Inguinal hernia (inguinal hernia)

If areas of the abdominal wall are perforated, this can lead to protuberances in the groin region. Doctors speak of an inguinal hernia. Everything about symptoms, diagnosis and therapy can be found here

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In the case of an inguinal hernia, tissue (often intestinal tissue) penetrates through a so-called hernial port and forms a protuberance (hernial sac)

© W & B / Szczesny

Inguinal hernia (inguinal hernia) - briefly explained

An inguinal hernia (inguinal hernia) is a gap that either already exists or has developed over time. The peritoneum (hernial sac) can slide in through this gap (hernial gate). Abdominal viscera (contents of the hernia) can also be found in this hernial sac. Therefore, the real problem of a hernia (Latin: rupture) is not the opening itself, but the resulting risk that abdominal organs (mostly parts of the intestine) can become trapped in this gap and, in the worst case, die. The main symptom of an inguinal hernia is the pain in the groin, sometimes a visible bulge in the groin region is noticeable. The therapy of an inguinal hernia consists in the operative care. Not every hernia needs to be operated on immediately. Most of the time, the patients have no major complaints. Nevertheless, you should point out that an entrapment with pain can occur at any time. Since this condition can have significant, harmful consequences, the patient should be advised to undergo an operation as soon as possible. There are different surgical procedures (open or endoscopic procedures) which are selected individually depending on the type of fracture and the patient.

What is an inguinal hernia?

If there is a gap in the groin region - either already existing, for example due to a widened inner inguinal ring, or a gap in the fascia of the muscles that form the inguinal canal - one speaks of an inguinal hernia. Intestines of the abdominal cavity (= contents of the hernia) together with the surrounding peritoneum (= hernial sac) can pass through this gap (= hernial opening).

Statistically, three percent of all women and 27 percent of all men suffer a hernia during their lifetime. The risk increases with age. If there is an inguinal hernia, 90 percent of the males are affected, this is mainly due to the anatomy (see also our guide: Inguinal pain, inguinal hernia). More often, an inguinal hernia is found on the right side. The surgical treatment of an inguinal hernia was again one of the 20 most frequent operations in abdominal surgery in 2017.

Schematic representation of the inguinal canal with inner and outer inguinal ring

© W & B / Szczesny

Background information - the inguinal canal

Structure of the inguinal canal

The groin forms the transition between the abdomen and thighs. The inguinal canal (canalis inguinalis) is located in this region; it runs above the inguinal ligament. Its length is about five centimeters. It runs obliquely from "outside-back" to "inside-front" and therefore penetrates the abdominal wall in order to guide important structures (vessels, nerves, cervical ligament or spermatic cord) to the genital organs. The structures mentioned enter through the so-called inner inguinal ring (inside in the sense of "in the abdomen") and leave the inguinal canal again at the outer inguinal ring. Among other things, this is important for understanding the various types of fracture (see direct and indirect hernia).

The inguinal canal is formed from the tendon plates (aponeuroses) and connective tissue sheaths (fascia) of the abdominal muscles and the inguinal ligament:
Front: tendon plate (aponeurosis) of the external oblique abdominal muscle (Musculus obliquus externus abdominis)
Upper side: surface of the internal oblique abdominal muscle (M. obliquus internus abdominis) and the transverse abdominal muscle (M. obliquus transversus)
Back: Fascia of the M. obliquus transversus
Underside: inguinal ligament

Schematic (simplified) representation of a hernia with hernial port, hernial sac and hernial content

© W & B / Felix Schneider

Intestines of the abdominal cavity (= contents of the hernia) together with the surrounding peritoneum (= hernial sac) can pass through a gap (= hernial opening).

This gap can either already exist, for example in the form of an inner (too large) inguinal ring, or it can only arise, for example due to the muscles giving way. Since these abdominal muscles form the wall of the inguinal canal, a break in the musculature leads to a hernial sac (depending on the size, also with the contents of the hernia) pushing into the inguinal canal (see also direct and indirect inguinal hernia) and moving along the inguinal canal towards the outside Ring can advance. This hernial sac is then visible from the outside as a bulge on the outer inguinal ring. A further advance to the testicles is also possible. In women in particular, a so-called thigh fracture is often found due to the anatomy (see also our guide: causes of inguinal hernia / thigh fracture).

Causes: How does an inguinal hernia occur?

