Chapter 37: Inguinal Hernias

KEY POINTS

1. Conservative management of asymptomatic inguinal hernias is acceptable.

2. A proficient understanding of groin anatomy is essential to successful inguinal hernia treatment.

3. Elective repair of inguinal hernias can be undertaken using an laparoscopic or open approach.

4. The use of prosthetic mesh as a reinforcement significantly improves recurrence rates, whether the repair is open or laparoscopic.

5. Recurrence, pain, and quality of life are important outcome factors.

6. Laparoscopic inguinal hernia repair results in less pain and faster recovery, yet requires specialized training and equipment.

INTRODUCTION

Inguinal hernia repair is the most commonly performed operation in the United States, owing to a significant lifetime incidence and variety of successful treatment modalities. Approximately 800,000 cases were performed in 2003, not including recurrent or bilateral hernias.¹ Advancements in perioperative anesthesia and operative technique have made this an outpatient ambulatory operation with low recurrence rates and morbidity. Given this success, quality of life and the avoidance of chronic pain have become the most important considerations in hernia repair.

Approximately 75% of abdominal wall hernias occur in the groin. The lifetime risk of inguinal hernia is 27% in men and 3% in women.² Of inguinal hernia repairs, 90% are performed in men and 10% in women. The incidence of inguinal hernias in males has a bimodal distribution, with peaks before the first year of age and after age 40. Abramson demonstrated the age dependence of inguinal hernias in 1978. Those age 25 to 34 years had a lifetime prevalence rate of 15%, whereas those age 75 years and over had a rate of 47% (Table 37-1).³ Approximately 70% of femoral hernia repairs are performed in women; however, inguinal hernias are five times more common than femoral hernias. The most common subtype of groin hernia in men and women is the indirect inguinal hernia.⁴

History

Evidence of surgical repair of inguinal hernias can be traced back to ancient civilizations of Egypt and Greece.⁵ Early management of inguinal hernias often involved a conservative approach with operative management reserved only for complications. Surgery often involved routine excision of the testicle, and wounds were closed with cauterization or left to granulate on their own. Considering these procedures were performed before the advent of the aseptic technique, it is safe to assume that mortality was quite high. For those that survived the operation, recurrence of the hernia was common.

From the late 1700s to the early 1800s, physicians including Hesselbach, Cooper, Camper, ...