Summary

An inguinal hernia is the protrusion of abdominal contents (omentum or bowel) through the inguinal canal. It is the most common hernia worldwide (75% of abdominal wall hernias), predominantly affecting men. Complications such as incarceration (stuck) and strangulation (ischemic) are medical emergencies. Elective repair (Herniorrhaphy) using Mesh is the standard of care for symptomatic patients. [1,2]

Classification

1. Indirect (80%): Protrudes through the Deep Ring, lateral to inferior epigastric vessels. Travels inside the spermatic cord. Congenital origin (Patent Processus Vaginalis). Can reach the scrotum.
2. Direct (20%): Protrudes through Hesselbach's Triangle (posterior wall defect), medial to inferior epigastric vessels. Acquired weakness (elderly). Rarely reaches scrotum.

Clinical Pearls

The Gender Rule:

• Men: Can safely "Watch and Wait" if asymptomatic. Risk of strangulation is very low (0.2%/year).
• Women: Should ALWAYS be offered repair. Why? Because a lump in a female groin is often a Femoral Hernia (which has a huge strangulation risk) or acts like one.

The "Reduction en Masse": NEVER forcefully try to reduce a tender, strangulated hernia. You might push the gangrenous bowel loop back into the abdomen while the constriction ring remains tight around its neck. The patient feels better, but the bowel dies inside, leading to fatal peritonitis.

Ilioinguinal Nerve: The most common nerve injured in Open Repair. Runs on top of the cord. Injury causes chronic numbness/burning of the inner thigh and root of the scrotum/labia.

• Inspection: Standing up. Cough. Look at scrotum.
• Palpation: Identify landmarks (ASIS, Pubic Tubercle).
• Deep Ring Occlusion Test: Reduce hernia. Press thumb over Deep Ring (midpoint of inguinal ligament). Ask patient to cough.
  • Hernia controlled? -> Indirect.
  • Hernia bulges anyway? -> Direct (comes through posterior wall medial to thumb).
  • Note: Historically taught, but clinically unreliable.

• Mortality: Negligible for elective. 10% for emergency strangulation resection (elderly).
• Recovery: Open (4-6 weeks heavy lifting restriction). Laparoscopic (1-2 weeks).

Key Guidelines

Landmark Evidence

1. The Fitzgibbons Trial (JAMA 2006)

• Randomized asymptomatic men to Repair vs Observation.
• Found no difference in pain/QoL at 2 years.
• Validated "Watch and Wait".
• Crossover rate: 23% of observation group eventually needed surgery for worsening pain.

What is it?

A weakness in the muscle wall of the tummy. A bit of fat or bowel pushes through the hole, creating a lump in the groin.

Is it dangerous?

Usually no. But if the bowel gets trapped ("strangulated") it can rot, which is life-threatening. This is rare but serious.

What is the treatment?

We patch the hole. We insert a plastic mesh (like a tea-bag material) which acts as a scaffold. Your body grows scar tissue into the mesh, making it super strong - "Reinforced Concrete".

Keyhole or Open?

Keyhole is better if you have hernias on both sides or want a faster return to sport. Open surgery is standard and very reliable, and can even be done awake with numbing injections.

Common Exam Questions

1. Anatomy: "Boundaries of Hesselbach's Triangle?"
   • Answer: Rectus abdominis, Inferior epigastric vessels, Inguinal ligament.
2. Diagnosis: "Lump below pubic tubercle?"
   • Answer: Femoral Hernia.
3. Management: "Asymptomatic male?"
   • Answer: Watch and wait.
4. Complication: "Numbness inner thigh post-op?"
   • Answer: Ilioinguinal nerve injury.

Viva Points

• Richter's Hernia: Only part of the bowel circumference (knuckle) is strangulated. Can strangulate/perforate without obstruction symptoms.
• Pantaloon Hernia: Both Direct AND Indirect hernias present on the same side (straddling the epigastric vessels like trouser legs).

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.