Inguinal Hernia and Femoral Hernia
What is an Inguinal Hernia?
An inguinal hernia occurs when part of the abdominal cavity, sometimes fat or intestines, bulges through an opening in the groin muscles. This bulge sometimes stays limited to the groin or goes down to the scrotal area in men, depending on the type of inguinal hernia. Inguinal hernias account for approximately 75-80% of all hernias and they are most common in men. A hernia is called a “reducible hernia” when the bulge can be pushed back into the abdomen. An incarcerated or a “non-reducible hernia” occurs when the contents inside the hernia sac cannot be pushed back into their normal anatomic position inside the abdomen. Incarcerated hernias can sometimes become “strangulated” when the blood supply to the organs that are entrapped (intestines or fat or other organs) becomes compromised and the tissue dies. This is a surgical emergency and is one of the reasons why hernias should be fixed in the first place in order to prevent this type of complication.
What is a Femoral Hernia?
A femoral hernia is a bulge that appears in the groin, sometimes upper thigh or near the "labia" (skin folds at the vaginal opening). They are more common in females (10 times more common in females but they do occur in males as well) and have a high risk of becoming strangulated. They should always be repaired surgically. Femoral hernias are often hard to distinguish from inguinal hernias on physical examination, but they typically occur lower in the groin near the inner thigh. In general, they are treated surgically the same way as inguinal hernias. Many times, a Femoral Hernia can occur at the same time of an Inguinal Hernia and they are often overlooked at surgery using 'conventional' repair techniques.
Symptoms of an Inguinal Hernia
The most common signs and symptoms of an inguinal hernia are pain in the groin or scrotum (in men) associated with a bulge. This bulge can increase in size with coughing, straining, pushing, heavy lifting or any maneuver that increases the intra-abdominal pressure. When the hernia is strangulated, sharp pain, redness of the surrounding skin, nausea, vomiting and intestinal obstruction can occur.
Diagnosis of an Inguinal Hernia
Most inguinal hernias are diagnosed on physical examination by an experienced physician or Hernia specialist. Sometimes with non-palpable hernias or in the obese patient additional tests are indicated to help in the diagnosis including groin ultrasound, CT scan of the abdomen and pelvis or MRI.
Treatment of Inguinal Hernias
Inguinal hernias can be repaired either via an open approach or a laparoscopic / robotic approach. With an open approach a small incision is made in the groin and the hernia is repaired either using a “tension-free” technique with the placement of a prosthesis or mesh or using a “suture” technique, where no mesh is placed and the muscles and tissues are sutured together in order to close the defect. For laparoscopic and robotic approaches, three small incisions are made in the abdomen (near the area of the umbilicus) through which long instruments are placed and the hernia is repaired with mesh.
Most open inguinal and femoral hernias can be fixed with local anesthesia and intravenous sedation. Sometimes general anesthesia is required depending on the patient’s conditions and the size of the hernia. For laparoscopic or robotic repair, general anesthesia is required.
10 Inguinal Hernia facts you should know
1.Worldwide, inguinal hernia repair is one of the most common surgeries, performed on more than 20 million people annually
2.Lifetime occurrence of groin hernia—intestines or fat tissue protrusions through the inguinal or femoral canal—is 27 to 43% in men and 3 to 6% in women
3.Inguinal hernias are almost always symptomatic. The only cure is surgery. A minority of patients are asymptomatic but even a watch-and-wait approach in this group results in surgery in approximately 70% within five years
4.Most inguinal hernias can be diagnosed with physical examination alone
5.When compared with general anesthesia, local anesthesia is associated with faster mobilization, earlier hospital discharge, lower hospital and total healthcare costs, and fewer complications such as urinary retention and early postoperative pain. However, when surgeons inexperienced in its use administer local anesthesia, more hernia recurrences might result.
6.One standard repair technique for all groin hernias does not exist but mesh repair is the first choice recommended approach
7.Mesh-based techniques compared to non-mesh techniques have a lower recurrence rate and an equal risk of post-operative pain
8.Since a generally accepted technique, suitable for all inguinal hernias, does not exist, it is recommended that surgeons provide both an open and a laparoscopic approach option
9.Physical activity restrictions are unnecessary after uncomplicated inguinal hernia repair and do not effect recurrence rates. Patients should be encouraged to resume normal activities as soon as possible
10.Discussions with patients about timing of hernia repair are recommended to involve attention to social environment, occupation and overall health
Source: World Guidelines for Groin Hernia Management / The HerniaSurge Group 2015
Incarcerated femoral hernia
Hernia surgery in The Middle Ages
What are the risks of groin hernia surgery?
1. Some pain lasting more than 6 months is reported in 7-12% of procedures. Severe pain is around 1-2% in adults after 6 months
2. In the United States, recurrence rate is reported around 1-3% with mesh repairs. Recurrence is more common with non-mesh repairs
3. Trouble urinating after surgery occurs in 0.5% of patients with local anesthesia and 2.5% with general anesthesia
4. Seromas or collections of clear yellow fluid can occur in 3-8% of surgeries
5. Wound infections can happen in around 0.5% with laparoscopic repairs and 2.5% with open surgeries
6. Testicular swelling and pain can occur in 0.8% of groin hernia surgery
7. Numbness in the groin or scrotum is reported around 5% of patients
8. Transient hematoma at the wound site or scrotum can occur around 5-10%. This usually resolves with time
NO MESH INGUINAL HERNIA SURGERY
At the Miami Hernia Center we also offer this proven technique for the repair of inguinal hernias without the use of mesh. It consists in sewing the muscle and fascias in the groin in four layers. It is usually done with intravenous sedation and local anesthetics.
The Shouldice repair is considered the "Gold Standard" for non-mesh repairs with very low recurrence rates demonstrated over the years. Thorough knowledge of inguinal anatomy and pathology is essential to achieving optimal results.