In principle, all factors that increase the pressure in the abdomen can promote the development of a hernia. In this case one speaks of a symptomatic hernia, since it arises as an expression of another disease. Factors that lead to an increase in pressure in the abdominal cavity (intra-abdominal pressure) are chronic constipation (constipation), enlarged prostate (prostatic hyperplasia), pregnancy and ascites. But even those who have to cough constantly, for example because of a chronic obstructive pulmonary disease (COPD), are more likely to get an inguinal hernia. Those who often carry or lift heavy loads also put constant pressure on the groin region. Doctors also observe an inguinal hernia more frequently in premature babies and boys with undescended testicles. However, this increased pressure in the abdomen usually does not cause problems in the groin region. Nowadays it is assumed that there must be a weakness of the connective tissue at the same time (disturbance of the extracellular matrix) in order for a hernia to form at all.

What is a "soft groin"?

Athletes, especially soccer players, hockey and tennis players, often complain of groin pain. However, there is no hernia behind this, but rather an incipient bulging of the posterior wall of the inguinal canal. However, an athlete's groin, as the soft groin is also called, can develop into a hernia.

Classification of inguinal hernias - indirect and direct inguinal hernia

Doctors differentiate between two types of inguinal hernias: direct and indirect. An indirect inguinal hernia can be congenital or acquired and often affects children and young people. In this form, the hernial sac runs through the inner inguinal ring, which represents the entrance to the inguinal canal. This ring can be expanded a little from birth. Men are anatomically burdened here, because in male unborn babies the testicles migrate from the abdominal cavity through the inguinal canal into the genital area - until birth. If the canal does not close completely afterwards, the existing gap promotes an inguinal hernia. It can also happen that the blocked canal opens a little later, especially if there are favorable factors.

Indirect inguinal hernia

  • Runs over the inner inguinal ring through the inguinal canal to the outer inguinal ring
  • Can be congenital (lack of adhesion after testicular penetration) or acquired (enlargement of the inner inguinal ring)

A direct inguinal hernia is always acquired. Here, a weak connective tissue has formed in the area of ​​the rear wall of the inguinal canal, through which the hernial sac squeezes. At one point there is a physiological weak point where there are no muscles. This is exactly where the groin tissue gives way under excessive stress. Age has a positive effect here. Because in the course of life our connective tissue becomes weaker. Older people are therefore more likely to suffer a direct hernia.

Direct inguinal hernia

  • The hernial sac penetrates the abdominal wall in a straight line and thus reaches the inguinal canal. He follows this to the outer inguinal ring.
  • It is always acquired, and mostly men are affected

More modern classifications of inguinal hernias try to describe the type and quality in more detail, in particular the Nyhus classification has established itself here. Among other things, it distinguishes whether there is a defect in the posterior wall and is also used to select the surgical procedure.

Visible swelling in the groin area is the most common symptom, along with pain in the groin region

© SPL / Dr. P. Marazzi

Symptoms: what symptoms does an inguinal hernia cause?

If it is a small break, usually only slight discomfort occurs. For example, if there is a pull in the groin region when a person moves or lifts something, this can indicate an inguinal hernia. The dragging subsides again when he lies down or rests. Other patients report a foreign body sensation in the groin. If the hernia enlarges, a kind of "bump" is noticeable in the groin. It occurs suddenly, for example from coughing or sneezing. It can often be pushed back inwards. Like pulling, the protuberance often disappears when the person is resting. Sometimes a swelling in the scrotum can also be a sign if the hernia extends to the testicles.

If, for example, there are intestinal parts in the hernial sac and the contents of the hernia become trapped (incarceration), severe pain occurs in the groin. In addition, there may be nausea, vomiting and fever. This is an emergency that requires immediate surgery. You should therefore go to a clinic as soon as possible or call the ambulance service.

If children have an inguinal hernia, the parents often notice this. If you wash the little one or change the diaper, you will notice the bulging in the groin area. The scrotum can swell in boys and the outer labia in girls. If the little one reacts sensitively when the parents press on the swelling or if this even causes pain for the offspring, the child has to see a doctor! Here, too, internal organs can be jammed in the hernial sac.

Groin pain can have other causes as well. Read about it here: Symptom Groin Pain.

Important: As long as hernias cause no or only slight discomfort, they are usually harmless. However, there is a risk that the contents of the break will be trapped. If a piece of intestine is stuck in the protuberance and is squeezed in, too little blood flows through the tissue at that point. In the worst case, it can die. Therefore, always see a doctor if you notice the typical swelling in the groin. If it hurts badly there, if you feel sick or if you feel feverish at the same time, go to the hospital immediately. It can be a pinched inguinal hernia, which is an emergency and requires immediate surgery. Such a hernia can also become infected. If the inflammation spreads to the abdomen, life-threatening peritonitis can develop.

