In general terms, we can say that a hernia occurs when the layers that make up the abdominal wall weaken. In other words, the fabric of muscle and other tissues which protect the gut, develops a defect, or weakness. Through that defect the peritoneum (PER-IT-TA-NEE-UM) - and perhaps other organs - push their way outward, forming a lump which can be felt - and sometimes seen - protruding from the abdomen.
During normal childhood development, boy's testes slowly descend from the interior of the abdomen, down into the scrotum. They pass through the abdominal wall by way of a natural passageway called the inguinal canal.
In men, the inguinal canal contains blood vessels that supply the testes, as well as the vessel that carries sperm to the penis. Hernias that occur due to a weakness in the abdominal wall at the inguinal canal, are called inguinal hernias. And not surprisingly, men are 25 times more likely than women to experience a hernia in this area.
Some inguinal hernias press directly through the floor of the inguinal canal.
Others follow the route taken by the blood vessels that supply the testes. This kind of hernia - called an indirect hernia - can even push all the way into scrotum.
There's no single cause. Most people understand that hernias can sometimes occur following sudden, forceful lifting. But most often, hernias develop gradually and finally make their appearance when the abdominal wall is under somewhat less dramatic pressure. Pregnancy, constipation, straining during urination - even repeated coughing - any of these actions can, in fact, put enough pressure on an abdominal weak spot to cause a hernia.
If you have a mild hernia, you may not even be aware of it. But in most cases, a hernia causes a noticeable lump or swelling. There may be some pain or discomfort - often increasing when standing, and subsiding when lying down.
Hernias become more serious problems if abdominal contents - such as part of the small intestine or another organ - slide into the hernia sack and become trapped there.
If those organs cannot slide easily back into the abdomen,the hernia is said to be irreducible. Irreducible hernias are often painful and can lead to complications.
For example, if the intestine becomes trapped in the hernia sack it is said to be incarcerated.
If the neck of the hernia sack actually pinches off the supply of blood to those organs which have become trapped inside, the hernia is said to be strangulated.
These are both considered to be medical emergencies and if left untreated, an incarcerated or especially a strangulated hernia can lead to very severe illness and even death.
Luckily, the vast majority of hernias are not considered to be emergencies. However, if you should ever feel a sudden onset of severe pain in your hernia, you should definitely seek immediate medical attention.
Types
Lichenstein
Shouldice
Bassini
McVay
Laparoscopic
TAPP = transabdominal pre-peritoneal (patch)
TEPP = total extra-peritoneal (patch)
Fig : Different types of inguinal hernias
Symptoms of an inguinal hernia
Groin discomfort or groin pain aggravated by bending or lifting
A tender groin lump or scrotum lump
A bulge or lump is usually seen in children.
Operation
The operation takes 30 to 50 minutes depending on the technique used.
There are two main types of inguinal hernia repair - open and keyhole (laparoscopic). Your surgeon will recommend which is suitable for you.
Open surgery
Open surgery is the most common way to repair an inguinal hernia.
Once the anaesthetic has taken effect, your surgeon will make a single cut (about 5 to 10cm long) in your groin, and push the bulge back into place. He or she will usually attach a synthetic mesh over the weak spot to strengthen the wall of the abdomen, before closing the cut with dissolvable stitches.
Keyhole surgery
There are two techniques for keyhole surgery - transabdominal peritoneal (TAPP) and totally extraperitoneal (TEP).
In a TAPP operation the mesh is inserted through the lining of your abdomen (peritoneum). TEP is a newer technique where the mesh is attached without cutting through your peritoneum. This is a more difficult operation but reduces the risk of damage to the organs in your abdomen.
Fig: Surgical incision in groin after inguinal hernia operation.
For both of these techniques about two or three small cuts (1 to 2cm long) are made on your lower abdomen and groin under general anaesthesia. Your surgeon will insert a tube-like telescopic camera (laparoscope) to view your hernia by looking at a monitor. After your hernia is repaired your surgeon will close the cuts in your skin with dissolvable stitches.
Complications
This is when problems occur during or after the operation. Most people are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).
Rarely, blood or fluid will build up in the space left by the hernia. This will usually resolve itself but you may need to have further treatment to drain the fluid.
In men, painful swelling of the scrotum or testicles occasionally occurs. This may require further surgery.
Very rarely, other tissues in the abdomen are damaged during surgery.
Pain or numbness in your groin area can continue for up to one year after the operation. If this is caused by an irritated nerve you may need another operation to treat it.
The inguinal hernia may re-occur, although this risk is reduced when using a mesh to repair the hernia.
There's a chance your surgeon may need to convert your keyhole operation to open surgery. This means making a bigger cut on your groin. This is only done if it's impossible to complete the operation safely using the keyhole technique.
The exact risks are specific to you and will differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you.
Result
benefits of surgery
You should stop having pain and the swelling will be gone. There should be no risk of a strangulated hernia. The traditional operation for a hernia repair is the open operation. Recently, laparoscopic surgery has become more common and laparoscopic hernia repair is becoming routine. But laparoscopic surgery is not possible in all cases. You should discuss the type of operation to be done with your surgeon.
Laparoscopic hernia repair has a number of advantages over the open operation, namely : -
A quicker recovery.
Less pain.
A lower risk of infection.
Smaller wounds.
Less formation of adhesions.
The surgeon can examine the rest of the abdomen.
The main disadvantages are that the operation takes longer than a straightforward open operation and injury to other organs, such as bowel, bladder or blood vessels is more likely.
The laparoscopic hernia repair has good advantages for hernias in both groins, called bilateral, because both hernias can be repaired through the same incisions, and recurrent hernias.
Risks
Healthy children who have a hernia repair have few risks. The surgery usually is done on an outpatient basis.
The surgeon may check to see whether a child younger than 1 year also has a hernia on the other side of the groin. If there is one, it may be repaired during the same surgery to avoid the risks of a second surgery. In males, this practice involves putting both testicles at risk at the same time.
Males with hydrocele and hernia may have both problems repaired at the same time to avoid the risks of a second surgery.
Premature babies are at risk for heart and lung complications during surgery.
Adults and children who have a hernia repair are at risk for : -
Reaction to anesthesia (main risk).
Infection and bleeding at the site.
Nerve damage, numbness of skin, loss of blood supply to scrotum or testicles resulting in testicular atrophy (all infrequent).
Damage to the cord that carries sperm from the testicles to the penis (vas deferens), resulting in an inability to father children.
Damage to the femoral artery or vein.
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