscopic approach tend to have a faster recovery. A laparoscopic inguinal hernia repair involves multiple small incisions at, and below the level of the umbilicus. Long instruments and a camera are used to develop a space (the pre-peritoneal space) behind the abdominal wall. The hole (the hernia) is patched with mesh from the inside. I generally do not use any “tacks”, but use a mesh that has wide coverage of the defect. I learned this procedure in my fellowship from Dr Maurice Arregui, who pioneered laparoscopic inguinal hernia repair, and literally wrote the chapter on this in the most used surgical textbook (Cameron’s Current Surgical Therapy). This is an outpatient procedure, and while there is variability in recovery, I have had some patients back jogging in a week. Other advantages of the laparoscopic approach are; that the other side can be viewed and repair at the same setting, if an occult hernia is found, and if it is a recurrent hernia after a prior open repair, it avoids the scarred tissue from the prior repair. The disadvantage of the laparoscopic approach is that it does require general anesthesia.

I use the open approach when patients have had some prior lower abdominal surgical procedures, which likely scarred the planes that would need to be developed for the laparoscopic approach. I also may recommend it for those that may have difficulty tolerating general anesthesia, and the open approach can often be done with heavy sedation and local anesthesia, or with spinal anesthesia. The open approach involves making an incision in the groin, at the site of the hernia, and dissecting through the abdominal wall to reduce the hernia. Mesh is placed in the abdominal wall and wound closed over top. This is also an outpatient procedure. Again post-op pain is variable. With this procedure, I limit lifting heavy objects until 6 weeks post-op.

Operative risks of hernia repair, open or laparoscopic, include bleeding, infection, injury to the surrounding structures (intestines, bladder and testicle), DVT and cardiopulmonary risks of anesthesia (which are increased if you already have heart or lung disease).

Post-operative risks are prolonged pain, persistent symptoms, and recurrence.

These complications are all, thankfully quite uncommon.