Inguinal hernia (Hernia inguinalis)

An inguinal hernia is a hernia in the area of the inguinal canal. The groin is the transition between the front abdominal wall and the legs, where the abdominal muscles and the leg muscles merge. At this point, the abdominal wall has several weak points, such as the right and left inguinal canal. In the case of an inguinal hernia, the parts of the intestines that normally pass through or are retained in the inguinal canal emerge from the abdominal cavity in the groin area, resulting in a sac-like protrusion of the peritoneum. In men, the inguinal canal contains the spermatic cord and the testicular arteries and veins. In women, it contains the uterine ligament (ligamentum teres uteri), which pulls toward the uterus.

Inguinal hernia is a relatively common condition, affecting men up to nine times more often than women. In childhood, it occurs in 1-3% of all children.

Inguinal hernias are mostly harmless. Nevertheless, they are mostly treated surgically in time, as otherwise there is a risk that parts of the intestine will be pinched off and thus die, leading to a life-threatening situation.

There are two types of inguinal hernia:

Indirect inguinal hernia: This is the more common form of inguinal hernia. It primarily affects newborns, children and young people. It is usually a congenital defect, affecting boys up to four times more often than girls. In this case, the hernia extends through the inner inguinal ring, so that the contents of the hernia escape along the spermatic cord or the uterine ligament.

Direct inguinal hernia: The condition is acquired in most cases. It mainly affects adults and older men. In this case, the contents of the hernia emerge directly from the abdominal cavity through the weakened abdominal muscles at the rear wall of the inguinal canal.

In most cases, inguinal hernias are congenital diseases. The cause lies in an incomplete abdominal wall closure during the development of the embryo. Weaknesses of the tissue, which can be caused by advancing age or surgery, are usually the reason for acquired hernias.

Several factors promote the development of a hernia. These include an increase in pressure in the abdominal cavity, which can occur during coughing, pregnancy, constipation or when lifting heavy loads. Furthermore, overweight also promotes the development of hernias.

In children, the main symptom of a hernia is a visible swelling in the groin area or on the testicle.

In adults, there are more varied signs:

• Visible or palpable swelling in the groin area, which can be provoked by physical exertion or even coughing. The swelling can often be "pushed away" without pain.
• Slight pain in the groin area, which may increase on palpation and radiate to the testis.
• Abdominal pain at times.
• Severe pain and vomiting. The cause is that when a hernia occurs, intestines can become trapped, cutting off their blood supply.

If swelling is noticed in the groin area of a child, it should be examined by a doctor for the presence of an inguinal hernia. If the pain is severe, the outpatient clinic should be visited immediately.

If a hernia is suspected, the doctor will perform a physical examination. The patient stands up straight, the doctor examines the area and feels it thoroughly. By feeling with the finger, it is checked whether the swelling is increased by coughing or by tightening the abdomen. Then it is checked whether the contents of the hernia can be pushed back into the hernia. Furthermore, a sonography (ultrasound examination) is also quite helpful for the clarification of an inguinal hernia.

Sometimes inguinal hernia-like swellings can also be caused by other diseases such as swelling of the lymph nodes, but this is rarely the case.

Surgery is the only way to safely prevent entrapment of the intestines and thus avoid life-threatening consequences. Therefore, non-surgical treatment methods, such as wearing a support corset or a tight hernia band, are not recommended. The fact that fractures tend to get bigger over time suggests early treatment.

Nowadays, due to modern procedures, operations can usually be performed on an outpatient basis. The operation can be performed under general anesthesia, but also under local anesthesia. Even in the case of large hernias and high-risk patients, hernia surgery is a relatively safe procedure.

A distinction is made between the following procedures:

• Operation according to Shouldice: Here, certain layers of the abdominal wall are doubled through an incision in the groin, which strengthens the posterior wall of the inguinal canal.
• Operation according to Lichtenstein: Here the posterior wall of the inguinal canal is reinforced with the help of a plastic net.
• Operation according to Rutkov: In addition to the plastic net (Lichtenstein method), a small net plate is sewn in through a tiny incision in the skin. This procedure can be performed on an outpatient basis and takes about 20 minutes.
• TAPP technique: The name TAPP means "transabdominal preperitoneal mesh implantation". This is a minimally invasive procedure in which a mesh is placed over the hernial orifice from the abdominal cavity and secured with metal clips.
• TEPPtechnique: TEPP means "total extraperitoneal hernioplasty". In this procedure, a mesh is also placed over the hernial orifice, but between the peritoneum and the muscles, where it holds on its own. Fixation by sutures or clips is not necessary here.

The operation according to Shouldice and the operation according to Rutkov are equally effective. It is up to the physician to decide which procedure should be used in specific cases. Long-term risks and successes of outpatient surgical treatment of inguinal hernias are not yet sufficiently known to make recommendations.

A non-surgical treatment method such as the support band is no longer recommended today, as this does not eliminate the cause of the hernia and the external pressure can lead to tissue damage.

In most cases, inguinal hernias are harmless, but there is always a risk of life-threatening complications developing, such as a clamping of the intestines. In this case, a loop of intestine is trapped in the hernia opening and thus no longer receives sufficient blood supply, which can lead to the death of tissue parts. If a pinch occurs, it must be operated on within six hours, otherwise it can lead to life-threatening peritonitis.

In a hernia operation, vessels, nerve cords and, in men, the spermatic cord can be damaged. The testicle can also regress as a result of the operation. In rare cases, there is an intolerance to the mesh that is used in the Lichtenstein operation. This must then be surgically removed.

Rarely, a new inguinal hernia (hernia recurrence) occurs, which must be treated again surgically.

It is practically impossible to prevent a hernia. However, if possible, the following risk factors should be avoided:

• Being overweight
• Lifting heavy loads
• Pressing during bowel movements - this, however, requires a soft consistency of the stool and an appropriate diet rich in fiber.