is Inguinal Hernia?
hernia repair, also known as
herniorrhaphy, is the surgical
correction of an inguinal hernia.
An inguinal hernia is an opening,
weakness, or bulge in the lining
tissue (peritoneum) of the abdominal
wall in the groin area between
the abdomen and the thigh.
surgery may be a standard open procedure
through an incision large enough to access
the hernia or a laparoscopic procedure performed
through tiny incisions, using an instrument
with a camera attached (laparoscope) and
a video monitor to guide the repair. When
the surgery involves reinforcing the weakened
area with steel mesh, the repair is called
Inguinal hernia repair is performed to close
or mend the weakened abdominal wall of an
The majority of hernias occur in males.
Nearly 25% of men and only 2% of women in
the United States will develop inguinal
hernias. Inguinal hernias occur nearly three
times more often in African American adults
than in Caucasians. Among children, the
risk of groin hernia is greater in premature
infants or those of low birth weight. Indirect
inguinal hernias will occur in 10–20 children
in every 1,000 live births.
About 75% of all hernias are classified
as inguinal hernias, which are the most
common type of hernia occurring in men and
women as a result of the activities of normal
living and aging. Because humans stand upright,
there is a greater downward force on the
lower abdomen, increasing pressure on the
less muscled and naturally weaker tissues
of the groin area. Inguinal hernias do not
include those caused by a cut (incision)
in the abdominal wall (incisional hernia).
According to the National Center for Health
Statistics, about 700,000 inguinal hernias
are repaired annually in the United States.
The inguinal hernia is usually seen or felt
first as a tender and sometimes painful
lump in the upper groin where the inguinal
canal passes through the abdominal wall.
The inguinal canal is the normal route by
which testes descend into the scrotum in
the male fetus, which is one reason these
hernias occur more frequently in men.
are divided into two categories: congenital
(from birth), also called indirect hernias,
and acquired, also called direct hernias.
Among the 75% of hernias classified as inguinal
hernias, 50% are indirect or congenital
hernias, occurring when the inguinal canal
entrance fails to close normally before
birth. The indirect inguinal hernia pushes
down from the abdomen and through the inguinal
canal. This condition is found in 2% of
all adult males and in 1–2% of male children.
Indirect inguinal hernias can occur in women,
too, when abdominal pressure pushes folds
of genital tissue into the inquinal canal
opening. In fact, women will more likely
have an indirect inguinal hernia than direct.
Direct or acquired inguinal hernias occur
when part of the large intestine protrudes
through a weakened area of muscles in the
groin. The weakening results from a variety
of factors encountered in the wear and tear
hernias may occur on one side of the groin
or both sides at the same or different times,
but occur most often on the right side.
About 60% of hernias found in children,
for example, will be on the right side,
about 30% on the left, and 10% on both sides.
The muscular weak spots develop because
of pressure on the abdominal muscles in
the groin area occurring during normal activities
such as lifting, coughing, straining during
urination or bowel movements, pregnancy,
or excessive weight gain. Internal organs
such as the intestines may then push through
this weak spot, causing a bulge of tissue.
A congenital indirect inguinal hernia may
be diagnosed in infancy, childhood, or later
in adulthood, influenced by the same causes
as direct hernia. There is evidence that
a tendency for inguinal hernia may be inherited.
direct and an indirect inguinal hernia may
occur at the same time; this combined hernia
is called a pantaloon hernia.
femoral hernia is another type of hernia
that appears in the groin, occurring when
abdominal organs and tissue press through
the femoral ring (passageway where the major
femoral artery and vein extend from the
leg into the abdomen) into the upper thigh.
About 3% of all hernias are femoral, and
84% of all femoral hernias occur in women.
These are not inquinal hernias, but they
can sometimes confuse the diagnosis of inguinal
hernias because they curve over the inguinal
area. They are more often accompanied by
intestinal obstruction than inguinal hernias.
inguinal hernias do not heal on their own
and can become larger or twisted, which
may close off the intestines, the prevailing
medical opinion is that hernias must be
treated surgically when they cause pain
or limit activity. Protruding intestines
can sometimes be pushed back temporarily
into the abdominal cavity, or an external
support (truss) may be worn to hold the
area in place until surgery can be performed.
