Diagnosis, Treatment and Surgery of Inguinal Hernias

Diagnosis of an Inguinal Hernia

The most important feature in diagnosing an inguinal hernia is identifying the bulge in the inguinal region. The bulge may be associated vague pain or discomfort in the groin region. Pain can be very severe if the hernia gets incarcerated or strangulated. Some patients may have abnormal sensations in the region due to pressure on the inguinal nerves.

Physical examination is essential to confirm the diagnosis. It is done with the patient lying and standing position. The bulge may disappear on lying down and appear on standing. The size of the bulge may also increase on standing or coughing (cough impulse). Ultrasonography (ultrasound examination) is useful in the diagnosis of the clinically undetectable inguinal hernias. In some situations, a laparoscopy may serve as the diagnostic as well as the therapeutic procedure at the same time.

Finger Invagination Test

A finger invagination test may be done to differentiate the direct and indirect inguinal hernia, but is not critical for the management of the hernia.

• The hernia is reduced and fingertip is placed in the inguinal canal.
• A bulge found to be progressing from the outer side to the inner side (lateral to medial) along the inguinal canal, upon coughing or increasing intra-abdominal pressure is suggestive of an indirect inguinal hernia.
• The hernial bulge of an indirect inguinal hernia can be blocked by the finger tip during the finger invagination test, while a direct inguinal hernia cannot be blocked with a finger.
• A hernial bulge below the inguinal ligament is most likely to be a femoral hernia.

Inguinal Hernia Management

An uncomplicated inguinal hernia can be managed with or without surgical repair. A wait and watch approach with avoidance of aggravating factors is a viable option and as many as 75% of cases may not ever need surgery. Additional protective measures like a truss may also be used may also be considered, however, there is a risk of atrophy of the testes, compression of the nerves (inguinal or femoral) or incarceration of the hernia with the use of a truss.

Anterior repair it the standard surgical approach, where the contents of the hernial sac are reduced and the sac is dissected. It is mobilized up to the neck of the sac and tied at the level of deep inguinal ring. It is then placed back into the peritoneal cavity. The defect in the abdominal wall is then repaired with use of a mesh. This approach is called tension-free repair, as tension at the repair site has been found to contribute in hernia recurrence. A mesh is not used in repair of strangulated hernia. Various surgical techniques are adopted in patients with a strangulated hernia to repair the posterior wall of inguinal canal (like Bassini’s repair or Shouldice repair).

Laparoscopic inguinal hernia repair is another option over the the tension-free mesh repair method. The laparoscopic approach offers quicker recovery, less pain and lower chances of post-operative infection. It is also useful in fixing all types of inguinal hernia defects and has a slightly higher recurrence rate compared to open surgical approach.

Complications of Inguinal Hernia

The complications associated with an inguinal hernia repair include :

• urinary retention
• wound infection
• urinary tract infection
• nerve damage
• pain
• ischemic injury to the testes
• injury to vas deferens and abdominal organs contained in the hernial sac