Inguinal Hernia

Question 1

What is an inguinal hernia?

Answer 1

A protrusion of abdominal contents into the inguinal canal

Most common hernia

Mostly in men

Question 2

Types/classification

Answer 2

Direct

Indirect

Question 3

Direct hernia

Answer 3

Adulthood

Commonly due to chronic straining/coughing

Arises medially to inferior epigastric artery and protrudes through the posterior wall of the inguinal canal

Question 4

Indirect hernia

Answer 4

Congenital and always in childhood

Arises laterally to inferior epigastric artery and protrudes into the deep inguinal ring

Caused by a patent vaginal process after birth

Question 5

Behaviors of inguinal hernias

Answer 5

Reducible: contents may be fully restored(pushed back) to the abdominal cavity
Incarcerated: part of/all the contents cannot be reduced
Strangulated: incarcerated and the blood supply can get compromised, may or may not lead to infarction

Question 6

Form of inguinal hernias

Answer 6

Inguinoscrotal: descends via the inguinal canal into the scrotum(often the end stage of indirect hernia)

Sliding (en-glissade): sac is partly formed by the retro peritoneal tissue of the iliac fossa

Pantaloon: both direct and indirect hernia descending on either side of the inferior epigastric artery

Question 7

Clinical presentations

Answer 7

Indirect - often narrow necked, and if it’s small it can be reduced by applying pressure to the site of origin (deep inguinal ring). Tends to descend via the inguinal canal toward the top of the scrotum

Direct - often wide necked and difficult to control. When applying pressure to deep inguinal ring, it tends to protrude directly anteriorly and making the inguinal skin crease more apparent

Question 8

Diagnosis

Answer 8

Based on clinical presentation

If difficult to diagnose, there are investigations that can help
CT
Herniography. - rare and uses contrast injection

Question 9

Treatment

Answer 9

Needs surgery! - highly symptomatic, narrow-necked, bowel obstruction

May need surgery - cosmetic hernias, moderately symptomatic, interferes with work/leisure

Question 10

Is a groin truss helpful

Answer 10

Not very beneficial as symptomatic treatment for non-surgical hernias

Question 11

Repair in children

Answer 11

Only involves excision of the sac and plication(folding) the deep inguinal ring, since the inguinal canal is usually not weak

Question 12

Repair in adults

Answer 12

May be performed by open surgery: for open mesh repair, LIchtenstein hernioplasty should be adopted
- recurrence rate drops to about 1% but due to open technique, chronic pain and testicular atrophy remain the problem

Endoscopic technique of mesh repair - either laparoscopic transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) - are the best available options for the patient(low recurrence and higher quality of life)

No straining or heavy lifting for 2 weeks