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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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Inguinal hernia in children: ultrasound vs. surgery - Tips from Other Journals
From American Family Physician, 5/1/97 by Barbara Apgar

Repair of inguinal hernias is one of the most commonly performed surgical procedures in children. Because clinically inapparent inguinal hernias are found on the opposite side in as many as 88 percent of children, debate has centered on whether the contralateral side should be routinely explored. Because of the lack of a reliable, noninvasive test for the presence of an occult inguinal hernia, the controversy has not been solved. Chou and associates analyzed the value of ultrasound in the preoperative recognition of clinically apparent and inapparent inguinal hernias in children.

Two hundred sixty children in whom a clinical diagnosis of inguinal hernia had been made underwent ultrasound examination of both sides of the groin before surgery. The contralateral internal inguinal ring was evaluated by means of intraoperative laparoscopy in 141 patients. The findings at ultrasound were compared with the findings at exploratory surgery, intraoperative laparoscopy, or both.

Among the 260 patients who underwent surgery for inguinal hernias, 246 hernias (95 percent) were correctly diagnosed at ultrasound. Ultrasound also enabled accurate diagnosis of hernias in 167 (93 percent) of 179 patients in whom the asymptomatic side of the groin was surgically repaired. Of the 141 patients who underwent laparoscopic study of the contralateral side, 119 had negative results and 22 had results that were positive for hernia or patent processus vaginalis.

Of the patients with positive results, four had no contralateral hernia at surgery, yielding a total accuracy rate of 96 percent at intraoperative laparoscopy only. Eightysix ultrasonographically positive bilateral hernias were confirmed at surgery in 79 patients; only 30 of these cases had clinical evidence of bilateral hernia. Unnecessary contralateral surgery was performed in the remaining seven patients who had false-positive ultrasound findings. However, 49 (22 percent) clinically unilateral cases that proved to be bilateral benefited from bilateral repair in one operation. Overall, a total of 97 percent of confirmable diagnoses were correctly obtained by the use of ultrasound.

The authors conclude that ultrasound is a rapid, reliable, convenient, noninvasive and easily performed screening technique for inguinal hernias in infants and children. The data suggest that ultrasound can prevent unnecessary herniorrhaphy.

COPYRIGHT 1997 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group

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