Evangelos Messaris
Presentation
A 55-year-old male patient with a history of hypertension and diabetes presents with right groin discomfort. He reports having right groin discomfort for the last 3 months. He also noticed a bulge in his right groin several months ago. He has no fever, chills, nausea, vomiting or dysuria. His vitals are normal. On exam it is noted that he has a mass in the right groin that extends into his scrotum. The mass is reducible, but it immediately recurs after reduction.
Differential Diagnosis
Groin discomfort usually is associated with an inguinal or femoral hernia or a process involving the spermatic cord or round ligament structures. Although, inguinal hernias are common, there are other medical conditions that can have similar presentation. Femoral hernias, enlarged inguinal nodes, hydroceles, testicular torsion, epididymitis, varicocele, spermatocele, epididymal cyst, and testicular tumors are less frequent but should be included in the differential diagnosis of a patient presenting with a symptomatic groin mass or groin discomfort.
Workup
The patient undergoes more extensive physical exam of his abdomen, in the standing and supine position, demonstrating a reducible inguinal mass at the level of the external ring of the inguinal canal with minimal overlying tenderness, suggestive of a right inguinal hernia.
The diagnosis of an inguinal hernia is based on physical examination. Reported sensitivity and specificity of physical examination for the diagnosis of inguinal hernia are 75% and 96%, respectively. In males, the index finger of the examiner should invaginate the scrotum in an attempt to find the external opening of the inguinal canal. The patient should then be asked to cough or perform a Valsalva maneuver. The examiner should then feel the hernia sac with all its contents at the tip of his index finger. Similarly, in female patients the examiner can feel for the hernia sac by palpating the inguinal area just laterally of the pubic tubercle. It should be noted that the exam is performed above the inguinal ligament, because if the protruding mass is below the inguinal ligament, then it is a femoral hernia. This distinction is not often easy, especially in obese patients. In all cases both sides should be examined (not only the symptomatic side) to rule out bilateral inguinal hernias. No laboratory studies can help with the diagnosis of an inguinal hernia.
Rarely the use of imaging studies is helpful in moving from the differential diagnosis to a single working diagnosis. Imaging studies are mostly used in obese patients where physical exam has limitations (Figure 1). An ultrasound can demonstrate or rule out enlarged inguinal nodes, hydroceles, testicular torsion, varicocele, spermatocele, epididymal cyst, and testicular tumors. Furthermore, an experienced ultra-sonographer can demonstrate an inguinal hernia sac and identify its contents. Computed tomography is mostly used on cases of very large inguinal hernias, to depict the contents of the sac and to identify aberrant anatomy in the inguinal canal (Figure 2).
FIGURE 1 • Axial cut of a CT demonstrating a moderate-size right inguinal hernia with omentum in the hernia sac in an obese patient where physical exam findings would be limited.
FIGURE 2 • Axial cut of a CT, demonstrating a left inguinal hernia with sigmoid colon in the hernia sac.
Diagnosis and Treatment
Ascertaining whether patients have symptoms from their hernia is important for decision making. For truly asymptomatic hernias, a watchful waiting strategy can be followed. Younger patients are almost always symptomatic because they are invariably active. However, older patients who are not physically active may not be bothered by their hernia and repair can be deferred indefinitely.
Inguinal hernias can present with many different symptoms. A reducible hernia will often present with groin discomfort that is exacerbated with activity. Patients with incarceration or strangulation will present with more severe pain and, potentially overlying skin erythema. The treatment of all symptomatic inguinal hernias is surgical repair. The goals of the repair are to relieve the symptoms and prevent any future incarceration or strangulation of the hernia. The timing for symptomatic hernia repairs depends on whether the hernia is reducible, incarcerated, or strangulated. Reducible hernias can be repaired in an elective outpatient fashion, incarcerated hernias warrant urgent repair within 12 hours of presentation, and strangulated hernias need to go to the operating room emergently, since the viability of an organ in the hernia sac is compromised.
