What is an Inguinal Hernia?

1Blausen Inguinal HerniaInguinal hernia is the protrusion of abdominal contents through a defect in the abdominal wall in the lower part of the abdomen called inguinal region or groin. There are several types and sometimes they might extent all the way to the scrotum in men.

Why does it occur?

The testis develops in the abdomen and later descends to the scrotum. The blood vessels to the testis, the spermatic cord which is the tube for passage of semen etc. pass through an opening in the abdominal wall called the inguinal canal. This is a weak spot in the abdominal wall and sometimes the original passage that should have closed at birth might not close at all. Any condition that increases the pressure inside the abdomen could push the abdominal contents through this weak area and cause the hernia.

How common is the hernia?

It is estimated that 15% of the adults could have inguinal hernia [1] and this is due to the alteration of the ratio of type 1 and type 2 collagen tissue [2]. The implication is that in some races like the Africans the incidence of hernia is very high. In men, the incidence rises from 11 per 10,000 person-years, aged 16-24 years, to 200 per 10,000 person-years, aged 75 years or above [3]. It affects about 3% of children and the man to women ratio is about 8 to 1.

What is the inguinal canal?

People have two inguinal canals, which is a passage through the lower abdomen wall – one on each side. In males: the spermatic cords pass through the inguinal canals and then connect to the testicles in the scrotum (the sac around the testicles). The spermatic cords contain: blood vessels, nerves, and spermatic duct which that carries sperm from the testicles to the penis. In females: the round ligaments which support the uterus, passes through the inguinal canals.

What causes inguinal hernia?

Once the type of inguinal hernia is diagnosed then the cause can be determined. Indirect inguinal hernias will be a defect in the abdominal wall that is present at birth. As mentioned earlier during the development of the fetus in the womb, the lining of the abdominal cavity forms and extends into the inguinal canal. In males: the spermatic cord and testicles descend out from inside the abdomen and through the abdominal lining to the scrotum through the inguinal canal. A few weeks before or after birth, the abdominal lining usually closes off the entrance to the inguinal canal. In females: the ovaries do not descend out from inside the abdomen, and a couple months before birth, the abdominal lining usually closes.

Sometimes the lining of the abdomen does not close, leaving an opening in the abdominal wall at the upper part of the inguinal canal. Part of the small intestine or fat can slide into the inguinal canal through this opening, which will cause a hernia. In females: the ovaries can also slide into the inguinal canal and cause a hernia.

Indirect hernias are the most common type of inguinal hernia in children. 2 to 3 percent of male children can have an indirect inguinal hernia. It’s less than 1 percent for female children.

1Direct_inguinal_herniaDirect inguinal hernias usually occur in male adults due to aging and stress or strain that weaken the abdominal muscles around the inguinal canal. Weaken abdominal muscles can also be from a previous surgery in the lower abdomen. In females, the broad ligament of the uterus acts as an additional barrier behind the muscle layer of the lower abdominal wall. The broad ligament of the uterus is a sheet of tissue which supports the uterus and other reproductive organs. Hence this type of hernia is uncommon in them.

What are the predisposing causes for hernia?

The following groups of people are more prone to developing inguinal hernia:

  • Premature infants have higher chances as they do not have sufficient time for the normal process
  • People who have family history have more chances of having hernia because as mentioned earlier the type of collagen ratio is altered
  • People of certain races have higher chances for the same reason as above
  • People who have chronic stress on the lower abdomen have higher chances and the stress could be due to
    • Chronic cough and asthma
    • Bladder outflow obstruction [Prostate disorders or strictures or narrowing]
    • Fluid or tumours or any swelling in the abdomen [including normal ones like pregnancy]
    • People who smoke have a higher incidence

What are the signs and symptoms of inguinal hernia?

The first sign is a small bulge on one or on both sides (which is rare) of the groin. Location of the hernia would be in the area just above the groin crease between the lower abdomen and the thigh. The bulge may increase in size over time and it will usually disappear when lying down.

Other signs and symptoms can include:

  • Discomfort or pain in the groin—when straining, lifting, coughing, or exercising. The discomfort or pain improves when resting.
  • Having feelings such as weakness, heaviness, burning, or aching in the groin.
  • A swollen or an enlarged scrotum in men or boys.
  • Indirect and direct inguinal hernias can slide in and out of the abdomen into the inguinal canal.

Why should the hernia be treated?

In addition to the pain and discomfort that the hernia causes, the treatment of hernia is essential to prevent the complications that can occur. For example:

1incarcerated Inquinal herniaAn incarcerated hernia is when a part of the fat or small intestine from inside the abdomen becomes stuck in the groin or scrotum and it cannot go back into the abdomen.

When an incarcerated hernia is not treated, the blood supply to the small intestine can become obstructed, which causes the “strangulation” of the small intestine. The lack of blood supply makes this an emergency situation. This can cause the section of the intestine to die.

This is a serious condition that needs immediate surgical treatment. Hence if any of the following are present seek immediate help:

  • Extreme tenderness or painful redness in the groin area
  • Sudden pain that worsens quickly and does not go away
  • The inability to have a bowel movement and to pass gas
  • Nausea and vomiting
  • Fever

How is the inguinal hernia diagnosed?

Examination by the doctor [surgeon] is sufficient to diagnose the hernia especially if it comes out easily. Sometimes coughing, squatting and straining are required to clearly see the hernia. Several clinical tests are available to the doctor to determine the type of hernia and whether it is complicated or not.

Is there any role for non operative treatment for hernia?

Small direct hernia with a wide opening in an old man with other complicating diseases need not have any surgical treatment as the chances of complications with such hernia might be much more than the chances of complications with surgery and anesthesia.

