An inguinal hernia is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the abdominal wall just above the inguinal ligament. Many inguinal hernias are asymptomatic, but some become incarcerated or strangulated, causing pain and requiring immediate surgery. Diagnosis is clinical. Treatment is surgical repair.
(See also Inguinal hernia in neonates.)
Approximately 75% of all abdominal wall hernias are inguinal (1).
Reference
1. Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date?. JRSM Short Rep. 2011;2(1):5. Published 2011 Jan 19. doi:10.1258/shorts.2010.010071
Classification of Inguinal Hernia
Inguinal hernias occur above the inguinal ligament. They can be
Indirect: Traversing the internal inguinal ring into the inguinal canal
Direct: Extending directly forward and not passing through the inguinal canal
Symptoms and Signs of Inguinal Hernia
Most patients have only a visible bulge, which may cause vague discomfort or be asymptomatic. They can often reduce the size of the bulge by pushing it back through the defect in the abdominal wall.
An incarcerated hernia cannot be reduced and can be the cause of a bowel obstruction.
A strangulated hernia causes steady, gradually increasing pain, typically with nausea and vomiting. The hernia itself is tender, and the overlying skin may be erythematous; peritonitis may develop depending on location, with diffuse tenderness, guarding, and rebound.
Diagnosis of Inguinal Hernia
Clinical evaluation
The diagnosis of an inguinal hernia is clinical (1). Because the hernia may be apparent only when abdominal pressure is increased, the patient should be examined in a standing position. If no hernia is palpable, the patient should cough or perform a Valsalva maneuver as the examiner palpates the groin (with a finger in the inguinal canal in males).
Most hernias, even large ones, can be manually reduced with persistent gentle pressure; placing the patient in the Trendelenburg position may help.
Inguinal masses that resemble hernias may be the result of adenopathy (infectious or malignant), an ectopic testis, or lipoma. These masses are solid and are not reducible. A scrotal mass may be a varicocele, hydrocele, or testicular tumor.
Ultrasound may be done if physical examination is equivocal.
Diagnosis reference
1. van Veenendaal N, Simons M, Hope W, Tumtavitikul S, Bonjer J; HerniaSurge Group. Consensus on international guidelines for management of groin hernias [published correction appears in Surg Endosc. 2020 Apr 22;:]. Surg Endosc. 2020;34(6):2359-2377. doi:10.1007/s00464-020-07516-5
Treatment of Inguinal Hernia
Surgical repair
Inguinal hernias typically should be repaired electively because of the risk of strangulation, which results in higher morbidity (and possible mortality in older patients). Asymptomatic inguinal hernias in men can be observed; if symptoms develop, they can be repaired electively (1). Repair may be through a standard incision or a laparoscope.
An incarcerated or strangulated hernia of any kind requires urgent surgical repair.
Treatment reference
1. van Veenendaal N, Simons M, Hope W, Tumtavitikul S, Bonjer J; HerniaSurge Group. Consensus on international guidelines for management of groin hernias [published correction appears in Surg Endosc. 2020 Apr 22;:]. Surg Endosc. 2020;34(6):2359-2377. doi:10.1007/s00464-020-07516-5
Key Points
Inguinal hernias can be direct or indirect.
Manifestations of strangulation include increasing pain and tenderness, sometimes erythema; peritonitis may follow.
Do elective surgical repair to avoid strangulation and urgent surgery.
