Inguinal Hernia

• • Groin bulge elicited with the Valsalva maneuver

  • Types of inguinal hernias

  • -Indirect: Patent processus vaginalis extension lateral to the inferior epigastrics in the anterior-medial position of the spermatic cord

    -Direct: Developed weakness in the abdominal wall located at Hesselbach triangle (inguinal ligament inferiorly, lateral edge of the rectus medially, and the inferior epigastric vessels superior-laterally)

    -Pantaloon hernia is a combined direct and indirect inguinal hernia

  • Classification of hernias

  • -Reducible: Visceral contents of the hernia sac able to retract into the abdominal cavity

    -Incarcerated: Visceral contents cannot be returned to the abdominal cavity

    -Strangulated: Incarcerated inguinal hernia where the blood flow to the entrapped viscera is compromised

    -Sliding: Abdominal viscera present in hernia sac; on the left, most commonly the sigmoid colon and bladder, and on the right, most commonly the cecum and bladder

Epidemiology

• • 5-10% of the world population develops an inguinal hernia in their lifetime

  • Premature infants most likely to develop inguinal hernia (> 10%)

  • Nearly all hernias in infants, children, and young adults are indirect

  • Indirect inguinal hernias develop more commonly on the right

  • Acute complications from inguinal hernias are more likely to develop in infants and children

  • Most common etiology of small bowel obstruction in children is incarcerated inguinal hernia

  • Second most common cause of small bowel obstruction in adults is incarcerated inguinal hernia

Symptoms and Signs

• • Asymptomatic inguinal bulge most common symptom

  • Exam of the groin reveals a bulge adjacent to the ipsilateral pubic tubercle that may extend into the scrotum

  • The hernia bulge may or may not be reducible

  • Patients may complain of a fullness or dragging sensation

  • As a hernia enlarges, it is likely to produce a sense of discomfort that may radiate into the ipsilateral groin

  • Sharp ilio-inguinal groin pain without a detectable groin bulge is most commonly a strained groin muscle

  • Incarcerated/strangulated inguinal hernia is exquisitely painful

  • Coughing or straining will help demonstrate small hernias

  • Small bowel obstruction symptoms (nausea, vomiting, abdominal distention) may be present with incarcerated inguinal hernias

Imaging Findings

• • US, although rarely needed, can verify the presence of a hernia sac and reliably differentiate between a hernia, solid cord mass, hydrocele, or lymphadenopathy

• • Femoral hernia

  • Hydrocele

  • Cord mass

  • Strained groin muscle

  • Epididymitis

  • Inguinal lymphadenopathy

  • Varicocele

  • Undescended testes

Rule Out

• • Strained groin muscle (chronic groin pain commonly develops in these patients following operative intervention)

• • Physical exam usually all that is required to accurately diagnose inguinal hernia

  • In equivocal cases, US may be helpful

When to Admit

• • Uncomplicated inguinal hernia management can be performed as an outpatient

  • Indications for admission include:

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