Diagnosis: how is an inguinal hernia diagnosed?

If the patient describes symptoms that suggest an inguinal hernia, the doctor first asks specific questions. For example, when the complaints occur and whether they persist. The doctor then examines the groin region. If he does not see a protuberance, he asks the patient to cough. Because this increases the pressure in the abdomen and the hernia becomes visible under the skin. If the swelling can already be seen in this way, the doctor feels it and tests whether it can be pushed inwards (repositioned). He also observes how the "bump" changes when lying down and standing. In the case of the standing patient, the outer inguinal ring is also palpated by the doctor and in the case of the man the testicles are also examined. In most cases, this clinical examination is sufficient to make the diagnosis of an inguinal hernia. If a hernia cannot be reliably detected by the examination (so-called occult, i.e. hidden hernias), an ultrasound examination of the groin region is carried out. If the ultrasound examination does not produce a clear result either, a magnetic resonance tomography (MRT) or computed tomography (CT) examination may be used. A hernia is not always the cause of groin pain; it can also be caused by swollen lymph nodes, tumors or vascular bulges.

Therapy: How is an inguinal hernia treated?

In the past and also today, the diagnosis of "inguinal hernia" is in principle the indication for surgery, as spontaneous healing, for example by strengthening the muscles, is not possible. Nowadays the wording is less clear. In the case of a male unilateral inguinal hernia without symptoms, it is also possible to wait ("watchfull waiting"). However, the current HerniaSurge guideline indicates that most patients with asymptomatic hernias develop symptoms over time and should therefore be operated on over time. Both the indication for surgery and the time for surgery should be clarified with the patient. Because with every hernia there is a risk that loops of intestine or parts of the peritoneum could become trapped in this gap and die. This condition is life-threatening and then requires immediate surgery (emergency surgery). Therefore, an inguinal hernia should be operated on before it becomes an emergency situation.

Which surgical method is suitable for an inguinal hernia depends on many factors. The age of the patient plays a role, as does the location and size of the fracture. Whether the fracture is unilateral or bilateral or whether it is a new fracture (relapse) is also important when choosing a therapy. In addition, some procedures are unsuitable because they require general anesthesia. This is not an option for every patient. The currently valid guidelines of the HerniaSurge Group recommend that for the treatment of one-sided inguinal hernia in men mainly mesh-based techniques in endoscopic procedures or open operations according to Lichtenstein (see picture gallery) should be used. However, this is only to be understood as a recommendation. Which method is chosen must be individually adapted to the patient under the above-mentioned aspects and is clarified with the patient in a detailed consultation with a doctor.

Important: An inguinal hernia operation should be performed by an experienced surgeon who specializes in one of the procedures described below.

In principle, three different surgical methods have established themselves: the Shouldice operation, the Lichtenstein operation and minimally invasive procedures. The doctor and patient must decide individually which procedure is used. The Shouldice and Lichtenstein operations involve so-called anterior (front) access routes, in which a skin incision is made on the groin. The minimally invasive procedure (TAPP and TEPP) is a so-called posterior (rear) access route in which the fracture gaps are treated using endoscopic devices (keyhole surgery) (see also our picture gallery, please click through).

Surgical procedure to treat the inguinal hernia

© W & B / Ulrike Möhle

TO THE PICTURE GALLERY

© W & B / Ulrike Möhle

Operation according to Shouldice

Procedure: The surgeon makes a skin incision in the groin region and exposes the break. He then opens the hernial sac that was formed by the hernia and carefully pushes the contents of the hernia back into the abdominal cavity. As a result, intestinal and / or fatty tissue return to their original positions. The hernial sac is then sewn up again. The hernia is then closed with a suture and sutured to the adjacent connective tissue to stabilize the groin region.

Advantages: The procedure can take place under local anesthesia, no general anesthesia is necessary. Little artificial material is required - only for sewing. Therefore there are hardly any allergic reactions or irritations.

Disadvantages: Patients have to take it easy for a long time after the operation. It usually takes two months before they are allowed to exercise again, lift something or do sports. After the procedure, you may experience drawing pain in the groin for a while.

For whom? Doctors sometimes recommend the Shouldice procedure for young people and for those who have suffered a minor hernia. The Shouldice surgical procedure is also an option for patients who refuse a mesh implantation.

© W & B / Ulrike Möhle

Operation according to Lichtenstein

Procedure: In principle, the operation proceeds like the Shouldice procedure. However, the surgeon stabilizes the break with a special plastic mesh. He places it over the hole made by the break and sews the net over it. In men, the mesh is positioned around the spermatic cord so that it can continue to run unhindered through the inguinal canal.