Sometimes, other medical conditions complicate
the presence of a hernia by adding constant
abdominal pressure. These conditions, including
chronic coughing, constipation, fluid retention,
or urinary obstruction, must be treated
simultaneously to reduce abdominal pressure
and the recurrence of hernias after repair.
A relationship between smoking and hernia
development has also been shown. Groin hernias
occur more frequently in smokers than nonsmokers,
especially in women. A hernia may become
incarcerated, which means that it is trapped
in place and cannot slip back into the abdomen.
This causes bowel obstruction, which may
require the removal of affected parts of
the intestines (bowel resection) as well
as hernia repair. If the herniated intestine
becomes twisted, blood supply to the intestines
may be cut off (intestinal ischemia) and
the hernia is said to be strangulated, a
condition causing severe pain and requiring
In open inguinal hernia repair procedures,
the patient is typically given a light general
anesthesia of short duration. Local or regional
anesthetics may be given to some patients.
Open surgical repair of an indirect hernia
begins with sterilizing and draping the
inguinal area of the abdomen just above
the thigh. An incision is made in the abdominal
wall and fatty tissue removed to expose
the inguinal canal and define the outer
margins of the hole or weakness in the muscle.
The weakened section of tissue is dissected
(cut and removed) and the inguinal canal
opening is sutured closed (primary closure),
making sure that no abdominal organ tissue
is within the sutured area. The exposed
inguinal canal is examined for any other
trouble spots that may need reinforcement.
Closing the underlayers of tissue (subcutaneous
tissue) with fine sutures and the outer
skin with staples completes the procedure.
A sterile dressing is then applied.
open repair of a direct hernia begins just
as the repair of an indirect hernia, with
an incision made in the same location above
the thigh, just large enough to allow visualization
of the hernia. The surgeon will look for
and palpate (touch) the bulging area of
the hernia and will reduce it by placing
sutures in the fat layer of the abdominal
wall. The hernial sac itself will be closed,
as in the repair of the indirect hernia,
by using a series of sutures from one end
of the weakened hernia defect to the other.
The repair will be checked for sturdiness
and for any tension on the new sutures.
The subcutaneous tissue and skin will be
closed and a sterile dressing applied.
procedures are conducted using general anesthesia.
The surgeon will make three tiny incisions
in the abdominal wall of the groin area
and inflate the abdomen with carbon dioxide
to expand the surgical area. A laparoscope,
which is a tube-like fiber-optic instrument
with a small video camera attached to its
tip, will be inserted in one incision and
surgical instruments inserted in the other
incisions. The surgeon will view the movement
of the instruments on a video monitor, as
the hernia is pushed back into place and
the hernial sac is repaired with surgical
sutures or staples. Laparoscopic surgery
is believed to produce less postoperative
pain and a quicker recovery time. The risk
of infection is also reduced because of
the small incisions required in laparoscopic
use of surgical (prosthetic) steel mesh
or polypropylene mesh in the repair of inguinal
hernias has been shown to help prevent recurrent
hernias. Instead of the tension that develops
between sutures and the skin in a conventionally
repaired area, hernioplasty using mesh patches
has been shown to virtually eliminate tension.
The procedure is often performed in an outpatient
facility with local anesthesia and patients
can walk away the same day, with little
restrictions in activity. Tension-free repair
is also quick and easy to perform using
the laparoscopic method, although general
anesthesia is usually used. In either open
or laparoscopic procedures, the mesh is
placed so that it overlaps the healthy skin
around the hernia opening and then is sutured
into place with fine silk. Rather than pulling
the hole closed as in conventional repair,
the mesh makes a bridge over the hole and
as normal healing take place, the mesh is
incorporated into normal tissue without
Reviewing the patient's symptoms and medical
history are the first steps in diagnosing
a hernia. The surgeon will ask when the
patient first noticed a lump or bulge in
the groin area, whether or not it has grown
larger, and how much pain the patient is
experiencing. The doctor will palpate the
area, looking for any abnormal bulging or
mass, and may ask the patient to cough or
strain in order to see and feel the hernia
more easily. This may be all that is needed
to diagnose an inguinal hernia. To confirm
the presence of the hernia, an ultrasound
examination may be performed. The ultrasound
scan will allow the doctor to visualize
the hernia and to make sure that the bulge
is not another type of abdominal mass such
as a tumor or enlarged lymph gland. It is
not usually possible to determine whether
the hernia is direct or indirect until surgery
Patients will have standard preoperative
blood and urine tests, an electrocardiogram,
and a chest x ray to make sure that the
heart, lungs, and major organ systems are
functioning well. A week or so before surgery,
medications may be discontinued, especially
aspirin or anticoagulant (blood-thinning)
drugs. Starting the night before surgery,
patients must not eat or drink anything.
