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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.
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
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 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.
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
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 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.
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.
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.
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.
Special equipment includes a prolene mesh.
Nothing to disclose.
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.
- 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
- 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
- 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
- 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
- Fitzgibbons RJ, Jr., Forse RA. Clinical practice. Groin hernias in adults. N Engl J Med. 2015;372(8):756-763. doi:10.1056/NEJMcp1404068
- 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
- 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
- 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
Table of Contents
- Identify and Expose Hernia Sac
- Open Hernia Sac
So we are presented with a 58-year-old male, who's been having recurrent bulging on his left inguinal area- eventually extending and involving the left scrotum. Incidentally, he has undergone a mesh hernia repair on the right side about 26 years ago. Now this current problem of his started 3 years ago, and- he's been diagnosed to have an indirect inguinal hernia on the left.
So we're about to perform a hernia repair on the left side this time- cutting. Dr. Enrico Jayma will be the surgeon for this case. He's now beginning the procedure by incising through the- left inguinal area. He will be extending the incision down to your left inguinal canal.
Adult, or acquired inguinal hernias, usually arise if you have a weakening on your inguinal floor. So the pathology is quite different from congenitals, or inborn hernias. Mosquito. Going through the abdominal layer, you'll be encountering the, branches of your inferior epigastric vessels. Here you can see the inferior epigastric vessels being litigated. Zip tie. Army-Navy. Here you can see Dr, Jayma ligating branches of your inferior epigastric artery. Passing through the subcutaneous layer, you will now encounter the layer of the Scarpa's fascia. beneath that layer, you're expecting to find your external oblique muscle, together with its aponeurosis. And we'll be- going through that layer as well- until we reach your inguinal canal, which contains your- spermatic cord. I think the opening- the exterior oblique aponeurosis is already obliterated. Sometimes if you have- chronicity of your conditions, your- anatomy becomes- disturbed. Like in this case, the anterolateral wall of your, abdominus already thinned out. It's very difficult to really show you an intact external oblique muscle. As you can see, this is the sac- your hernial sac, containing- I would surmise- I would guess small bowels and omentum. Mosquito.
In- less complicated cases, after opening your external oblique, you'll be going through your cremasteric muscle, but in this case, those layers are already thinned out and- difficult to point out. Mosquito. Dr. Jayma is now trying to access your hernial Sac. Mosquito. Here, the hernial sac has been opened. We'll be enlarging the opening, so we can see what's inside. Hold please, okay.
We will be first releasing, or taking out, what has been incarcerated in the scrotal area, before we reduce it to the abdominal compartment. Most commonly, the omentum is involved in these cases, but- for our patient, what has gone inside are segments of your large intestine, probably a redundant sigmoid. When… When segments of your gastrointestinal tract- have very loose mesenteric attachments, they tend to, be involved in big hernias. Dr. Jayma is now carefully inspecting the distal sac, to see if there are any attachments or adhesions, which he might need to release.
After clearing the distal sac, he will not try to attempt to reduce- these bowel segments back into the abdominal cavity. You have to open it up, we have to make it enlarged. If in cases of difficulty- if you encounter difficulty in doing this, we can further enlarge your- opening, sometimes even- cutting open your internal ring. The internal ring is only I think 6 cm. 6 cm? So we have to open it up. The patient is quite lucky- that the internal ring is also big. If the internal ring is quite small, it can- it can compress on your bowel segments, eventually- costing- compromising your blood supply, strangulating your bowel, so to speak. If in case that happens, that segment of the bowel involved would undergo necrosis and eventually rupture, and it'll be an emergency for this case. It's a good thing that the internal ring is quite accommodating. As you can see, the bowels are viable and quite healthy. Yes. Dr. Jayma must now increase the diameter of your- internal inguinal ring. He's now attempting to reduce this segment of the large bowel, back into the abdominal cavity. Army-Navy. Some retraction can help. There's really no strict rule in performing the reduction back into the abdominal cavity, you just need to be careful not to traumatize the bowel segments- the segments, not the rupture any mesenteric vessels, or cause hematomas and possible injuries. Sometimes, when the omentum is incarcerated, involved in the incarceration, and there is difficulty in reducing it, we sometimes perform a partial omentectomy, but of course structures involved in this case are your- segments of your gastrointestinal tract, and it would be not advisable to perform resection. This is a segment of your sigmoid colon. Obviously your large intestine, or your colon, evidenced