Inguinal Hernia
Shirin Towfigh, MD, and Leigh Neumayer, MD, MS
OVERVIEW
Inguinal hernia repair remains the most common general surgical
procedure in the United States, with over 800,000 performed annually. It has a long history, and thus a wide variety of techniques have
been described. The goals of inguinal hernia repair, however, remain
the same for all techniques: to provide long-lasting, secure closure of
the pelvic floor defect, reduce pain, and improve quality of life. In
modern-day repair, recurrence after hernia repair has remained fairly
low. A concerning trend is the increase in chronic pain seen after
inguinal hernia repair. Though mesh implantation has been associated with this trend, most believe that chronic pain is a result of
surgical technique, difficulty with identification of hernia anatomy,
and other unknown patient factors. In this chapter, we review diagnosis of inguinal hernias among adults, common procedures for
inguinal hernia repair and their expected outcomes, and the issue of
chronic postinguinal herniorrhaphy pain.
DIAGNOSIS
Patients with inguinal hernias may present with complaints of a
painless bulge, pain in the groin without a bulge, or some variation
in between. It is very important to accurately document the preoperative symptoms and confirm that they are consistent with an inguinal hernia. Some patients may have other causes for their symptoms,
such as epididymitis, testicular pain, or endometriosis. Symptoms
from an inguinal hernia may include a burning or pinching sensation
in the groin. The pain may radiate into the scrotum, labia, or vagina,
down the leg, or around the back. They may have worsening pain
with prolonged sitting, prolonged standing, bending, coughing,
straining, getting out of a car, or toward the end of the day. Lying flat
almost always results in improvement of their symptoms. Women
may also report worse pain during their menses. Obstructive symptoms may include bloatedness, nausea, and vomiting.
Inguinal hernias are most commonly seen in men and are of the
indirect typethat is, the result of a patent processus vaginalis. These
hernias typically present with a bulge in the groin that may extend
into the scrotum or labia. A less common variant, an interstitial
hernia, dissects within the oblique muscle layers and presents with
an oblong bulge extending superolaterally. Direct hernias are a result
of weakness in the transversalis fascia and are more commonly seen
in older males. Femoral hernias are rare and typically seen in women,
as their pelvis is broad and the femoral space is wider. This compares
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532
Inguinal Hernia
Tissue Repair
The technique of nonmesh or tissue repair dates back to ancient
Egypt. Hundreds of techniques have been described since. Though
mesh repair has become the standard in the United States, tissue
repair remains the primary technique across the world and is growing
in its application in the United States due to the increased concern
with chronic pain. Tissue repair is considered to be superior to mesh
repair in terms of chronic pain, though most studies show that acute
postoperative pain and hernia recurrence are significantly worse
when mesh is not used. Tissue repair is indicated for patients at risk
for mesh infection, such as with a strangulated hernia requiring
bowel resection. Also, it should be considered for patients at higher
risk for chronic pain, such as women and those who present with a
history of chronic pain.
The type of tissue repair and its outcome is dependent on technique and surgeon experience. No single technique is considered to
be superior. The surgeon should be familiar with at least one or two
techniques and perfect them in order to have the best outcome. All
tissue repairs share a similar concept: closure of the defect and reinforcing the pelvic floor. A relaxing incision is often incorporated to
reduce the tension on the repair. Repairs are performed with permanent suture.
Mesh Repair
The gold standard in the United States involves implantation of
mesh. It has been shown to provide a secure repair with little or no
tension, as compared with tissue repair. Also, since most patients have
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533
H ERNI A
int. oblique
int. oblique
ext. oblique
ext. oblique
iliohypogastric
nerve
ilioinguinal nerve
ilioinguinal
nerve
iliohypogastric
nerve
spermatic cord
epigastric vessels
epigastric vessels
spermatic cord
stump of cremasteric
muscle
stump of cremasteric
muscle
flap of ext. oblique
(reflected back)
shelving border
of inguinal lig.
spermatic veins in
cord space of Bogros transversalis
fascia
(under trans. fascia)
spermatic
cord
transversalis
fascia
shelving border
of inguinal lig.
iliohypogastric
nerve
ext. oblique
ext. oblique
iliohypogastric
nerve
ilioinguinal nerve
ilioinguinal
nerve
spermatic cord
2nd line of repair
stump of
cremasteric muscle
spermatic cord
shelving
border of
inguinal lig.
spermatic
cord
1st line shelving border
of sutures of inguinal lig.
