Inguinal Hernia Repair

Published on 11/04/2015 by admin

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CHAPTER 4 Inguinal Hernia Repair

Demetri J. Merianos, Steven E. Raper

Case Study

A 29-year-old male presents to his primary care physician’s office complaining of a bulge in his right groin, which he first noticed 2 weeks earlier. He denies associated pain, nausea, or vomiting. He denies a history of constipation, difficulty with urination, or chronic cough. He recently began a rigorous exercise program involving heavy lifting. Physical examination shows a nontender, reducible right groin mass that protrudes into the right scrotum when the patient coughs.

BACKGROUND

A hernia is defined as the protrusion of any structure beyond its normal anatomic boundaries. In the case of an inguinal hernia, a peritoneum-lined sac containing abdominal organs (e.g., small intestine or omentum) protrudes through a defect in the inguinal region of the abdominal wall. When a hernia can be replaced within the abdominal wall musculature, it is described as reducible; when it cannot, it is described as incarcerated. Strangulation, which is caused by compromise of the blood supply to the contents of an incarcerated hernia, is the most serious complication of an untreated hernia.

Inguinal hernias are further characterized as either indirect or direct. Indirect inguinal hernias enter the inguinal canal through the deep inguinal ring lateral to the inferior epigastric vessels and may communicate with the scrotum. Direct inguinal hernias protrude directly through the floor of the inguinal canal medial to the inferior epigastric vessels through a space known as Hesselbach’s triangle. The term pantaloon hernia describes concomitant direct and indirect hernias. Indirect inguinal hernias are the most common type in both male and female patients and are believed to result from persistent patency of the processus vaginalis. Factors that result in elevation of intra-abdominal pressure (e.g., lifting, straining with urination or defecation, ascites, chronic cough) may contribute to the development of both indirect and direct inguinal hernias.

The processus vaginalis is an outpouching of the peritoneum through which the testicle descends into the scrotum during development.

Hesselbach’s triangle is the space bounded by the lateral border of the rectus abdominis medially, the inguinal ligament inferiorly, and the inferior epigastric vessels laterally. Direct inguinal hernias protrude through this space.

Approximately 700,000 inguinal hernia repairs are performed annually, making this one of the most common surgical procedures. Historically, surgeons repaired inguinal hernias by directly approximating tissues to reinforce the area of abdominal wall weakness. Over the course of the last two decades, the “tension-free” repair, using prosthetic mesh to repair the hernia defect, has emerged as the preferred technique. More recently, a variety of laparoscopic approaches have gained popularity. The open (anterior) mesh repair is the primary focus of this chapter, but several other approaches are briefly described.

INDICATIONS FOR INGUINAL HERNIA REPAIR

I. Reducible Hernias: Traditionally, the presence of an inguinal hernia constituted an indication for its repair. Two major arguments were made in favor of this approach: (1) over time, hernias tend to enlarge and become symptomatic; and (2) the seriousness of complications associated with untreated hernias, namely, incarceration and strangulation, justifies the risks associated with surgical repair. Although many surgeons continue to subscribe to this approach, a role for expectant management of asymptomatic inguinal hernias has emerged, particularly in high-risk patients. Low- to moderate-risk patients are generally offered the option of hernia repair.

II. Incarcerated Hernias: Edema of the contents of a hernia, or formation of adhesions to the peritoneum-lined hernia sac, may result in incarceration. Incarceration of a bowel-containing hernia may result in intestinal obstruction and, if left untreated, strangulation and bowel necrosis. Incarceration of a hernia that contains only one sidewall of the bowel may progress to strangulation without signs of obstruction; such hernias are known as Richter’s hernias. Acutely incarcerated hernias require immediate operative repair. Strangulated, nonviable bowel requires resection at the time of surgery. In contrast, in the absence of pain or obstructive symptoms (e.g., nausea and vomiting), chronically incarcerated hernias may be repaired electively (Fig. 4-1).

Figure 4-1 Algorithm for the management of reducible versus incarcerated inguinal hernias.

ACUTE INCARCERATION OF A HERNIA GENERALLY MANDATES URGENT OPERATIVE REPAIR TO PREVENT STRANGULATION.

PREOPERATIVE EVALUATION

A thorough history and physical examination are nearly always sufficient to make the diagnosis of an inguinal hernia.

I. History: Important components of the history include the chronicity of a hernia and the presence of associated symptoms. Additionally, an attempt should be made to elicit a history of straining from constipation, urinary obstruction, or chronic cough; these symptoms sometimes reflect underlying comorbidities necessitating additional evaluation (e.g., colonoscopy or urologic evaluation).

II. Physical Examination: Physical examination is performed with the patient supine and standing. The examiner generally places one hand over the inguinal ligament and, if the patient is male, palpates the superficial inguinal ring through the scrotal skin with the other hand. The patient is asked to cough or perform a Valsalva maneuver. Appreciation of a bulge moving from lateral to medial against the examiner’s finger suggests an indirect inguinal hernia; a mass that protrudes directly through the abdominal wall suggests a direct hernia. Bilateral examination should be performed to rule out a contralateral hernia. In appropriate patients, a digital rectal examination should be performed to exclude enlargement of the prostate or a rectal mass.

What predisposing factors may have contributed to hernia formation in your patient?

III. Imaging. In rare cases, the diagnosis of a hernia may be aided by ultrasound or cross-sectional imaging (e.g., computed tomography scan or magnetic resonance imaging).

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