Inguinal hernia

What is an Inguinal Hernia?

Inguinal Hernia – Some General Information

An inguinal hernia is the most common type of hernia, particularly in the male population, and it results from a weakening of the abdominal wall. The weakening of the abdominal wall can be caused by factors such as excess weight (obesity), lifting heavy objects, intense physical exertion, and other factors that will be discussed below.

Typically, an inguinal hernia presents with swelling in the groin area, which causes discomfort, pain, and a sensation of pressure locally. Even if the symptoms are mild, an inguinal hernia should not be underestimated, as it can worsen and pose a serious risk, even to the patient’s life.

As a rule, the diagnosis of an inguinal hernia is clinical. However, sometimes, especially when the diagnosis is unclear, diagnostic imaging may be required to aid in the differential diagnosis.

The treatment of an inguinal hernia largely depends on the severity of the symptoms. If the condition is asymptomatic, the typical approach is regular monitoring. However, if the severity of the symptoms increases, surgical intervention is required.

What is an Inguinal Hernia: A Brief Overview

What is an Inguinal Hernia?

The video belongs to the channel Johns Hopkins

The term hernia refers to the protrusion of an internal organ through an abdominal wall opening. This opening may be due to a rupture of the abdominal wall or a natural anatomical hole that, when expanded, causes the hernia. Among the different types of hernias (umbilical hernias, femoral hernias, etc.), the inguinal hernia is the most common (between 70% and 80% of all hernia cases are inguinal hernias), and most often, the protruding organ is the intestine. More rarely, it can involve the urinary bladder or a section of fatty tissue near the abdominal organs next to the inguinal canal.

Inguinal hernias are more common in middle-aged adults but can also appear in children and the elderly. Typically, inguinal hernias occur on the right or left side of the body, and less frequently on both sides (bilateral inguinal hernia).

What is the Inguinal Canal?

The inguinal canal is an oblique passage between the muscles of the anterior abdominal wall, located above the inner part of the inguinal ligament. Characterized by an internal opening (internal orifice) and an external opening (external orifice), the inguinal canal primarily serves as a pathway for blood vessels and nerves to the external genitalia. During fetal development, the inguinal canal also allows for the descent of the testes into the scrotum.

In men, the inguinal canal is about 4 cm long and 2 cm in diameter, through which the blood vessels of the spermatic cord and nerves that go to the penis root and the upper part of the scrotum pass. In women, the inguinal canal is slightly longer and narrower, allowing the passage of the round ligament of the uterus. The inguinal hernia forms at the anatomical point where the inguinal canal is located. As the name suggests, the inguinal canal is found in the groin area, which is the boundary between the abdomen and the lower limbs.

Not all inguinal hernias are detectable in the same location within the confines of the groin area. The exact location may vary depending on how far the abdominal organs protrude into the inguinal canal.

Cyst Coccyx: Causes

Although there are several theories about the causes of the disease, today most scientists believe that cysts are acquired lesions (and not congenital or congenital as previously believed). Their appearance is related to an infection of the hair follicle, which, once dilated, allows the hair to become encapsulated. In response to these ingrown hairs, a local inflammatory reaction develops that causes a cystic structure to form.

Excessive pressure, friction, or repetitive trauma to the area of the sacrococcygeal ligament may predispose individuals to develop the cyst or cause irritation of an existing coccygeal lesion.

How Does an Inguinal Hernia Appear?

The abdominal wall consists of muscles that create a strong envelope that holds and protects the organs within the abdominal cavity.

However, the abdominal wall also has a weak spot: the inguinal canal. Here, as space must be made for other important anatomical structures, the abdominal muscles may offer less resistance, allowing an organ (usually a loop of intestine) to begin protruding through this weak area of the abdomen. This forms a small bulge or lump (a small “egg-shaped” protrusion): the hernia.

What Causes an Inguinal Hernia?