ext. oblique
ext. oblique
int. oblique
ilioinguinal nerve
ilioinguinal nerve
int. oblique
iliohypogastric
nerve
iliohypogastric
nerve
spermatic cord
4th line of
repair
2nd line of
repair
spermatic
cord
spermatic
flap of ext. oblique
cord
(reflected back)
FIGURE 2 Shouldice hernia repair. A, Splitting of the transversalis fascia from the internal ring to the pubic crest as far as desired. B, First
suture line continues to tack the lateral flap of transversalis fascia to the transversalis fascia lying medially beneath the rectus, transversus
abdominis, and internal oblique muscles. C, Reconstruction of the internal ring incorporating transversalis fascia and the proximal stump of
cremasteric muscle. D, Second suture line carrying the previously established medial flap of tissue to the curved or shelving edge of the
inguinal ligament. E, The undersurface of the external oblique close to inguinal ligament is now in this third line of sutures being tacked over the
internal oblique. F, The fourth line of sutures tacks more of the lower flap of the external oblique over the internal oblique. (From Shouldice EB:
The Shouldice repair for groin hernias, Surgical Clinics of North America 83:11631187, 2003.)
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534
Inguinal Hernia
intrinsically weak pelvic floor tissue or may have a wide defect with
absent tissue, the implant can augment the security of repair by
bolstering the muscles or bridging the defect. Hernia recurrence rates
using mesh implantation are typically under 5% nationally and are
reported by experts to be less than 1%. This compares to recurrence
after elective tissue repair, which may reach as high as 15% to 20%,
depending on the patient characteristics and surgical technique
performed. There are a multitude of hernia mesh biomaterials and
techniques that have been developed. Outcomes are variable and
dependent on surgeon technique and expertise. No single repair is
considered to be superior. For the best outcome, it is important that
the surgeon be informed about the risks and benefits of each implant
and to know the correct surgical technique recommended for the
chosen mesh biomaterial.
The onlay patch repair, reported by Lichtenstein and modified by
Amid, is one of the most commonly performed inguinal hernia
repairs with mesh. After the hernia sac and fat are reduced, flat mesh,
8 15cm or 3 6 inches, is sutured in running fashion starting
inferomedially at the anterior rectus fascia over the pubic tubercle
and continuing along the ilioinguinal ligament, stopping at the internal ring. A few interrupted sutures are placed at the superior edge of
the mesh. Care is taken to place sutures only in conjoint tendon and
anterior rectus fascia, as the iliohypogastric nerve runs through the
internal oblique muscle layer and can be entrapped if sutures are
placed through this muscle. A lateral slit in the mesh accommodates
the spermatic cord or round ligament. The round ligament can be
sacrificed in most women, so a slit may not be necessary. In the Amid
modification of this repair, the tails of the mesh are sutured to each
other laterally at the level of the inguinal ligament, thus forming a
three-dimensional tunnel for the recreated internal ring (Figure 3).
This conforms to the contour of the pelvis and has lower risk of ring
tightness as compared to the keyhole technique. The lateral tails of
the mesh are tucked under the external oblique. For large indirect
hernias, some advocate narrowing the internal ring with absorbable
suture. For direct hernias, it is recommended to imbricate the
Iliohypogastric n.
External oblique
aponeurosis
Internal oblique m.
and aponeurosis
Iliolinguinal n.
External
spermatic v.
Genital branch
of genitofemoral n.
Pubic tubercle
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H ERN I A
535
For most indirect hernias, the mesh can be placed without fixation
or with the use of tissue glue alone. For direct hernias, the mesh
should provide wide overlap medially and be fixed with permanent
fixation. When using a fixation device, care should be taken not to
injure the bladder inferomedially; external iliac vessels, genitofemoral
nerves, and lateral femoral cutaneous nerves inferolaterally; and the
ilioinguinal and iliohypogastric nerves superolaterally.
For patients with large scrotal hernias, with loss of pelvic floor
domain, or with bilateral inguinal hernias that are not amenable to
laparoscopic repair, the Stoppa repair is a tension-free technique that
can offer long-lasting repair. It is also known as a giant prosthetic
reinforcement of the visceral sac. Essentially, it is a wide preperitoneal
repair that involves implantation of a flat piece of mesh from left to
right anterior superior iliac spine in the transverse dimension and
from mid-anterior rectus muscle to sacrum in the longitudinal
dimension. It can also be modified for unilateral hernias.
CHRONIC POSTINGUINAL
HERNIORRHAPHY PAIN
Surgical techniques for inguinal hernia repair have advanced rapidly
in the past few decades. With the introduction of mesh implantation
in the 1980s, average hernia recurrence rates have dramatically
reduced. Recurrence rates are now less than 5% overall and less than
1% as reported by most experts. Thus, most of the efforts toward
advancement of hernia repair have been concentrated on developing
techniques and biomaterials that reduce operating time, reduce surgical incision length and dissection, and reduce postoperative pain
and recovery time.