Surgical Approach
The surgical approach for a symptomatic inguinal hernia could be open or laparoscopic, with local, spinal, or general anesthesia. In the open procedures the repair can be suture based (Bassini, McVay, Shouldice) or using mesh (e.g., Lichtenstein). Mesh is also used in all the laparoscopic cases that can be further divided in total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP), depending on whether the peritoneal cavity is used for access to the inguinal region or not. Although many suggest using open repair for unilateral primary hernias and laparoscopic repair for bilateral and recurrent inguinal hernias, surgeon’s experience should guide the choice of repair. Laparoscopic inguinal hernia repair has a steep learning curve, and most experts suggest 100 to 250 cases are necessary to develop proficiency. For surgeons who are not proficient at laparoscopic herniography, open mesh repair is the best choice, even for recurrences and bilateral repairs.
Regardless of the technique employed, the main goal of surgical therapy is a tension-free repair of the defect to decrease the recurrence rate. All elective and the majority of the emergent repairs, except those where bowel is compromised and a bowel resection is performed, achieve this goal by placing mesh over the defect, or in the case of the laparoscopic approach, behind the defect. In contaminated cases, a suture-based technique (Bassini, McVay, or Shouldice) or biologic mesh can be used. However, these patients will have a higher recurrence rate.
Preoperative Care
All patients are placed in a supine position on the operating table. Patients should have thigh-length sequential compression devices and in our practice we give 5,000 units of unfractionated heparin subcutaneously if they are older than 40 years. Administration of a first-generation cephalosporin intravenously within 1 hour prior to incision is recommended, especially in cases where mesh is going to be used. Skin preparation should be done with chlorhexidine and should include the scrotum, in case manipulation is needed for the hernia sac reduction or to facilitate the return of the testicle into its proper location.
Local anesthesia can be given either as a nerve block of the ilioinguinal and iliohypogastric nerves or as direct infiltration into the incision site, always in combination with some conscious sedation. Alternatively, spinal or general anesthesia can be used.
All patients should void prior to the procedure, otherwise intraoperative bladder decompression with a bladder catheter is advised.
Open Inguinal Hernia Repair
Lichtenstein open, tension-free hernioplasty is considered the “gold standard” for open hernia repair (Table 1). The skin incision is placed over the inguinal canal and angled only slightly cephalad as it progresses laterally. The major anatomical landmark is exposure over the pubic tubercl, medially. The incision is carried down to the abdominal wall fascia that consists of the external oblique aponeurosis to expose the external inguinal ring. The aponeurosis is incised in the direction of its fibers. The cord structures are dissected from the cremasteric muscle and transversalis fascia fibers and retracted off the inguinal canal floor. The cord is explored for an indirect hernia sac or cord lipoma. All hernia sacs and cord lipomas are transected at the level of the internal ring. An appropriate size polypropylene mesh is secured to the shelving edge of the inguinal ligament from the pubic tubercle to past the insertion of the arch of the internal oblique to Poupart’s ligament using running or interrupted 2-0 Prolene suture. Similarly, the upper edge of the mesh is sutured to the rectus sheath and internal oblique muscle. The internal ring is reconstructed by suturing the two leaves of the mesh together lateral to the cord. The spermatic cord is returned to its original position and the aponeurosis of the external oblique is reapproximated using 2-0 absorbable suture in a running fashion, avoiding injuries of the ilioinguinal nerve.
TABLE 1. Key Steps to Open Lichtenstein Tension-free Hernioplasty
Laparoscopic Inguinal Hernia Repair
The TEP repair of inguinal hernias was developed out of concern for possible complications related to intra-abdominal access required for transabdominal approach (Table 2). In detail, the skin incision is made at the inferior aspect of the umbilicus and the anterior rectus sheath is incised lateral to the midline. Blunt dissection is used to sweep the rectus muscle laterally from the midline to expose the posterior rectus sheath fascia. A dissecting balloon is placed in the space between the rectus muscle anteriorly and the posterior fascia, and directed down to the pubis. Under direct visualization, the dissector is inflated. The balloon is then replaced by a standard blunt port and the previously created extraperitoneal space is insufflated with CO2 to reach 12 mm Hg. Two 5-mm trocars are placed in the lower midline. After identification of the inferior epigastric vessels superiorly, Cooper’s ligament medially, and the ileopubic tract laterally, the hernia sac is reduced, paying particular attention to completely detach the sac off the cord structures. A preformed or custom-made polyester mesh can be used for the repair. The mesh is positioned from a medial to lateral direction under the cord structures paying particular attention to cover the internal ring both laterally and superiorly, while its medial aspect is tucked below the Cooper’s ligament. When the mesh is correctly positioned, it can be fixated using tacks, staples, fibrin glue, or just be left in place without any fixation.