However treatment methods like the use of a Hernia belt or Truss are not recommended as they are not effective and complications are more common in those using these as compared to those not using these [4]. They also make the repair more difficult.

What are the types of available surgeries for hernia repair?

In children extensive repair is not necessary and simply the closure of the hernia sac called high flush ligation is sufficient. This is a simple operation that could be carried out either by open or laparoscopic surgical techniques.

1Right_Inguinal_HerniaIn adults some sort of repair is required in addition and the current consensus is that a mesh should be used to reinforce the weak tissues in all patients since 1984 [5]. Since it is the abdominal pressure that pushes the hernia through the opening placing the mesh inside the abdomen is theoretically better and this is possible with laparoscopic surgery. However, laparoscopic surgery for hernia is an advanced surgical procedure and requires lot of skill and expensive equipment it is not available in many places and hence the open surgeries with mesh [onlay mesh] are used at most places in the world.

What is the best option for hernia repair in rural areas?

1Light_Mesh_Graft_by_TEP_OperationThe laparoscopic surgery for hernia has several advantages. It is minimally invasive and the recovery is quick. Also it has the theoretical advantage of having the mesh from inside and the abdominal pressure keeps the mesh in place and prevents hernia from recurring. All these are good for the rural areas. However highly skilled surgeons and expensive equipment are necessary in rural areas and these are not easily available or affordable. The option of gas less laparoscopic surgery offers the best option for patients who are not obese.

Are there any complications of hernia surgery?

The Surgery is quite safe and complications are uncommon to repair an inguinal hernia. However as with any surgical procedure there can be complications:

  • Risk of general anesthesia: Before the surgery, the anesthesiologist, this is a doctor who administers anesthesia, reviews the risks of anesthesia with the patient and asks about medical history and any allergies to medications. Complications will most likely occur in older people and those with other types of medical conditions. Common complications include: nausea, vomiting, urinary retention, sore throat, and headache. More serious problems can include: heart attack, stroke, pneumonia, and blood clots in the legs. To help reduce the risk of complications such as pneumonia and blood clots, as soon as the doctor allows, you should get out of bed after surgery and get moving.
  • Hernia recurrence: A hernia can recur up to several years after repair. Recurrence is the most common complication of inguinal hernia repair, causing patients to have a second operation. Hernia recurrence occurs less often when a hernioplasty [repair with mesh] is performed.
  • Bleeding: Bleeding inside the incision can be a complication of the inguinal hernia repair. It can cause severe swelling and bluish discoloration of the skin around the incision. Surgery may be needed to open the incision and to stop the bleeding. Bleeding is unusual and occurs in less than 2 % of patients that undergo a hernia operation.
  • Wound infection: The risk of wound infection is small, less than 2 %, and has a higher chance to occur in older adults or people who undergo more complex hernia repair surgery. The person may experience a fever, discharge from the incision, and redness, swelling, or tenderness around the incision. A postoperative infection requires antibiotics and may need another procedure that requires local anesthesia to make a small opening in the incision to drain the infection.
  • Painful scar: Sometimes people can experience sharp, tingling pain in a specific area near the incision after it has healed. With time the pain will usually stop but if it continues, medicine can be injected in the area to help. Injury to internal organs: Although extremely rare, injury to the intestine, bladder, kidneys, nerves and blood vessels leading to the legs, internal female organs, and vas deferens (the tube that carries sperm) can occur during a hernia surgery. If injury to other organs does happen then future operations will be needed.

What are the options available at SEESHA centers?

The SEESHA surgical camps, especially at the Bethesda Hospital in Aizawl in Mizoram, offer all the possible treatment mentioned so far. The surgical treatment is also available at: the Karunya community hospital, ICC hospital at Coimbatore, the Sielmat hospital at Churachandpur and the Family health clinic at Dimpur.

Laparoscopic surgery is carried out through the most modern and safe procedure of single incision gas less laparoscopic surgery. With only a small incision at the level of the umbilicus there is hardly any scar tissue visible. It can be carried out in rural areas with spinal anesthesia.

Gnanaraj-64 Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

Image: Inguinal Hernia. Author: BruceBlaus. 11 February 2014. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Blausen_0560_InguinalHernia.png

Image: 1. Direct hernia, 2. Epigastric vessels. Author: Anpol42. 23 April 2003. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Direct_inguinal_hernia.jpg

Image: An incarcerated inguinal hernia as seen on CT. Author: James Heilman, MD. 2 June 2011. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Inquinalhernia.png

Image: Surgical operation for repair of right inguinal hernia. Author: haitham alfalah. 2010-02-28. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Right_Inguinal_Hernia.JPG

Image: Light Mesh Graft is lying in praeperitoneal Space. Laparoscopic veiw by laparoscopicHernia Operation TEP. Author: Anpol42. 30 January 2004. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Light_Mesh_Graft_by_TEP_Operation.JPG

References (click to show/hide)

  1. Awad SS, Fagan SP. Current approaches to inguinal hernia repair. Am J Surg. 2004 Dec. 188(6A Suppl):9S-16S.
  2. Hosgor M, Karaca I, Ozer E, Suzek D, Ulukus C, Ozdamar A. Do alterations in collagen synthesis play an etiologic role in childhood inguinoscrotal pathologies: an immunohistochemical study. J Pediatr Surg. 2004 Jul. 39(7):1024-9
  3. Jenkins JT, O'Dwyer PJ; Inguinal hernias. BMJ. 2008 Feb 2;336(7638):269-72
  4. Available from: https://en.wikipedia.org/wiki/Inguinal_hernia [Reference 14]
  5. Woods B, Neumayer L. Open repair of inguinal hernia: an evidence-based review. Surg Clin North Am. 2008 Feb. 88(1):139-55