By Gregory E. Jeansonne
All information condensed from Schwartz: Principles of Surgery & Companion Handbook / 7th Edition.
Background Information: The groin is a naturally weak area in the
Definitions: Hernia=viscus protruding through it's containing cavity wall. Hernial Orifice=innermost aponeurotic layer defect. Hernial Sac=peritonial outpouching. External=extending outside of the abdominal wall. Internal=completely within the visceral cavity. Reducible=viscus can be returned to abdomen. Strangulated=viscus blood supply is compromised which may lead to necrosis. Incarcerated=irreducible with or without strangulation. Richter's=sac contains only one side of intestine.
Common Sites: Groin">
By Gregory E. Jeansonne
All information condensed from Schwartz: Principles of Surgery & Companion Handbook / 7th Edition.
Background Information: The groin is a naturally weak area in the
Definitions: Hernia=viscus protruding through it's containing cavity wall. Hernial Orifice=innermost aponeurotic layer defect. Hernial Sac=peritonial outpouching. External=extending outside of the abdominal wall. Internal=completely within the visceral cavity. Reducible=viscus can be returned to abdomen. Strangulated=viscus blood supply is compromised which may lead to necrosis. Incarcerated=irreducible with or without strangulation. Richter's=sac contains only one side of intestine.
Common Sites: Groin, Umbilicus, Linea Alba, Semilunar line of Spieghel, Diaphragm, and Surgical Sites.
INFORMATION BELOW LIMITED TO GROIN HERNIA.
Types: Congenital vs. Acquired. Inguinal vs. Femoral. Direct vs. Indirect.
Anatomy: Hesselbach's Triangle defines groin hernias. It is composed of the Inferior Epigastric Vessels (Laterally), the Inguinal Ligament (Inferiorly), and the Lateral Border of the Rectus Abdominus Muscle (Medially).
Pathophysiology: Causes associated with all groin hernias: erect human posture, muscle deficits, and connective tissue changes (secondary to smoking, age, or systemic changes). Femoral: weakening of the neck of the femoral canal (below the inguinal ligament) with protrusion of abdominal contects through femoral ring usually medial to the femoral sheath. Indirect Inguinal: Failure of transversalis fascia to keep abdominal contects out of a patent processus vaginalis. All are congenital and follow the patent processus vaginalis (lateral to Hessellback's Triangle). The processus vaginalis is patent in 80% of newborns, 50% of 1year olds, and 20% of adults. Direct Inguinal: weakening of the abdominal wall within Hesselback's Triangle and are usually contained by the External Oblique Aponeurosis.
Incidence: Groin is the most common herniation site with incidence of 3-4% w/ strangulation in 1.3-3.0% of those. Femoral less common (Female>Males=rare) w/ higher rate of strangulation. Inguinal most common w/ Indirect > Direct (2:1 Males, Direct rare Females). For Females, Femoral Hernia is more common than it is in males, but Inguinal Hernia is still the most common type overall (VERY IMPORTANT). Activity level is not a risk factor.
Clinical Findings:
Symptoms: Usually Slowly progressive but may be precipitated by forceful muscular event. Time increases deformity, risk of irreducibility, and strangulation. Symptoms are worse at the end of the day and relieved during rest. Abdominal Discomfort worst at night relieved by rest. Strangulation leads to intense pain within the hernia followed by abdominal tenderness, viscus obstruction, and sepsis.
Signs: Most are palpable (check for reducibility unless strangulation is suspected). Enlargement with valsalva or other increased abdominal pressure. Differentiate from Hydrocele via Transillumination (Hernias do not transilluminate).
Labs: Not helpful.
Imaging: CT or Ultrasound may be helpful.
Tx: Surgical Repair if the patient is able with the objective to restore myopectineal integrity. Trusses may alleviate symptoms for patients unable to withstand surgery, but are contraindicated in femoral hernias due to the increased risk of strangulation. For males <3years old, exploration of the contralateral side is indicated.
Procedure:
Classic Procedures
Marcy = Simple Ring Closure = Tighten Deep Inguinal Ring Only.
Bassini-Shouldice = High Sac Ligation & Approximation of the Conjoined Tendon &
Internal Oblique to the Inguinal Ligament.
McVay-Lotheissen = Approximation of the Transverse Aponeurosis to Cooper's Ligament and
the Femoral Sheath with mandatory relaxing incisions in the aponeurosis.
Properitoneal/Prosthetic Repair
Stoppa = Giant Prosthetic Reinforcement of the
of the Visceral Sac = Replace the transversalis fascia with prosthetic mesh.
All may be done via Anterior Approach through Groin Incision or Posterior Approach through
Abdomen. Laparoscopic procedures can be done and show decreased wound infection and
post-operative pain, but significantly higher morbidity, mortality, and recurrence rates.
See Operation Procedure for Details of this case.
Px: 1-3% recurrence rate at 10year follow-up. Recurrences are attributed to excessive tension, deficient tissue, inadequate repair, and unrecognized additional pre-existing hernia. Ischemic Orchitis and Residual Neuralgia are uncommon but important complications.
Revised: August 05, 2002.