by your appendages, your haustrations and your taenias. These are your taenia coli, you have 3, these are strips of longitudinal muscles in your large intestines. Dr. Jayam is patiently reducing the sigmoid colon. It's not surprising to find that these, segments are also filled with feces. Reducing the incarcerated segments is of course dependent on how much has been passed through the hernial sac. We've pushed around half of the incarcerated segment already. It really takes a lot of practice to somehow perfect this maneuver, as the bowel segment should be handled very carefully. There you go. So, approximately the hernial sac contained around- approximately 100-150 cm of bowel, large intestine. Sometimes it's- it helps if you lower the patient's head and get some assist from gravity. See the large intestine exhibiting peristaltic movements. So, it's your- it's evidence of the- that your incarnated segment is still viable, plus of course the color. This can be tiring, but Dr. Jayma is very patient. So now you only have around one third of what's been incarcerated- still outside. A few centimeters more. These are your appendices epiploicae, these are fat deposits- on the external surface of your large intestine, one of the features that differentiates it from your small intestines. Sometimes the reduction is easy, and sometimes it's difficult. Once reduction is completed, we'll be inspecting the inside of your hernial sac. The hernia sac is an extension of your peritoneal layer, which has- evaginated through the inguinal rings. And because the scrotal area is the point of least resistance, chronicity allowed for that part of your anatomy to be involved. So inguinal hernials usually present as a bulging in your inguinal-scrotal area. There, Dr. Jayma has been very patient and has been successful at this point. Mosquito, please. Yes please, yes please. At this point, we can ask the anesthesiologist to level the patient, bring the head up again. Dr. Jayma will now show you how big the internal opening has been. Can I have a- DeBakey? This is the defect. Dr. Jayma will pinch and show you the edge of the peritoneal cavity- of the abdominal cavity. There. Inguinal ring, it's very big. And the rest of the distal sac, now empty. No bleeding, no adhesions. Mosquito. Dr. Jayma has now identified the bridge of the hernial sac, point where we will be separating the proximal from the distal segment.
So the sac has been opened, we are not trying to separate it from the rest of the spermatic cord. Open every last one. Yes. Where are we now, here. We're now at the bridge. And we have cut the hernial sac all the way around. So now you can see the hernial sac has been divided into 2 parts. One directed towards the abdominal cavity, and the other towards the scrotum. So it is the proximal segment that we're interested in. The first part of the hernia repair is to ligate the sac. Another mosquito, please. Mosquito. Dr. Jayma is now attempting to separate- the other components of your spermatic cord from the hernial Sac. Of course, the spermatic cord contains your vas deferens, your pampiniform vein plexus, your testicular artery. So we did not involve them in the ligation. Of course care should also be taken, so as not to- cut open the proximal segment of your hernial sac. He's kind of releasing the- hernial sac from its attachments. We're trying to isolate it, so we can ligate it and close the defect. Army-Navy. Usually we just a ligate the... No, no, no. Silk? Silk 2-0 with round needle. Usually, we just ligate the sac freely by tying that space, but for bigger defects, we might need to anchor the sutures, or- applying suture ligature. We'll be making use of a- silk suture- with a traumatic needle. I'm trying to, ligate the sac as high as possible. About the level of your peritoneal reflection. So this is- your internal inguinal ring, opening into your abdominal cavity. We're just releasing more attachments. He's making sure all the structures are involved.
Dr. Jayma will now be applying the sutures. Encircling the opening. About the peritoneal reflection. He's now going around the sac- encircling it. That white edge there marks the peritoneal reflection. Pickup. Pickup. Here, Dr. Jayma has gone all the way around the internal ring. As he tries to close the opening, the assist has to make sure- that all structures that were incarcerated are completely inside the cavity. This is the first of two components in your hernia repair, the high ligation of the sac. Army-Navy, Army-Navy. There you go. He's making one more turn, just to make sure everything is snug. Knife- Mayo? Scissors? Second tie. Just to make sure, Dr. Jayma is putting on a second ligature. Mosquito. Dr. Jayma will now be removing- the excess hernial sac. All right. So reviewing the anatomy, this is now the- proximal hernial sac, this is the distal sac.
Dr. Jayma is now inspecting the segment of your distal sac- trying to check if there are bleeders. Cautery. Making use of electrocautery, he's trying to control some bleeding, or oozers. Hold, please.
He will now identify the remaining segments of your spermatic cord. Through blunt dissection, he'll be separating it from the- inguinal floor. The second stage in your hernia repair is- strengthening or repairing the inguinal floor. So you have your vas deferens there. Your pampiniform plexus, and your testicular artery. And cremasteric muscle. Dr. Jayma is now trying to separate the rest of the spermatic cord from the inguinal floor. There you go. Penrose drain, ready. So Dr. Jayma is now holding the spermatic cord. So Dr. Jayma has now completed the separation. He's trying to enlarge the opening, as- in chronic cases like this, these aponeurotic layers can be- can become thick. Can you hold this one? Pickup, pickup. There's the floor. So Dr. Jayma is now examining the floor, trying to assess how loose it has become, so he can plan the placement of his mesh.