We are now dealing with the phenomenon of chronic postinguinal herniorrhaphy groin pain, or inguinodynia. Chronic pain, defined
as persistent pain lasting longer than 3 months postoperatively, is
reported to be 15% to 33%. Three percent of patients suffer from
severe debilitating pain. With over 800,000 inguinal hernia repairs
performed annually in the United States, a large number of patients
are suffering from pain due to their operation. A recent hernia database using the Caroline Comfort Scale for preoperative and postoperative evaluation of patients followed patients for up to 2 years
postoperatively. Results showed that young patients and women are
at highest risk for chronic pain. It is important to carefully evaluate
the symptoms of all patients preoperatively, counsel patients about
the risk of chronic pain as part of the informed consent process, and
tailor the surgical plan and technique to meet the patients specific
needs.
The four main causes of chronic postoperative pain include
hernia recurrence, mesh-related pain, nerve-related pain, and infection. Patients with chronic pain after hernia repair may suffer from
one or a combination of these causes.
Hernia recurrence, if not obvious from exam and history, can be
confirmed by radiologic studies if necessary. These patients typically
complain of recurrence of their preoperative pain. Their pain may
be activity-related. The pain is relieved when lying flat. Some may
have new pain due to a missed femoral hernia or a new direct inguinal hernia. Repair of the recurrent hernia will treat this problem.
Patients with mesh-related pain may have pain due to a persistent
inflammatory reaction to the mesh. In most patients, the inflammation associated with mesh resolves with time. In a small subset, the
inflammatory reaction persists, resulting in swelling and chronic pain
in the affected area. CT scan or MRI may show an abnormal inflammatory reaction in the groin that is not typical of postoperative
changes after mesh repair. In most patients, antiinflammatory treatments such as ice packs, nonsteroidal antiinflammatory medications,
or steroid injections may relieve their discomfort. In rare cases, the
mesh must be removed.
A more common mesh-related complication is termed meshoma,
and it is due to the folding or balling of mesh (Figure 4). This is
perceived by the patient as a mass in the groin and can sometimes
be felt on exam. The patient typically has pain with hip flexion.
Activities such as sitting, driving, and bending are uncomfortable. It
is not unusual for the patient to prefer to stand or to slouch back
when sitting, with ipsilateral leg extended. Radiologic studies may
confirm this diagnosis by showing a thickened pelvic floor or a
foreign body mass with adjacent mass effect, such as distortion of the
bladder. Removal of the mesh is the only treatment for this problem.
Neuropathic pain may be due to direct nerve injury at the time
of hernia surgery, ingrowth of the mesh into a nerve, entrapment of
the nerve by suture, fixation material, scar tissue or a fold in the mesh
(see Figure 4), or impingement on the nerve from the mass effect of
a meshoma. These patients typically have a burning pain or electrical
shooting sensation in the dermatome of the affected nerve. Any
external pressure from belts, jeans, or underpants causes discomfort.
Diagnostic testing includes a local nerve block. Treatment may
include serial nerve blocks, topical lidocaine patch, nerve ablation, or
neurectomy. The mesh may or may not need to be removed.
An active infection of the mesh will present with purulent drainage from the wound or a fluid collection around mesh implant. In
some patients, their mesh can be seeded from bacteremia, such as
tooth infection. They may present with a chronic infection, resulting
in pain and intermittent swelling in the groin. They may also have
associated constitutional symptoms such as fever, night sweats,
fatigue, or joint pain. Radiologic study may show an inflammatory
reaction, thickening of the soft tissue, or a fluid collection with or
without gas. Antibiotics alone will improve their symptoms. In most
cases, mesh removal is necessary.
Regardless of the cause of the chronic pain, it is important that
the surgeon address this issue in a timely manner. Urologists and pain
management specialists may also be consulted to help address the
patients needs. Early treatment of the cause of chronic pain provides
the best outcome.
Suggested Readings
Alfieri S, Amid PK, Campanelli G, et al: International guidelines for prevention and management of post-operative chronic pain following inguinal
hernia surgery, Hernia 15:3949, 2011.
Amid PK: Lichtenstein tension-free hernioplasty: its inception, evolution, and
principles, Hernia 8:17, 2004.
Campanelli G, Pascual MH, Hoeferlin A, et al: Randomized, controlled,
blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing
Lichtenstein technique for primary inguinal hernia repair. Results of the
TIMELI trial, Ann Surg 255(4):650657, 2012.
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Shouldice EB: The Shouldice repair for groin hernias, Surg Clin North Am
83:11631187, 2003.
Simons MP, Aufenacker T, Bay-Nielsen M, et al: European Hernia Society
guidelines on the treatment of inguinal hernia in adult patients, Hernia
13:343403, 2009.
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