Sometimes, an inguinal hernia appears without any obvious cause. Other times, it results from one or more of the following factors:

• Excess weight or obesity (increases the pressure the internal organs place on the abdominal muscles)
• Intense physical activity
• Chronic or severe coughing
• Pregnancy
• Excessive straining during bowel movements (usually related to chronic constipation)
• Weaker abdominal muscles than normal
• Advanced age (including weakening of the muscles, including the abdominal muscles)
• Congenital defect (a malformation in the closure of the inguinal canal)
• Sedentary lifestyle
• Abnormal formation of the inguinal canal
• Smoking

It is important to note that in some cases, an inguinal hernia seems to be hereditary: There are situations where the problem appears in family members (genetic inheritance).

Inguinal Hernia: Why It Affects Men More Frequently

As mentioned earlier, inguinal hernias affect men more often than women. This is due to anatomical differences between men and women at the level of the inguinal canal: In men, the larger diameter of the inguinal canal facilitates the abnormal entry of abdominal organs into the canal, making hernias more likely to develop.

Symptoms and Complications

Typically, an inguinal hernia presents with:

• Swelling (lump) in the groin area, which may increase in size when standing (compared to when lying down) or during physical activity or severe coughing.
• Intense pain in the bulging area.
• Feeling of tension or pressure, heaviness, and/or burning in the groin area.

Sometimes, the inguinal hernia may be asymptomatic or cause only mild discomfort. In other cases, it may cause pain but no swelling.

Pain in the Groin: Characteristics

In an inguinal hernia, pain is caused by the pressure of the internal organs inside the hernia sac. This means that the pain is more pronounced as the hernia increases in size. In severe cases, when the hernia becomes strangulated, the pain can be dramatically intense, almost unbearable. If the patient is lying down, the pain often decreases, and in some cases, disappears entirely. However, once the patient stands up, the pain returns. Generally, coughing, sneezing, and physical activity increase the pain associated with an inguinal hernia.

Inguinal Hernia in Children: Symptoms

In infants and small children, an inguinal hernia tends to present with the typical swelling only in certain cases, such as crying, coughing, or straining during bowel movements. Infants and small children (who cannot speak yet) typically show irritability and loss of appetite when they have an inguinal hernia. For older children, the condition is similar to adults. The only additional note is that an inguinal hernia is often visible, even when the child has been standing for a long time.

Inguinal Hernia: When Is It Dangerous?

An inguinal hernia should never be underestimated. In fact, if neglected, it can cause severe complications, such as:

• Gradually increasing in size and compressing surrounding tissues more and more. In men, there is a risk it may reach the scrotum, causing even more pain.
• The protruding organ becoming trapped in the hole in the abdominal wall (irreducible or, worse, strangulated hernia). When this involves the intestine, as is the case with most inguinal hernias, intestinal obstruction may occur, leading to nausea, vomiting, severe pain, and difficulty with bowel movements.
• Strangulation or gangrene of the hernia. This occurs when the contents of the hernia are compressed so tightly that the blood supply to the affected organ is cut off, leading to tissue necrosis. This requires emergency surgery within six hours of symptom onset.
• Peritonitis: A strangulated hernia is a medical emergency and, if not treated promptly, can be fatal.

Inguinal Hernia: When Should You Be Concerned?

Any swelling or bulge in the groin area should be reported to your doctor. If you have an inguinal hernia but it doesn’t cause significant problems, it is still advisable to watch for any changes in symptoms and inform your doctor before complications arise.

Diagnosis: How Is an Inguinal Hernia Detected?

The diagnosis of an inguinal hernia is generally clinical, meaning it is based on the patient’s symptoms and a physical examination.

During the physical exam, the doctor will assess the presence of swelling in the groin area and any pain associated with this swelling, as well as whether the pain worsens during coughing or when the patient moves from a lying to a standing position.

If these clinical evaluations are insufficient to confirm the diagnosis, imaging techniques like ultrasound, MRI, or CT scans may be necessary.

How is an Inguinal Hernia Treated?

Treatment for an inguinal hernia varies depending on the severity of the symptoms.

If the hernia causes mild or no symptoms, it may only require regular monitoring. If the hernia worsens, consult your doctor immediately.

