Inguinal Hernia

A hernia occurs when part or all of a viscus protrudes from a normal location in the body. Most hernias are protrusions of part of the abdominal viscus through the abdominal wall. Although many kinds of abdominal hernias are possible, inguinal hernias are most common.

In an inguinal hernia, the large or small intestine, omentum, or bladder protrudes into the inguinal canal. Hernias can be reducible (if the hernia can be manipulated back into place with relative ease by the contents being pushed back into the abdominal cavity), incarcerated (if the hernia can't be reduced because adhesions have formed in the hernial sac), or strangulated (part of the herniated intestine becomes twisted or edematous, seriously interfering with normal blood flow and peristalsis and possibly leading to intestinal obstruction and necrosis).

Causes

A hernia can develop in the first few months after the baby is born because of a weakness in the muscles of the abdomen.

As a male fetus grows and matures during pregnancy, the testicles develop in the abdomen and then move down into the scrotum through an area called the inguinal canal. Shortly after the baby is born, the inguinal canal closes, preventing the testicles from moving back into the abdomen. If this area does not close off completely, a loop of intestine can move into the inguinal canal through the weakened area of the lower abdominal wall and cause a hernia.

Although girls do not have testicles, they do have an inguinal canal, so they can develop hernias in this area as well.

Signs and symptoms

Inguinal hernia usually causes a lump over the herniated area when the patient stands or strains. The lump disappears when the patient is supine. Tension on the herniated contents may cause a sharp, steady pain in the groin, which fades when the hernia is reduced.

CLINICAL TIP

The patient complains of a dull ache or bulge in the groin area. Initial herniation may be noted as a short period of burning sensation when straining.

Strangulation produces severe pain and may lead to partial or complete bowel obstruction and even intestinal necrosis. Partial bowel obstruction may cause anorexia, vomiting, pain and tenderness in the groin, an irreducible mass, and diminished bowel sounds. Complete obstruction may cause shock, high fever, absent bowel sounds, and bloody stools. In an infant, an inguinal hernia often coexists with an undescended testis or a hydrocele.

Diagnosis

In a patient with a large hernia, physical examination reveals an obvious swelling or lump in the inguinal area. In the patient with a small hernia, the affected area may simply appear full. Palpation of the inguinal area while the patient is performing Valsalva's maneuver confirms the diagnosis.

To detect a hernia in a male patient, the patient is asked to stand with his ipsilateral leg slightly flexed and his weight resting on the other leg. The examiner inserts an index finger into the lower part of the scrotum and invaginates the scrotal skin so the finger advances through the external inguinal ring to the internal ring (about 1½ " to 2" [4 to 5 cm] through the inguinal canal). The patient is then told to cough. If the examiner feels pressure against the fingertip, an indirect hernia exists; if pressure is felt against the side of the finger, a direct hernia exists.

A patient history of sharp or "catching" pain when lifting or straining may help confirm the diagnosis. A suspected bowel obstruction requires X-rays and a white blood cell count (which may be elevated).

Treatment

If the hernia is reducible, the pain may be temporarily relieved by pushing the hernia back into place. A truss may keep the abdominal contents from protruding into the hernial sac, although it won't cure the hernia. This device is especially beneficial for an elderly or a debilitated patient for whom surgery is potentially hazardous.

Herniorrhaphy

Herniorrhaphy, the treatment of choice, returns the contents of the hernial sac to the abdominal cavity and closes the opening. It's commonly performed under local anesthestic as an outpatient procedure. Another effective surgical procedure is hernioplasty, which reinforces the weakened area with steel mesh, fascia, or wire. Complications can include urine retention, wound infection, hydrocele formation, and scrotal edema.

Bowel resection

A strangulated or necrotic hernia necessitates bowel resection. Rarely, an extensive resection may require temporary colostomy. In either case, resection lengthens postoperative recovery and requires antibiotics, parenteral fluids, and electrolyte replacements.

Prevention

• Use proper lifting techniques.
• Lose weight if you are overweight.
• Relieve or avoid constipation by eating plenty of fiber, drinking lots of fluid, going to the bathroom as soon as you have the urge, and exercising regularly.