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Left Indirect Inguinal Hernioplasty

Liborio "Jun" Soledad, MD*; Enrico Jayma, MD*; C. Haddon Mullins, IV, MD**
*Operating Surgeons, World Surgical Foundation
**Resident, General Surgery, University of Alabama at Birmingham

Abstract

The expression “inguinal hernia” refers to protrusion (or herniation) of abdominal contents through a weak spot in the abdominal wall in the region of the inguinal ligament. Inguinal hernias are 10 times more common in males than in females. Other risk factors include family history, premature birth, overweight or obesity, pregnancy, chronic cough, and constipation. There are two types of inguinal hernia: indirect and direct.

An indirect inguinal hernia, the more common type, often occurs in premature infants born prior to closure of the inguinal canal; however, it can occur at any age. Direct inguinal hernias occur in adults with a frequency that increases with age. They are believed to be caused by the weakening of the abdominal wall musculature over time. Some individuals with inguinal hernias experience heaviness or pressure in the groin, while others feel pain or discomfort especially when bending, coughing, or lifting.

An inguinal hernia is usually diagnosed clinically by physical examination. However, if the diagnosis is in doubt, ultrasound, CT or MRI may be needed.

Small and asymptomatic inguinal hernias may be managed expectantly, while large and symptomatic inguinal hernias require surgical repair. Inguinal hernia repair is performed by returning the protruding intestinal contents to the abdominal cavity and reinforcing the weakened abdominal wall with a synthetic mesh.

Here we present a 58-year-old male with a left indirect inguinal hernia. He presented with a bulge in the left inguinal area that extended into the scrotum. Intraoperatively, we found that his sigmoid colon had herniated into the scrotal sac.

Case Overview

Background

Indirect inguinal hernias refer to a protrusion of abdominal contents through a weakened abdominal wall lateral to the epigastric vasculature. While the indirect hernia is most common as a congenital defect, it may occur at any age, as seen in this patient. When combined with direct hernias, where the operative approach is similar, the combined risk has been found to increase with age, up to 4.2% at 80 years.1 

Focused History of the Patient

Our patient is a 58-year-old male who presented with recurrent bulging in his left inguinal area extending to the left scrotum. The current problem began three years ago, and he has an incidental history of hernia repair with mesh on the right side 26 years ago. 

Physical Exam

Physical exam disclosed a visible bulge and palpable mass in the left scrotal and groin area.

Differentiation between direct and indirect hernias on physical exam may not always be possible but is also not always necessary as the treatment is similar for both. Symptoms may include pain or discomfort, especially with coughing, defecation, or exercise. The presentation of sudden onset, acute pain in the area of the hernia may indicate strangulation, which is a surgical emergency. 

Imaging

Typically, a history and physical exam are sufficient for the diagnosis of an inguinal hernia. In patients with atypical symptoms or in the absence of physical exam findings, however, CT and MRI may be useful. Ultrasound is a less expensive and radiation-free option, but its accuracy is less reliable.2

Natural History

Recently, there has been increasing interest in nonoperative management for patients with minimally symptomatic, fully reducible hernias in men.3,4 Still, any symptomatic patient should be offered surgical repair, and a majority of patients who enter watchful waiting will end up receiving surgery due to increasing pain. 

Furthermore, any patient presenting with an incarcerated hernia should be offered surgical repair, and patients presenting with acute onset pain should be considered for emergent surgical treatment with concern for strangulation. 

Options for Treatment

Options for treatment include surgical repair of the defect and return of abdominal contents into the abdominal cavity. Some patients may elect for observation rather than surgery, and while this is a safe option, it most likely only delays inevitable surgery due to increasing symptoms associated with the hernia.   

Rationale for Treatment

The goal for treatment is an increase in quality of life and symptom resolution. Furthermore, treatment goals include a reduction in the risk of strangulation, especially for women, where the incidence of femoral hernia is much higher. 

Special Considerations

Differentiation between femoral and inguinal hernia on a physical exam can be difficult, and the risk of complications, including strangulation, associated with femoral hernias should prompt surgical management where they are suspected. This is especially the case for women presenting with groin hernias, where the incidence of femoral hernia is much higher. 

Discussion

Here we present the case of a 58-year-old male with an indirect inguinal hernia. He underwent an uncomplicated open, tension-free repair with synthetic mesh. Notably, this case involved a large hernia of 100 to 150 cm of bowel including a segment of sigmoid colon.

Patients generally may be treated as an outpatient and may return home the same day as surgery. Moderate activities of daily living may be resumed immediately, the patient will be asked to perform routine wound care, and a follow-up appointment will be scheduled for 1-week postoperatively. Any heavy lifting should be restricted until the patient is 6-8 weeks post-operation. 

The most important postoperative complication to be aware of is the development of chronic post-herniorrhaphy groin pain. Of those that undergo inguinal hernia repair, up to 54%, with an average of around 10%, of patients will experience chronic pain.5 Treatment can include NSAIDs at first followed by neurectomy or mesh excision for refractory cases after recurrence has been excluded.6

While this case represents an open repair, minimally invasive (laparoscopic or robotic) repairs have emerged as options for surgeons with proper experience. Numerous studies have attempted to evaluate the efficacy and efficiency of minimally invasive approaches to open approaches with mixed results.7,8 Most likely, recurrence rates and complications are similar given adequate surgeon experience with the laparoscopic approach.

Equipment

Special equipment includes a prolene mesh.

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

    Citations

    1. Burcharth J, Pedersen M, Bisgaard T, Pedersen C, Rosenberg J. Nationwide prevalence of groin hernia repair. PLoS One. 2013;8(1):e54367. doi:10.1371/journal.pone.0054367
    2. Poelman MM, van den Heuvel B, Deelder JD, et al. EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc. 2013;27(10):3505-3519. doi:10.3389/fsurg.2014.00020
    3. Fitzgibbons RJ, Jr., Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295(3):285-292. doi:10.001/jama.295.3.285
    4. O'Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg. 2006;244(2):167-173. doi:10.1001/jama.295.3.285
    5. Fitzgibbons RJ, Jr., Forse RA. Clinical practice. Groin hernias in adults. N Engl J Med. 2015;372(8):756-763. doi:10.1056/NEJMcp1404068
    6. Montgomery J, Dimick JB, Telem DA. Management of Groin Hernias in Adults-2018. JAMA. 2018;320(10):1029-1030. doi:10.1001/jama.2018.10680
    7. McCormack K, Scott NW, Go PM, Ross S, Grant AM, Collaboration EUHT. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003(1):CD001785. doi: 10.1089/lap.2019.0656
    8. O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012;255(5):846-853. doi:10.1097/SLA.0b013e31824e96cf