Once in the hospital, a tube may be placed
into a vein in the arm (intravenous line)
to deliver fluid and medication during surgery.
A sedative may be given to relax the patient.
The hernia repair site must be kept clean
and any sign of swelling or redness reported
to the surgeon. Patients should also report
a fever, and men should report any pain
or swelling of the testicles. The surgeon
may remove the outer sutures in a follow-up
visit about a week after surgery. Activities
may be limited to non-strenuous movement
for up to two weeks, depending on the type
of surgery performed and whether or not
the surgery is the first hernia repair.
To allow proper healing of muscle tissue,
hernia repair patients should avoid heavy
lifting for six to eight weeks after surgery.
The postoperative activities of patients
undergoing repeat procedures may be even
of indirect hernias, which are congenital,
is not possible. However, preventing direct
hernias and reducing the risk of recurrence
of direct and indirect hernias can be accomplished
body weight suitable for age and height
strengthening abdominal muscles through
reducing abdominal pressure by avoiding
constipation and the build-up of excess
body fluids, achieved by adopting a high-fiber,
lifting heavy objects in a safe, low-stress
way, using arm and leg muscles
Hernia surgery is considered to be a relatively
safe procedure, although complication rates
range from 1–26%, most in the 7–12% range.
This means that about 10% of the 700,000
inguinal hernia repairs each year will have
complications. Certain specialized clinics
report markedly fewer complications, often
related to whether open or laparoscopic
technique is used. One of the greatest risks
of inquinal hernia repair is that the hernia
will recur. Unfortunately, 10–15% of hernias
may develop again at the same site in adults,
representing about 100,000 recurrences annually.
The risk of recurrence in children is only
about 1%. Recurrent hernias can present
a serious problem because incarceration
and strangulation are more likely and because
additional surgical repair is more difficult
than the first surgery. When the first hernia
repair breaks down, the surgeon must work
around scar tissue as well as the recurrent
hernia. Incisional hernias, which are hernias
that occur at the site of a prior surgery,
present the same circumstance of combined
scar tissue and hernia and even greater
risk of recurrence. Each time a repair is
performed, the surgery is less likely to
be successful. Recurrence and infection
rates for mesh repairs have been shown in
some studies to be lower than with conventional
that can occur during surgery include injury
to the spermatic cord structure; injuries
to veins or arteries, causing hemorrhage;
severing or entrapping nerves, which can
cause paralysis; injuries to the bladder
or bowel; reactions to anesthesia; and systemic
complications such as cardiac arrythmias,
cardiac arrest, or death. Postoperative
complications include infection of the surgical
incision (less in laparoscopy); the formation
of blood clots at the site that can travel
to other parts of the body; pulmonary (lung)
problems; and urinary retention or urinary
Inguinal hernia repair is usually effective,
depending on the size of the hernia, how
much time has gone by between its first
appearance and the corrective surgery, and
the underlying condition of the patient.
Most first-time hernia repair procedures
will be one-day surgeries, in which the
patient will go home the same day or in
24 hours. Only the most challenging cases
will require an overnight stay. Recovery
times will vary, depending on the type of
surgery performed. Patients undergoing open
surgery will experience little discomfort
and will resume normal activities within
one to two weeks. Laparoscopy patients will
be able to enjoy normal activities within
one or two days, returning to a normal work
routine and lifestyle within four to seven
days, with the exception of heavy lifting
and contact sports.
and mortality rates
Mortality related to inguinal hernia repair
or postoperative complications is unlikely,
but with advanced age or severe underlying
conditions, deaths do occur. Recurrence
is a notable complication and is associated
with increased morbidity, with recurrence
rates for indirect hernias from less than
1–7% and 4–10% for direct.
If a hernia is not surgically repaired,
an incarcerated or strangulated hernia can
result, sometimes involving life-threatening
bowel obstruction or ischemia.
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