Inguinal hernia surgery

Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the inguinal canal in the groin region. There are two different clusters of hernia: groin and ventral (abdominal) wall. Groin hernia includes femoral, obturator, and inguinal. Inguinal hernia is the most common type of hernia and consist of about 75% of all hernia surgery cases in the US. Inguinal hernia, which results from lower abdominal wall weakness or defect, is more common among men with about 90% of total cases. In the inguinal hernia, fatty tissue or a part of the small intestine gets inserted into the inguinal canal. Other structures that are uncommon but may get stuck in inguinal hernia can be the appendix, caecum, and transverse colon. Hernias can be asymptomatic, incarcerated, or strangled. Incarcerated hernia leads to impairment of intestinal flow, and strangled hernia obstructs blood flow in addition to intestinal flow. Inguinal hernia can make a small lump in the groin region which can be detected during a physical exam and verified by imaging techniques such as computed tomography (CT). This lump can disappear by lying down and reappear through physical activities, laughing, crying, or forceful bowel movement. Other symptoms can include pain around the groin, an increase in the size of the bulge over time, pain while lifting, and a dull aching sensation. In occult (hidden) hernia, the bulge cannot be detected by physical examination and magnetic resonance imaging (MRI) can be more helpful in this situation. Males who have asymptomatic inguinal hernia and pregnant women with uncomplicated inguinal hernia can be observed, but the definitive treatment is mostly surgery. Surgery remains the ultimate treatment for all types of hernias as they will not get better on their own, however not all require immediate repair. Elective surgery is offered to most patients taking into account their level of pain, discomfort, degree of disruption in normal activity, as well as their overall level of health. Emergency surgery is typically reserved for patients with life-threatening complications of inguinal hernias such as incarceration and strangulation. Incarceration occurs when intra-abdominal fat or small intestine becomes stuck within the canal and cannot slide back into the abdominal cavity either on its own or with manual maneuvers. Left untreated, incarceration may progress to bowel strangulation as a result of restricted blood supply to the trapped segment of small intestine causing that portion to die. Successful outcomes of repair are usually measured via rates of hernia recurrence, pain and subsequent quality of life. Surgical repair of inguinal hernias is one of the most commonly performed operations worldwide and the most commonly performed surgery within the United States. A combined 20 million cases of both inguinal and femoral hernia repair are performed every year around the world with 800,000 cases in the US as of 2003. The UK reports around 70,000 cases performed every year. Groin hernias account for almost 75% of all abdominal wall hernias with the lifetime risk of an inguinal hernia in men and women being 27% and 3% respectively. Men account for nearly 90% of all repairs performed and have a bimodal incidence of inguinal hernias peaking at 1 year of age and again in those over the age of 40. Although women account for roughly 70% of femoral hernia repairs, indirect inguinal hernias are still the most common subtype of groin hernia in both males and females. Inguinal hernia surgery is also one of the most common surgical procedures, with an estimated incidence of 0.8-2% and increasing up to 20% in preterm children.

Indications for surgery Surgical intervention for hernias is guided by various factors, including the severity of symptoms, hernia type, medical history, hernia size, bowel incarceration (bowel can no longer return to the abdomen) and the overall general health of the person.

Non-urgent repair Elective surgery is planned in order to help relieve symptoms, respect the person's preference, and prevent future complications that may require emergency surgery. Surgery is offered to the majority of people who:

have symptoms that interfere with their normal level of activity. have hernias that become increasingly difficult to reduce. are female as it is often difficult to classify the subtype of hernia based on an exam alone. Symptomatic hernias tend to cause pain or discomfort within the groin region that may increase with exertion and improve with rest. A swollen scrotum within males may coincide with persistent feelings of heaviness or generalized lower abdominal discomfort. The sensation of groin pressure tends to be most prominent at the end of the day as well as after strenuous activities. Changes in sensation may be experienced along the scrotum and inner thigh.

Urgent repair A hernia in which the small intestine has become incarcerated or strangulated constitutes a surgical emergency. Symptoms include:

Fever Nausea and vomiting Extreme pain in the area of the hernia Warm hernia bulge with surrounding skin redness Can no longer pass gas or stool Surgical repair within 6 hours of the above symptoms may be able to save the strangulated portion of the intestine. Although pediatric inguinal hernias sometimes present asymptomatically, surgical repair is still the standard of care to prevent hernia incarceration, which for children who are born with hernias has a risk of 12% in full-term children and 39% in preterm children. In preterm neonates, the timing for intervention appears to be of utter importance as surgical hernia repair after neonatal intensive care unit (NICU) discharge might decrease recurrence and anesthesia-induced respiratory difficulties compared to surgery before NICU discharge.

Contraindications to surgery The person with the hernia should be given an opportunity to participate in the shared decision-making with their physicians as almost all procedures carry significant risks. The benefits of inguinal hernia repair can become overshadowed by risks such that elective repair is no longer in a person's best interest. Such cases include:

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