Surgical Repair of Groin Hernias
A groin hernia is not a "rupture" per se, but rather a groin bulge or mass that develops due to weakened layers of the abdominal wall and protrusion of intra-abdominal contents through the defect. Numerous classification systems for groin hernias have been described, but none have gained universal acceptance. The traditional classification system includes direct, indirect, and femoral hernias. Direct inguinal hernias develop when the posterior portion of the inguinal canal attenuates, allowing the underlying contents of the abdominal cavity to protrude. An indirect inguinal hernia occurs along the spermatic cord or round ligament in the inguinal canal. A femoral hernia passes behind the inguinal canal and herniates alongside of the femoral vessels.
Symptoms and Diagnosis
More difficult to diagnose is the occasional patient with groin pain, or inguinodynia, but no history of groin bulge and no physical findings. Such a patient may not have a hernia, but rather a groin muscle strain. In contrast, if a hernia is not found on physical examination, but the patient describes a groin bulge, a hernia is still possible. Femoral hernias can present as pain in the upper thigh rather than a bulge, and are particularly difficult to diagnose in the elderly or obese patient. Ultrasound or axial imaging may be useful in delineating the abnormality. Although these rarer hernias occur mostly in elderly women, the most common type of groin hernia seen in this patient population is still the indirect inguinal hernia.
Most groin hernias are readily reducible, have minimal or no tenderness, and can be electively referred to a surgeon within a period of weeks. However, if the hernia is tender and not reducible, the patient should be referred immediately due to the risk of strangulated bowel or other viscera. Aggressive attempts to reduce a groin hernia with sedation, ice packs, or sustained weight or pressure should not be pursued. Symptoms such as nausea and vomiting suggest bowel obstruction, which also mandate immediate referral to a surgeon.
Inguinal hernias should be repaired surgically. Hernia belts or trusses should be discouraged, and should be limited to patients who are not candidates for an elective operation. Chronic scarring from their use can lead to a more difficult repair and higher risks of complications. Femoral hernias should always be repaired because of the high incidence of associated bowel herniation. Elderly patients with minor co-morbid conditions will easily tolerate an outpatient elective hernia repair, which can be accomplished with intravenous sedation and local anesthesia. All attempts should be made to avoid emergent repairs of chronically incarcerated hernias, which occur primarily in the elderly. The timing of repair is determined by the symptoms.
The objective of any inguinal or femoral hernia operation is to repair the defect in the abdominal wall. The three basic approaches are: (1) open repair (the traditional repair, utilizing the patient's own tissue); (2) open tension-free repair (in which mesh is used to bridge or cover the defect); and (3) laparoscopic repair, a tension-free repair also utilizing mesh. In general, the traditional, tissue-based repairs have been replaced by tension-free or mesh-based repairs. These include the Lichtenstein, Plug and Patch, laparoscopic, and “hybrid” techniques. No particular technique has been found to be superior, and all of them can be expected to result in excellent outcomes when performed by adequately trained surgeons with sufficient experience in their performance. Open techniques of hernia repair may be safely performed under local, regional, or general anesthesia with equivalent outcomes, while laparoscopic hernia repair requires general anesthesia.
Some selected hernias can be treated nonoperatively with careful observation. Suitable hernias for nonoperative management are direct hernias with a wide neck that easily reduce particularly in elderly asymptomatic patients or patients at a heightened risk for operative intervention.
Qualifications for performing inguinal and femoral hernia repairs
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Keywords - patient, guideline, groin hernia, inguinal hernia, femoral hernia, open repair, tension-free repair, laparoscopic repair, recurrence, groin pain, complications, mesh, incarcerated