Abdominal Wall: Groin Hernias

Inguinal Hernias

Types

  • Indirect Inguinal Hernia
    • Most Common Inguinal Hernia
    • Through Processus Vaginalis
      • Sac Anterior/Medial to Cord Structures
    • Lateral to Inferior Epigastrics Mn
  • Direct Inguinal Hernia
    • Through Hasselbach’s Triangle
      • From Weakness in the Transversalis Fascia
    • Medial to Inferior Epigastrics Mn
    • Lower Risk of Incarceration, Higher Recurrence
  • Pantaloon Hernia
    • Both Direct & Indirect Components Mn

Asymptomatic Prognosis

  • Low-Risk of Incarceration (0.3% at 2 Years)
  • High-Risk of Developing Symptoms in Future (68-80% in 10 Years)

Treatment

  • Asymptomatic or Minimal Symptoms: Conservative
  • Symptomatic: Repair (Open vs Minimally Invasive)
  • Necrotic Bowel: Open Repair & Small Bowel Resection
    • Avoid Permanent Mesh with Bowel Necrosis – Historically Did a Tissue Repair but Now Able to Use Absorbable/Biologic Mesh

Open vs Laparoscopic Comparison

  • Similar Recurrence
  • Laparoscopic Benefits:
    • Faster Return to Function
    • Less Pain After Inguinal Hernias (No Difference After Ventral Hernias)
  • Open Benefits:
    • Shorter Operative Time
    • Can Possibly Avoid General Anesthesia if Severe Comorbidities

Indirect Inguinal Hernia 1

Direct Inguinal Hernia 2

Inguinal Hernia on CT

Femoral Hernia

Basics

  • Definition: Hernia Through the Femoral Canal
  • More Common in Women, Inguinal Hernia Still Most Common Overall
  • Highest Risk of Strangulation (40% Present Emergently)

Treatment

  • Tx: Repair All (Open or Laparoscopic)
    • Open Procedure: McVay & Divide Inguinal Ligament (To Reduce Bowel)

Obturator Hernia

Basics

  • Definition: Hernia Through Obturator Foramen
  • Sx: Nonspecific
  • Risk Factors:
    • 9x More Common in Women (Wider Pelvis)
    • Multiparous
    • Elderly
    • *Nicknamed “Little Old Lady’s Hernia”
  • Howship-Romberg Sign: Medial Thigh Pain with Extension & Internal Rotation

Treatment

  • Tx: Repair All
    • Laparoscopic TAPP Repair Preferred
    • If Unable to Reduce: Incise Obturator Membrane

Athletic Pubalgia (Sports Hernia/Core Muscle Injury)

Basics

  • Definition: Chronic Groin Pain (> 6-8 Weeks) without Mass in the Setting of Frequent Athletic/Strenuous Activity
  • From Chronic-Repetitive Trauma/Stress to the Groin
  • Most Common in High-Intensity Sports – Rugby, Football, Hockey & Soccer
    • Can Occur Even in Low-Intensity Activity

Causes

  • Muscle Tears
  • Impingement
  • Compartment Syndrome
  • Inflammation
  • *Incipient Hernia May Play a Role – Not Entirely Understood

Treatment

  • Initial: Rest & Physical Therapy
    • Consider NSAIDs or Steroid Injections
    • Will Relieve Most Cases
  • If Fails: Surgical Repair
    • Explore & Reinforce the Wall (Similar to Inguinal Herniorrhaphy)

Mnemonics

Inguinal Hernia Relationship to Epigastric Vessels

  • “M.D.s don’t LIe”
  • Medial to Epigastrics – Direct
  • Lateral to Epigastrics – Indirect

Pantaloon Hernia

  • Pantaloon – Think “Pant” Legs Going Down Both Sides

References

  1. Carter J, Duh QY. Laparoscopic repair of inguinal hernias. World J Surg. 2011 Jul;35(7):1519-25. (License: CC BY-ND-4.0)
  2. Wikimedia Commons (License: CC BY-NC-SA-3.0)