Inguinal hernia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2] [3] [4] [5] [6]

Inguinal hernia may be classified according to integrity of the posterior wall and the deep inguinal ring into 4 groups. Inguinal hernia may be classified according to presence or absence of a peritoneal sac, size of the internal ring and integrity of the posterior wall of the canal into 5 groups. Directed inguinal hernia is caused by protrusion through Hesselbach’s triangle, passes medial to inferior epigastric vessels. Indirected inguinal hernia is caused by passes through internal inguinal ring, traverses inguinal canal to external ring, and may extend into scrotum in males and labia major in females. Common causes of inguinal hernia include combination of increased pressure within the abdomen and a pre-existing weak spot in the abdominal wall, chronic coughing or sneezing, heavy lifting such as weightlifting, abdominal wall defects and advanced age. Inguinal hernia must be differentiated testicular torsion, epididymitis, hydrocele, varicocele, spermatocele, epididymal cyst and testicular tumor. Male are more commonly affected by inguinal hernia than female. The male to female ratio is approximately 9 to 1. Common risk factors in the development of inguinal hernia include history of hernia or prior hernia repair, older age, male gender, obesity. The symptoms of inguinal hernia usually develop in the 4th decade of life. Prognosis is generally good, and mortalilty is very rare. Symptoms of inguinal hernia include nausea and vomiting, heaviness or dull discomfort in the groin, especially when straining, lifting, coughing, or exercising that improves when resting. Patients with inguinal hernia usually appear good. Physical examination of patients with inguinal hernia is usually remarkable for bulge in the groin, painless scrotal mass and palpable abdominal mass may be present. Pharmacologic medical therapies for inguinal hernia include pain reliever, antibiotics, topical medications. Surgery is the mainstay of treatment for inguinal hernia and there are many types of surgical techniques.

Reinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring was first discovered by Stromayr in 1559. In 1871, new use of carbolized catgut ligature was developed by Marcy to treat inguinal hernia. Twisted and suture-transfixed the peritoneal sac in the lateral musclesthrough the external ring was developed by Kocher to treat inguinal hernia.

Inguinal hernia may be classified according to integrity of the posterior wall and the deep inguinal ring into 4 groups. Inguinal hernia may be classified according to presence or absence of a peritoneal sac, size of the internal ring and integrity of the posterior wall of the canal into 5 groups.

Directed inguinal hernia is caused by protrusion through Hesselbach triangle, passes medial to inferior epigastric vessels. Indirected inguinal hernia is caused by passes through internal inguinal ring, traverses inguinal canal to external ring, and may extend into scrotum in males and labia majora in females.

Common causes of inguinal hernia include combination of increased pressure within the abdomen and a pre-existing weak spot in the abdominal wall, chronic coughing or sneezing, heavy lifting such as weightlifting, abdominal wall defects and advanced age.

Inguinal hernia must be differentiated testicular torsion, epididymitis, hydrocele, varicocele, spermatocele, epididymal cyst and testicular tumor.

The incidence of inguinal hernia is approximately 110 per 100,000 individuals in years aged 16-24 years to 2000 per 100,000 person years aged 75 years or above in men. The prevalence of inguinal hernia is approximately 1700 per 100,000 individuals for all ages and 4000 per 100,000 for those aged over 45 years worldwide. The incidence of inguinal hernia increases with age; the median age at diagnosis is 40-59 years. Male are more commonly affected by inguinal hernia than female. The male to female ratio is approximately 9 to 1.

Common risk factors in the development of inguinal hernia include history of hernia or prior hernia repair, older age, male gender, obesity.

There is insufficient evidence to recommend routine screening for inguinal hernia.

The symptoms of inguinal hernia usually develop in the 4th decade of life, and start with symptoms such as bulging, heaviness, burning, or aching in the groin.

Common complications of inguinal hernia include bowel obstruction, bowel strangulation and incarceration.

Prognosis is generally good, and mortality is very rare.

The diagnosis of inguinal hernia is based on clinical examination and symptoms.

Symptoms of inguinal hernia include nausea and vomiting, heaviness or dull discomfort in the groin, especially when straining, lifting, coughing, or exercising that improves when resting.

Patients with inguinal hernia usually appear good. Physical examination of patients with inguinal hernia is usually remarkable for bulge in the groin, painless scrotal mass and palpable abdominal mass may be present.

Laboratory findings is usually normal among patients with inguinal hernia.

CT scan may be helpful in the diagnosis of inguinal hernia. Findings on CT scan suggestive of inguinal hernia include defect in the abdominal wall muscles, appearance of bowel loops within the lesion, lateral crescent sign.

There are no other diagnostic studies associated with inguinal hernia.

Pharmacologic medical therapies for inguinal hernia include pain reliever, antibiotics, topical medications.

Surgery is the mainstay of treatment for inguinal hernia and there are many types of surgical techniques.

Effective measures for the primary prevention of inguinal hernia include avoid becoming overweight, avoid rapid weight loss, use good body mechanics meanwhile lifting heavy objects.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Reinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring was first discovered by Stromayr in 1559. In 1871, new use of carbolized catgut ligature was developed by Marcy to treat inguinal hernia. Twisted and suture-transfixed the peritoneal sac in the lateral muscles through the external ring was developed by Kocher to treat inguinal hernia.

• Reinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring was first discovered by Stromayr in 1559.^[1]
• Reinforcement of the posterior wall of the inguinal canal and the tightening of the internal inguinal ring via an intraabdominal approach by laparotomy was first discovered by Tait in 1891.^[2]
• Reinforcement of the posterior wall of the inguinal canal and the tightening of the internal inguinal ring via laparoscopically was first discovered by Velez and Klein in 1990.

• In 1871, new use of carbolized catgut ligature was developed by Marcy to treat inguinal hernia.^[3]
• In 1876, ligating and excising the indirect peritoneal sac through the external ring was developed by Czerny to treat inguinal hernia.^[1]
• Twisted and suture-transfixed the peritoneal sac in the lateral muscles through the external ring was developed by Kocher to treat inguinal hernia.
• In 1886, reefed the peritoneal sac into a plug to block the internal ring was developed by MacEwen to treat inguinal hernia.^[4]
• Opened the external oblique aponeurosis to expose the entire inguinal canal was developed by Lucas-Championniere to treat inguinal hernia.
• In 1935, tensionless technique was based on strengthening of the posterior wall of inguinal canal with prosthetic material by Lichtenstein to treat inguinal hernia.^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Inguinal hernia may be classified according to integrity of the posterior wall and the deep inguinal ring into 4 groups. Inguinal hernia may be classified according to presence or absence of a peritoneal sac, size of the internal ring and integrity of the posterior wall of the canal into 5 groups.

• Inguinal hernia may be classified into several subtypes based on:^[1]
  • Nyhus classification
  • Gilbert classification
  • Casten classification
  • Mc Vay classification

• Inguinal hernia may be classified according to the integrity of the posterior wall, and the deep inguinal ring, into 4 groups:^[2]

• Normal inguinal ring, peritoneal sac is in the inguinal canal.

• Enlarged deep inguinal ring with the posterior wall intact, sac not in the scrotum

• Posterior wall (inguinal floor) defects:
  • Type 3a:
    • Direct hernia with a posterior floor defect only
  • Type 3b:
    • Indirect hernia with enlargement of deep inguinal ring and posterior floor defect
  • Type 3c:
    • Femoral hernia
  • Type 4:
    • Recurrent hernia
• Inguinal hernia may be classified according to the presence or absence of a peritoneal sac, size of the internal ring and integrity of the posterior wall of the canal, Gilbert classification, into 5 groups:^[3]
  • Type 1:
    • Hernias with a peritoneal sac passing through an intact internal ring, unable to admit 1 finger breadth (ie,<1 cm.) and the posterior wall is intact.
  • Type 2:
    • Hernias with a peritoneal sac coming through a 1-finger breadth internal ring (ie, ≤2 cm.) and the posterior wall is intact.
  • Type 3:
    • Hernias have a peritoneal sac that is able to accommodate a 2-finger breadth or wider internal ring (ie, >2 cm).
  • Type 4:
    • Hernias have posterior wall with either complete breakdown or multiple defects. There is intact inguinal ring with no peritoneal sac.
  • Type 5:
    • Hernias are pubic tubercle recurrence or primary diverticular hernias.

NOTE: Types 1, 2 and 3 are indirect hernias; types 4 and 5 are direct.

• Inguinal hernia may be classified according to Casten method into 3 stages:
  • Stage 1: an indirect hernia with a normal internal ring
  • Stage 2: an indirect hernia with an enlarged or distorted internal ring
  • Stage 3: all direct or femoral hernias

• Inguinal hernia may be classified according to McVay method into 4 classes:
  • Class 1: small indirect hernia
  • Class 2: medium indirect hernia
  • Class 3: large indirect hernia or direct hernia
  • Class 4: femoral hernia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Directed inguinal hernia is caused by protrusion through Hesselbach triangle, passes medial to inferior epigastric vessels. Indirected inguinal hernia is caused by passes through internal inguinal ring, traverses inguinal canal to external ring, and may extend into scrotum in males and labia majora in females.

• It is understood that indirect inguinal hernia is caused by:^[1][2]
  • Passes through internal inguinal ring, traverses inguinal canal to external ring
  • May extend into scrotum in males and labia major in females
  • Passes lateral to inferior epigastric vessels and has an oblique inferior course
  • Considered a congenital defect and associated with a patent processus vaginalis
• It is understood that directed inguinal hernia is caused by:
  • Protrusion through Hesselbach triangle
  • Generally does not extend into scrotum
  • Passes medial to inferior epigastric vessels
  • Considered an acquired defect

• Genes involved in the pathogenesis of inguinal hernia include microdeletion disorders such as 22q11.2 microdeletion.^[3]

• On microscopic histopathological analysis, inflammatory infiltration, vascular damage and regressive nerve lesions, fibrohyaline degeneration and fatty dystrophy of the muscle fibers are characteristic findings of inguinal hernia. ^[4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Common causes of inguinal hernia include combination of increased pressure within the abdomen and a pre-existing weak spot in the abdominal wall, chronic coughing or sneezing, heavy lifting such as weightlifting, abdominal wall defects and advanced age.