Advantages: No general anesthesia is required for this method, local anesthesia is sufficient. The risk of a new break is low. Patients are allowed to exercise again earlier than after the Shouldice procedure.

Disadvantages: The plastic net is absorbed into the body as a foreign material. With modern networks, however, it is very rare that the body reacts sensitively to them.

For whom? The Lichtenstein operation is suitable for the elderly and for patients with a major hernia. This method is also recommended if the fracture is repeated or if the person concerned has to be fit again quickly for professional reasons.

© W & B / Ulrike Möhle

Minimally invasive procedures: TAPP / TEP

Procedure: Minimally invasive means that there is no need for a large skin incision, only tiny incisions. Experts differentiate the so-called TEP (total extraperitoneal hernioplasty) method from the TAPP (transabdominal preperitoneal hernioplasty) method. In both cases, the surgeon inserts an endoscope and the necessary instruments through the small abdominal incisions and pushes them forward to the hernia.

With the TEP technique, the doctor uses a fine tissue gap that is naturally located between the skin and the peritoneum. There he cuts the skin and smuggles in the instruments. The surgeon pushes the hernial sac back into the abdominal cavity and inserts a plastic mesh through the above-mentioned gap, which he attaches over the hernia. The net fixes itself, no metal clips or the like are necessary. With the TAPP procedure, the skin incisions are in the area of ​​the navel and the mid-abdomen. Then the belly has to be inflated with the help of carbon dioxide. The surgeon also pushes the hernial sac back into the abdominal cavity. He pushes the plastic net from the abdomen - i.e. from the inside - to the hernia. He does a laparoscopy for this.

Advantages: The risk of a new break is considered to be low. The patient can soon exercise again - after just seven to ten days. The doctor places the plastic mesh without having to pull the break closed. The operated person is usually spared pulling pain and can move quickly again. Another great advantage is that bilateral hernias can also be treated in one operation with this method.

Disadvantages: The operation is performed under general anesthesia, which can be problematic for older people, for example. The surgeon rarely injures the peritoneum during this procedure, which leads to pain after the operation.

For whom? According to experts, this procedure is recommended for all patients for whom there are no contraindications against the procedure. Anyone who, for professional reasons, needs to be able to cope with physical strain again quickly can, for example, opt for this surgical method.

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Trusses

Doctors generally no longer recommend trusses. The affected person stretches a truss externally around the groin region. The tape is intended to push the contents of the hernia into the inguinal canal. However, it has some drawbacks: it does not fix the hernia. In addition, long-term use weakens the abdominal wall, which makes subsequent operations more difficult.

Dr. Peter Harding

© W & B / private

Our advisory expert:

Dr. Peter Harding is a doctor for general surgery, trauma surgery and visceral surgery. He is chief physician at the clinic for general and visceral surgery, trauma surgery and proctology at the St. Sixtus Hospital in Haltern am See. His professional focus is on hernia surgery, minimally invasive surgery ("keyhole surgery"), tumor diseases of the gastrointestinal tract, liver and pancreas.

Swell:

  • Der Chirurg, Volume 89, Issue 8, August 2018. D Weyhe et al., "HerniaSurge: international guidelines for the therapy of inguinal hernias in adults. Comment from the Surgical Working Group on Hernia (CHD / DGAV) and the German Hernia Society (DHG) on the most important Recommendations ", pp. 631-638
  • Surgeon 2017 · 88: 274–275, DOI 10.1007 / s00104-017-0390-7, F. Köckerling, "Guideline-compliant surgery of inguinal hernias"
  • Working group (AWMF), "Guidelines of the German Society for Pediatric Surgery - Inguinal Hernia, Hydrocele". Online: https://www.awmf.org/uploads/tx_szleitlinien/006-030l_S1_Leistenhernie_Hydrozele_2014-09-verlaengert.pdf (accessed on March 5, 2019)
  • Deutsches Ärzteblatt, Berger D., Evidence-Based Treatment of Adults. Online: https://www.aerzteblatt.de/archiv/175103/Evidenzbasierte-Behlassung-der-Leistenhernie-des-Erwachsenen (accessed on February 27, 2019)
  • Federal Statistical Office, DEStatis, The 20 most frequent operations in total (OPS code 5). Online: https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Gesundheit/Krankenhaeuser/Tabellen/DRGOperationenInsammlung.html (accessed on February 27, 2019)

Important NOTE:

This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.

Intestines