Snapshot
- A 35-year-old man presents to the general surgeon’s office with pain in his right groin. He recently noticed a bulge in this region after performing heavy weight lifting at the gym. The pain and bulge comes and goes sporadically and he thinks it is associated with his workouts. He denies any change in bowel or bladder function.
Overview
Introduction
- Clinical definition
- a protrusion of peritoneum through an opening or weakness into another body cavity
- Increased risk with structural weakness or increased intra-abdominal pressure
- Classification based on the anatomy of Hesselbach’s triangle
- borders
- lateral – inferior epigastric artery
- medial – lateral border of rectus abdominis
- inferior – inguinal ligament
- borders
- Types
- indirect inguinal
- travels the entire length of the inguinal canal following descent path of the testes
- enters internal inguinal ring lateral to inferior epigastric artery and exits external inguinal ring
- may enter scrotum
- most commonly seen in male infants
- due to patent processus vaginalis
- peritoneal connection between inguinal canal and tunica vaginalis
- due to patent processus vaginalis
- travels the entire length of the inguinal canal following descent path of the testes
- direct inguinal
- bulges through the inguinal (Hesselbach’s) triangle
- medial to inferior epigastric artery
- covered only by external spermatic fascia
- most commonly in older men
- bulges through the inguinal (Hesselbach’s) triangle
- femoral
- protrudes below inguinal ligament through femoral canal
- lateral to pubic tubercle
- more common in women
- protrudes below inguinal ligament through femoral canal
- umbilical
- most commonly in adults
- associated with pregnancy, ascites, and obesity
- most commonly in adults
- incisional
- indirect inguinal
- occurs at previous surgical sites
Treatment
- Indirect and direct inguinal hernia
- surgical placement of mesh over Hesselbach’s triangle/inguinal canal and reinforce abdominal wall
- Femoral
- surgical joining of Cooper’s ligament to transversalis fascia
- Incisional
- associated with previous incision through the fascia
- goal is to achieve primary fascial closure with mesh reinforcement
- number of different repairs are possible including mesh underlay, inlay, overlay or bridging repairs
Prognosis, Prevention, and Complications
- Incarceration and strangulation
- seen in all hernia types where hernia contents get stuck within the defect
- the larger the hernia defect the smaller risk of incarceration
- femoral hernia has greatest risk
- Post-herniorrhaphy neuropathy