• There are no life-threatening causes of inguinal hernia, however complications resulting from untreated inguinal hernia is common.

Inguinal hernia may be caused by:^[1][2]

• Increased pressure within the abdomen
• Pre-existing weak spot in the abdominal wall
• Combination of increased pressure within the abdomen and a pre-existing weak spot in the abdominal wall
• Repetitive straining during urination or bowel movements
• Strenuous activity
• Pregnancy
• Chronic coughing or sneezing
• Heavy lifting, such as weightlifting
• Abdominal wall defects
• Advanced age
• Ascites
• Connective tissue disorders
• Cystic fibrosis
• Prematurity
• Positive family history
• Shunt for hydrocephalus
• Undescended testis

List the causes of the disease in alphabetical order. {{columns-list|

• Increased pressure within the abdomen
• Pre-existing weak spot in the abdominal wall
• Combination of increased pressure within the abdomen and a pre-existing weak spot in the abdominal wall
• Repetitive straining during urination or bowel movements
• Strenuous activity
• Pregnancy
• Chronic coughing or sneezing
• Heavy lifting, such as weightlifting
• Abdominal wall defects
• Advanced age
• Ascites
• Connective tissue disorders
• Cystic fibrosis
• Prematurity
• Positive family history
• Shunt for hydrocephalus
• Undescended testis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Inguinal hernia must be differentiated testicular torsion, epididymitis, hydrocele, varicocele, spermatocele, epididymal cyst and testicular tumor.

• Inguinal hernia must be differentiated testicular torsion, epididymitis, hydrocele, varicocele, spermatocele, epididymal cyst and testicular tumor.^[1][2][3][4]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

The incidence of inguinal hernia is approximately 110 per 100,000 individuals in years aged 16-24 years to 2000 per 100,000 person years aged 75 years or above in men. The prevalence of inguinal hernia is approximately 1700 per 100,000 individuals for all ages and 4000 per 100,000 for those aged over 45 years worldwide. The incidence of inguinal hernia increases with age; the median age at diagnosis is 40-59 years. Male are more commonly affected by inguinal hernia than female. The male to female ratio is approximately 9 to 1.

• The incidence of inguinal hernia is approximately 110 per 100,000 individuals in years aged 16-24 years to 2000 per 100,000 person years aged 75 years or above in men.^[1]

• The prevalence of inguinal hernia is approximately 1700 per 100,000 individuals for all ages and 4000 per 100,000 for those aged over 45 years worldwide.^[2]

• The 30 day mortality rate of 2000 per 100,000 in patients under 60 years old and 48000 per 100,000 individuals in those over 60 years old after elective surgery.^[3]

• Patients of all age groups may develop inguinal hernia.^[4]
• The incidence of inguinal hernia increases with age; the median age at diagnosis is 40-59 years.^[5]
• Direct inguinal hernia commonly affects middle-aged and elderly individuals because the abdominal walls weakens with age.
• Indirect inguinal hernias can occur at any age including the young individuals.

• Inguinal hernia affects individuals of the Caucasian more than Afriacn-American.^[6]

• Male are more commonly affected by inguinal hernia than female. The male to female ratio is approximately 9 to 1.^[7]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Common risk factors in the development of inguinal hernia include history of hernia or prior hernia repair, older age, male gender, obesity.

• Common risk factors in the development of inguinal herna include pregnancy, history of hernia or prior hernia repair, obesity, male gender, older age.

• Common risk factors in the development of inguinal hernia include:^[1][2]
  • History of hernia or prior hernia repair
  • Older age
  • Male gender
  • Smoking
  • Family history of hernia
  • Obesity
  • Pregnancy
  • Chronic obstructive pulmonary disease
  • Peritoneal dialysis
  • Collagen vascular disease
  • Previous open appendectomy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

There is insufficient evidence to recommend routine screening for inguinal hernia.

• There is insufficient evidence to recommend routine screening for inguinal hernia.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

The symptoms of inguinal hernia usually develop in the 4th decade of life, and start with symptoms such as bulging, heaviness, burning, or aching in the groin. If left untreated, patients with inguinal hernia may progress to develop incarceration, strangulation. Prognosis is generally good, and mortality is very rare.

• The symptoms of inguinal hernia usually develop in the 4th decade of life, and start with symptoms such as bulging, heaviness, burning, or aching in the groin.
• If left untreated, patients with inguinal hernia may progress to develop incarceration, strangulation.^[1]

• Common complications of inguinal hernia include:^[2][3][4]
  • Bruising and haematoma
  • Chronic and persisting pain
  • Infertility
  • Incarceration
  • Bowel obstruction
  • Bowel strangulation
  • Postoperative complications
    • Seroma / hematoma formation
    • Urinary retention
    • Neuralgias
    • Testicular pain and swelling
    • Mesh infection and wound infection
    • Recurrence

• Prognosis is generally good, and mortality is very rare.

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