If the hernia is large and causes painful symptoms, surgery is required

Conservative Treatment: Regular Monitoring

In cases where medical observation is sufficient, the doctor may recommend wearing special elastic undergarments (hernia briefs) to replace a hernia belt. Hernia briefs and belts do not treat the hernia but help prevent symptoms from appearing.

Currently, there are no medications that can resolve an inguinal hernia, and the only definitive solution is surgery.

Surgery

Surgery for an inguinal hernia is performed in a hospital with a one-day stay. This means that the patient can return home the same day as the surgery.

Briefly, the procedure involves retracting the contents of the hernia into the abdomen and placing a mesh made of a biocompatible material – usually polypropylene.

In short, the procedure involves returning the hernia contents back into the abdomen and placing a biocompatible mesh (usually polypropylene).

There are two surgical techniques to perform the above procedure:

• Open surgery, which involves an incision in the groin area.
• Laparoscopic surgery, which uses small incisions and specialized instruments.

With the laparoscopic technique, no large incisions are made, but small incisions that allow the surgeon to reposition the internal organs and place a biocompatible mesh, sometimes made from biodegradable materials, to close the “defect” in the abdominal wall and prevent the formation of a new hernia. This type of surgery is always performed under general anesthesia.

The classic “open” surgical approach is particularly recommended for small hernias because the repair is done with only local anesthesia. However, the traditional surgery may also be preferred for larger hernias when it is judged that laparoscopic intervention would not be very effective.

After the surgery, the patient can typically return to their normal routines and activities within a few days.

In any case, inguinal hernia surgery is considered a low-risk, routine procedure with reliable results.

Prevention

An inguinal hernia is not a condition that can be completely prevented, especially if there is a family history or congenital predisposition. However, it is worth noting that there are several lifestyle changes that, if adopted, can significantly reduce the risk.

Specifically, the likelihood of developing an inguinal hernia is reduced by:

• Strengthening the abdominal muscles.
• Maintaining a healthy body weight through a balanced diet and physical exercise.
• Using proper techniques when lifting heavy objects.
• Quitting smoking.

Inguinal Hernia and Exercise

In the gym, when lifting very heavy loads during exercises that put excessive pressure on the lumbar spine, it is advisable to wear a support belt.

The belt is used to prevent disc herniation (herniated intervertebral disc), but it is important to remember that if it is worn throughout the entire workout, it prevents the abdominal muscles from “working” freely, which interferes with their development. Additionally, if the belt is too tight, it increases the risk of developing an inguinal hernia due to the significant rise in intra-abdominal pressure.

Returning to Exercise After Surgery

After inguinal hernia surgery, the patient can usually resume training 10-15 days later. However, it should be noted that before starting to use heavy weights in exercises that significantly increase intra-abdominal pressure, it is advisable to wait approximately 6-10 weeks. Of course, the type of surgery performed will also play a role in the recovery process.

As with any surgical procedure, even after inguinal hernia repair surgery, the resumption of exercise should always be done with the approval of the treating physician and under their guidance.

Inguinal Hernia and Obesity

Although there are many causes of inguinal hernia, obesity is considered a particular case and requires special management.

In overweight patients with accumulated fat in the groin area, diagnosis may be difficult, and a non-reducible hernia might be overlooked.

Therefore, the first step in managing the condition is to evaluate whether the hernia surgery should be performed before bariatric surgery or vice versa.

The clinical experience of the doctor is crucial: Once the size and location of the hernia are determined, the specialized treating physician will decide whether to perform hernia surgery first or bariatric surgery for weight loss — or both at the same time.

However, the best approach for the success of hernia repair surgery is to achieve weight loss first. This is because obesity and the weight of the abdominal wall significantly complicate inguinal hernia surgery, leading to greater postoperative complications, such as a higher frequency of wound infections or post-surgical seromas.

Inguinal Hernia and Obesity: The Importance of Ultrasound Monitoring

Ultrasound diagnosis in all patients with hernias, particularly in obese patients, provides an additional tool for better determining the size of the hernia, its exact location, and distinguishing between hernias containing only fat and those that already contain intestinal contents, which pose a higher risk of complications. Additionally, ultrasound allows for more accurate identification of non-reducible or strangulated hernias.