Now repairing the floor has had several techniques, but most of them are not free of tension. So putting on a mesh is one of the tension-free repairs in the- hernia repair. We are going to use a Prolene mesh, it's made of a polypropylene material, it's a non-absorbable material. Dr. Jayma is just cutting the- the material to ensure fit. He will now be applying the mesh over the inguinal floor. And he will be anchoring this with a Prolene suture- series of Prolene suture. Now the patients react tissues, reacting to this foreign body will cause fibrosis and eventual attachment and strengthening or thickening of that area. Pickup. Hold this. Hold please, hold please. Hold please. Pickup. Sorry. Not so much. Wait, wait, wait. We'll just apply it- place, there. Pickup. Dr. Jayma is feeling for the pubic bone, just make- trying to make use of it as a landmark. Prolene. Okay, now we'll be anchoring this Prolene mesh to the underlying structures. A few sutures will do. Dr. Jayma is just making sure he doesn't hit any vessel, big or small, nor the bladder. The femoral artery. As you can see, the anatomy has been distorted somewhat. Just a few interrupted su- sutures will do the trick in anchoring the Prolene mesh to the inguinal floor. The other side. Very good. He's trying to feel for the pulsations again. With an intact anatomy, you're supposed to identify the inguinal ligament, which is just nothing more but this shelving edge of your external oblique aponeurosis- that's on the lateral side, but… It's already obliterated, the inguinal ligament. The structures have become thinned out already, so it's very difficult to identify them. So Dr. Jayma is now attempting to anchor the Prolene mesh to where the inguinal ligament is- supposedly is. Hold, please. So Dr. Jayma has now encircled the spermatic cord- for the anchoring what remains of the- mesh. Let's make it wide. Identify the- external oblique. The external obligue aponeurosis is already destroyed- obliterated. You have to put it here, like that. I'm releasing suture. He's trying to lay down the- finishing interrupted sutures. The anchor, the Prolene mesh. There you go. This is the last suture- before we close the- incision. Release. Release. So the mesh has been laid down. We will now close the inguinal canal. Mosquito.
Trying to pick up the thin edge of your- external oblique aponeurosis. Mosquito. And close it, burying the mesh and the spermatic cord beneath it. We'll be making use of absorbable Vicryl. Mayo. The large size of your hernia, has expanded and thinned out the external oblique aponeurosis. And Dr. Jayma is now trying to repair and close what's left of it- with a continuous interrupted- or an interrupted suture technique using- absorbable sutures. He's now applying a continuous interlocking. Now he's trying to use every layer he can find to- strengthen the closure. Because this layer is already weakened from the size of your- from the enormous size of your- defect. Now with that layer closed, we can now end by repairing the skin defect. We'll be making use of absorbable sutures- after closing the subcutaneous layer of the skin. Just checking to see if there's more bleeders. Closing the subcutaneous fascia layer. So running through the procedure, we have accessed the inguinal canal, opened the hernial sac, reducing the bowel that has been incarcerated, ligating the hernial sac, and then repairing the floor with the use of a Prolene mesh. And then closing the layers, until we get to the skin. I'm inspecting the scrotal area, seeing that it's now empty of the incarcerated segments. It's expected that you have a redundancy of skin on your scrotal area- due to the largeness of the defect. Now Dr. Jayma is now using an absorbable 4-0 suture and applying the final layer of closure. Now with this repair, you can expect the patient to carry out moderately-heavy activities again, without endangering his bowel. And this is called the subcuticular skin closure. And this type of closure, we bury the suture in the subcuticular layer of the skin. Dr. Jayma has done a very good job in closing the skin, with the edges well opposed. He'll be ending by anchoring the suture with the knot in the end, and burying it under the skin to hide it. So we just finished a mesh hernioplasty on this 58-year-old patient. He's now going to make the final knot, and eventually bury the suture- beneath the skin, and hide the knot with it.
After the surgery, the patient is allowed to- get up and walk around, do some moderate activities like- their usual activities of daily living. He's asked to take care of his wound, make sure he continues taking the antibiotics and pain medications. And- follow-up is also advised in about a week or so, just to have this wound checked. And he's returned to performing moderate-to-heavy activity is advised at around- after 6-8 weeks, or that's 1.5-2 months. Thank you.