The deep inguinal ring lies midway between the anterior superior iliac spine and the pubic tubercle. An indirect inguinal hernia emerges here to extend downwards and medially along the inguinal canal. Two fingers placed at this site may sense a cough impulse if not already noted on visual inspection.
The impulse of a direct inguinal hernia arises medial to the deep ring, while a femoral hernia typically emerges below the inguinal ligament, lateral and inferior to the pubic tubercle. Femoral hernias, when present, are almost always irreducible.
If not elicited in the supine position, a suspected hernia may manifest if the patient lifts their head off the pillow as if to do a sit-up, which increases intra-abdominal pressure.
Failing that, adopting a standing position may allow gravity to assist demonstration of hernia prolapse. Forcible reduction of a painful hernia is contraindicated, as this may be a sign of strangulation with necrotic bowel. Immediate surgical referral is required.
No imaging investigations are indicated for a groin hernia evident on clinical examination, 7 or where the patient convincingly describes a groin swelling that arises on exertion and subsides with relaxation, lying down or manual compression. However, ultrasonography may be useful in distinguishing an irreducible or strangulated hernia from lymphadenopathy. It may also occasionally be indicated for confirming the diagnosis when physical examination is difficult, such as in patients who are morbidly obese.
While orthotic devices can be fitted for patients deemed ineligible for surgery, they are less efficacious in relieving symptoms than operative repair.
The basic principles of hernia repair are reduction of sac contents, excision of the sac herniotomy and repair of the abdominal wall defect herniorrhaphy. Current best evidence indicates that tension-free repair with prosthetic mesh gives the lowest recurrence rate. With laparoscopic repair, mesh is placed deep to the transversalis fascia, either by a trans-abdominal pre-peritoneal TAPP or TEP approach.
Strangulation is an absolute contraindication to laparoscopic repair. As with any minimally invasive procedure, patients are advised that conversion to open operation is likely if access is technically compromised.
Femoral hernias follow similar operative principles to inguinal hernias, although because of the small size of femoral canal defect, open repair may not require mesh; approximation of the pectineal fascia to the inguinal ligament with non-absorbable sutures usually suffices. With a laparoscopic approach, mesh is laid over the femoral opening and the posterior wall of the inguinal canal.
Comorbidities or social circumstances notwithstanding, elective laparoscopic or open repairs can be performed as day surgery.
Hospital stay may occasionally be prolonged if urinary catheterisation is required for post-operative retention, typically in older male patients. Recurrence is the main late complication. Regarding emergency repairs, overall complications are increased, compared with elective repairs; this is especially true for elderly patients because of increased comorbidities. No study has shown that resumption of normal activities earlier than the usually prescribed three to five days increases the risk of recurrence or other complications following elective repair.
Driving a vehicle merits specific discussion. Common sense should prevail — if reaction time to manipulate foot controls is likely to be slowed as a result of groin pain, a patient should refrain from driving.
Did you know you can now log your CPD with a click of a button? Background Patients, particularly adult males, commonly present to general practice with groin hernias.
Although rarely life-threatening, groin hernias can be associated with considerable morbidity and limitation of earning capacity. General practitioners should be equipped with a sound knowledge of the relevant anatomy, clinical findings and management principles in order to facilitate all aspects of the patient journey.
Objective Drawing on evidence from the literature and personal clinical experience, this article seeks to enhance understanding of groin hernias and provide information on what is considered current best practice.
Discussion A number of key points have been generated that will serve to inform the management of patients with groin hernias in the primary care setting. This article is the first in a two-part series on the management of hernias. Anatomy A hernia is the protrusion of a viscus beyond the cavity in which it is normally contained. Figure 1. Types of groin hernia: anterior view Indirect inguinal hernias arise from the deep inguinal ring, through which remnants of a persistent processus vaginalis the hernia sac may extend for a variable length down the inguinal canal.
An inguinal hernia involves a portion of intestine bulging into or through the inguinal canal. A femoral hernia involves a portion of intestine bulging through the femoral canal, which houses the femoral artery as it runs from the abdomen to the groin and upper thigh.
Femoral hernias have a higher risk of incarceration due to the narrowness of the femoral canal. Femoral hernias are also more common in women than men. Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. Sometimes, hernia goes away on their own but sometimes they need immediate medical attention. Let us know the difference between the two most common types of hernia. An inguinal hernia occurs in the abdomen near the groin area.
It occurs when intestinal tissues protrude through a weak muscle in the abdomen. It is at the base of the abdomen. The protrusion along the groin area may increase in size when you cough or stand up. The symptoms of an inguinal hernia include:. Inguinal hernia can be direct or indirect. An indirect hernia happens in premature births before the inguinal canal becomes closed off.
On the other hand, a direct hernia can develop at any time during your life. Moreover, a direct hernia is more likely to occur in males. An incarcerated inguinal hernia occurs when tissues get stuck in the groin and cannot be reduced. Also, when intestine in an incarcerated hernia has its blood flow cut off, it is known as strangulation.
Your muscles are strong enough to keep your organs and intestine intact. Sometimes, your intra-abdominal tissues get back through the weak spot in the muscle when there is a strain on them. To diagnose a femoral hernia, a physical examination of the groin area is performed. In female patients, an abdominal x-ray showing both a painful groin lump and small bowel clearly suggests a femoral hernia. It can be difficult to determine if a hernia is a femoral hernia or an inguinal hernia.
They are differenent only in their location relative to the inguinal ligament. A hernia in the groin area above the inguinal ligament is an inguinal hernia; below the ligament a femoral hernia.
A highly skilled and experienced surgeon who does the procedure in high volumne is helpful to determine what type of hernia is present. Sometimes this is only evident at the time of surgery. In adults, femoral hernias that enlarge, cause symptoms, or become incarcerated are treated surgically. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient.
The two main types of surgery for hernias are as follows:. In open hernia repair, also called herniorrhaphy, a person is given local anesthesia in the abdomen or spine to numb the area, general anesthesia , or a combination of the two.
The surgeon makes an incision in the groin, moves the hernia back into the abdomen. Repair is either performed by suturing the inguinal ligament to the pectineal ligament using strong non-absorbable sutures or by placing a mesh plug in the femoral ring. Laparoscopic surgery is a minimally invasive procedure performed using general anesthesia. The surgeon makes several small incisions in the lower abdomen and inserts a laparoscope-a thin tube with a tiny video camera attached to one end.
The camera sends a magnified image from inside the body to a monitor, giving the surgeon a close-up view of the hernia and surrounding tissue. While viewing the monitor, the surgeon uses instruments to carefully repair the hernia using synthetic mesh. People who undergo laparoscopic surgery generally experience a somewhat shorter recovery time.
However, the doctor may determine laparoscopic surgery is not the best option if the hernia is very large or the person has had pelvic surgery.
Most adults experience discomfort after surgery and require pain medication. Vigorous activity and heavy lifting are restricted for several weeks. The doctor will discuss when a person may safely return to work. Infants and children also experience some discomfort but usually resume normal activities after several days.
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