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Inguinal hernia

Inguinal hernias are protrusions of abdominal cavity contents through an area of the abdominal wall, commonly referred to as the groin, and known in anatomic language as the inguinal area or the myopectineal orifice. They are very common and their repair is one of the most frequently performed surgical operations. They usually arise as a consequence of the descent of the testis from the abdomen into the scrotum during early fetal life, and are therefore far more commonly seen in men than women. They present as painless bulges in the groin area that can become more prominent when coughing, straining, or standing up. The bulge commonly disappears on lying down. more...

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The presence of pain, or the inability to "reduce" the bulge back into the abdomen, usually indicates the onset of complications.

As the hernia progresses, contents of the abdominal cavity, such as the intestine, can descend into the hernia and run the risk of being strangulated within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine that is caught in the hernia is compromised, gut ischemia and gangrene can result, with serious consequences. The time of occurrence of complications is not predictable; some hernias can remain static for years, others can progress rapidly from the time of onset. Therefore, provided there are no serious co-existing medical problems, patients are advised to get the hernia repaired surgically at the earliest convenience after a diagnosis is made. Emergency surgery for complications such as obstruction and strangulation carry much higher risk than planned, "elective" procedures.

Despite the profusion of medical technology that is now available, the diagnosis of inguinal hernia rests on the history given by the patient and the physician's findings on examination of the groin. No tests are needed to confirm the problem.

Surgical correction of inguinal hernia is a simple operation that is now done in most places as an ambulatory or "day surgery" procedure. A workable technique of repairing hernia was first described by Bassini in the 1800s; the Bassini technique was a "tension" repair, one in which the edges of the defect are simply sewn back together without any reinforcement or prosthesis. Although tension repairs are no longer the standard of care due to their high recurrence rates, long recovery period and severe post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the Cooper's/McVay repair.

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). The meshes used are typically made from polypropylene or polyester, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond over-the-counter pain relievers such as aspirin or acetaminophen. Patients are encouraged to walk and move around immediately post-operatively, and can usually resume all their normal activities within a week or two of operation. Recurrence rates are very low - one percent or less compared with over 10% for a tension repair.


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Does Inguinal Hernia Repair Affect Sexual Function? - Brief Article
From American Family Physician, 10/15/01 by Anne D. Walling

Tension-free inguinal hernia repair for augmentation of the inguinal canal used to be popular. Techniques using meshes can be performed under local anesthesia and result in excellent patient comfort and low rates of recurrence. Unfortunately, fibrotic healing can result in hardening and shrinking of the mesh. Zieren and colleagues investigated testicular perfusion and sexual functioning in men following plug and patch repair of inguinal hernia.

The study included 73 men undergoing surgery for primary inguinal hernia at a German university hospital. Men younger than 18 years, those with recurrent or incarcerated herniae, and those with scrotal diseases (tumor, orchitis) were excluded from the study. All surgeries were performed under local anesthesia and involved use of Prolene plugs behind the internal ring plus a patch under the external aponeurosis. Testicular volume and blood flow in the spermatic artery were measured by scrotal ultrasonography and color duplex sonography preoperatively, three months postoperatively and then every six months. Sexual function was assessed using a standardized questionnaire containing 40 items.

The average age of the men was 57 years. Most herniae (71 percent) were indirect. No complications occurred during surgery; 27 patients had superficial complications such as wound hematoma, seroma, infection or neuralgia pain following the procedure. Before surgery, 11 (15 percent) men experienced inguinal pain during sex because of the hernia. Postoperative testicular volume and blood flow measurements showed no significant change from preoperative levels. Sexual disorders attributed to inguinal pain were significantly reduced following surgery. However, 10 (14 percent) patients described new limitation of sexual activity following surgery. Four of these were attributed to pain and six to loss of sensation. In six of these patients, symptoms resolved spontaneously within one year. No correlation could be made between sexual symptoms and measures of testicular volume or blood flow.

The authors conclude that there is, so far, no evidence of impairment of cord structures or sexual function following inguinal hernia repair using mesh techniques.

EDITOR'S NOTE: Family physicians are frequently asked the questions that patients hesitate to ask specialists, including surgeons. In addition, family physicians learn to recognize the hesitancy of a patient who has an unvoiced concern about a "minor, routine surgery". This study empowers physicians to ask men if they are concerned about sexual performance after hernia surgery and to reassure them and their partners.--A.D.W.

COPYRIGHT 2001 American Academy of Family Physicians
COPYRIGHT 2001 Gale Group

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