TABLE 2. Key Steps to Laparoscopic Totally Extraperitoneal Repair of Inguinal Hernia
Special Intraoperative Considerations
In all inguinal hernia repair cases, all types and all approaches, the major key point for a successful operation is knowing the anatomy of the inguinal canal (Tables 1 and 2).
For open repairs, attention should be paid to the dissection and preservation of the ilioinguinal and iliohypogastric nerve. Nerve entrapment can cause significant neuralgia in the postoperative period. If during the procedure a nerve is injured, then complete transection of the nerve is advised.
During laparoscopic repairs, the dissection in the groin area will cause some lacerations to the peritoneum and the peritoneal cavity contents maybe encountered. Each defect of the peritoneum should be closed using an endo-loop ligature (2-0 vicryl), and if the peritoneal cavity is insufflated with CO2, then it can be decompressed using a Veress needle.
Intraoperative complications include femoral vessel or inferior epigastric vessel injuries, bladder or testicular injuries, and vas deferens injury or nerve injury.
Postoperative Management
For elective cases or cases with omental incarceration, the patient usually can be discharged within 3 to 4 hours postoperatively. The patient should void without any problems and have adequate pain control before being discharged. Urinary retention is frequent after inguinal surgery and it is associated with the use of narcotics, the type of surgery, and the amount of intravenous fluids administered to the patients.
For urgent or emergent cases if no bowel was affected usually 24 hours of observation are adequate before discharge. In cases where bowel was found strangulated and bowel resection was done, the patients are usually followed in the hospital for 2 to 3 days.
Follow-up in all cases usually is scheduled 3 to 4 weeks postoperatively to check the wound healing (rule out any wound infections—rare <1%, or seromas or hematomas). Routine examination should rule out early recurrence and any neuralgia from nerve injury or entrapment. Most patients are able to return to work within 2 weeks from surgery, and even earlier if performed laparoscopically. No heavy weight lifting is advisable up to 3 months from the operation.
Case Conclusion
The patient underwent a successful laparoscopic right inguinal repair with mesh and was discharged 4 hours postoperatively. He returned to the office in 3 weeks with well-healed port sites and was pain free. During his routine postoperative appointment, the patient reported feeling a bulge in the right groin that was similar to the hernia that he had before. Exam did not reveal a recurrence and an ultrasound demonstrated a seroma at the repair site. No intervention was performed and the patient was seen 3 months postoperatively and the seroma was completely resolved.
TAKE HOME POINTS
· Inguinal hernias are common, comprising three-fourths of all abdominal wall defects. Lifetime risk for developing an inguinal hernia is 15% for males and 5% for females.
· All symptomatic inguinal hernias need to be surgically repaired to relieve symptoms and prevent any future incarceration or strangulation of the hernia.
· There are several described procedures for inguinal hernia repair and they can be open or laparoscopic.
· Regardless of the technique employed, the main goal of surgical therapy is a tension-free repair of the defect to decrease the recurrence rate.
· Seromas, neuralgia, and recurrence are some of the most frequent postoperative complications.
SUGGESTED READINGS
Amato B, Moja L, Panico S, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2009;(4):CD001543.
Langeveld HR, van’t Riet M, Weidema WF, et al. Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial): a randomized controlled trial. Ann Surg. 2010;251(5):819–824.
Messaris E, Nicastri G, Dudrick SJ. Total extraperitoneal laparoscopic inguinal hernia repair without mesh fixation: prospective study with 1-year follow-up results. Arch Surg. 2010;145(4):334–338.
Neumayer L, Giobbie-Hurder A, Jonasson O, et al.; Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350(18):1819–1827.
Nordin P, Zetterström H, Gunnarsson U, et al. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet. 2003;362(9387):853–858.