Inguinal hernia is a gap in the inguinal canal that often occurs in men and causes rather pulling discomfort in the groin area in addition to a bump. Incarceration of fatty tissue or intestine is very rare.
Inguinal hernia is the most common type of hernia that we know and treat. More often the hernia occurs in men and especially in adolescence or in men over 50 years of age.
The cause varies widely and is congenital in young men and usually connective tissue weakness in older people. Often only a small to large bump appears, which is painless and recedes when lying down.
Complaints such as a pulling sensation are more likely to occur with physical exertion or when pressing, such as during bowel movements.
An inguinal hernia should usually be operated on, but the risk of entrapment of fatty tissue or parts of the intestine in the course of life is only 2.7%.
For experienced surgeons, a glance is enough for a diagnosis. When standing and pressing (coughing), a bulge appears in the groin area. The hernia usually recedes when the patient is lying down.
In the case of unclear findings or previously operated groins, an ultrasound examination (sonography) or magnetic resonance imaging (MRI) can be performed. The examination should be performed with the patient pressing (Valsalva).
Patients with a new hernia of the abdominal wall who are older than 50 years and who have not yet had a colonoscopy should definitely undergo this examination as a preventive examination before surgery in order to rule out an intestinal tumor.
IMPORTANT: Preventive colonoscopy is recommended for men over 50 years of age and for women 55 years of age, and the costs are covered in full by statutory and private health insurance companies.
Patients often have no complaints, i.e. they are asymptomatic. In addition to the incidental finding during a urological or general practitioner's examination, patients notice a painless protrusion on exertion or when standing. Many are not even aware that a hernia is present.
In addition to the aesthetic problem, there is more often a pulling discomfort in the groin area, which is intensified during movement or sports activities. In this case, the bulging hernia sac presses into the inguinal canal and onto very fine nerves, which radiate into the testicles in men and into the labia in women. This causes the discomfort.
When an inguinal hernia becomes larger, this hernia can extend far into the scrotum in men, which is called a scrotal hernia. In this case, the hernia may become firmly fused to the scrotum, so that the hernia cannot be moved back when the patient is lying down.
Also, in larger hernias, bowel or parts of the urinary bladder may be present in the hernia sac, which can lead to digestive or bladder dysfunction.
There is a 2.7% chance of incarceration with an existing inguinal hernia over a lifetime. When bowel is incarcerated, it is always a life-threatening emergency that requires surgery within 6 hours. In this case the patient:s have very severe abdominal pain with nausea and vomiting.
Inguinal hernia operations are divided into 3 classical procedures. We present here only the procedures recommended in the guidelines. Overall, there are many variants of the operations. It is important to note that these operations should be performed by qualified hernia surgeons who perform more than 25 operations per year.
Young men under the age of 25 or patients who do not wish to have a mesh despite an increased risk of recurrence can be operated on using the Shouldice technique.
In this procedure, a small incision of 5cm is made in the inguinal region and the posterior wall of the inguinal canal is reinforced with a double suture of a non-dissolving suture.
This operation is indicated for small inguinal hernias and can be performed well on an outpatient basis.
In principle, this operation, called the Lichtenstein technique, can be performed on all patients.
This procedure is particularly suitable for patients who have had multiple abdominal or prostate surgeries, are taking blood thinning medications such as Plavix or Marcumar, or have a hernia that extends into the scrotum.
In this case, a skin incision of about 8 cm is made in the groin and an 8x10 cm polypropylene mesh is implanted. In healthy patients, the operation can also be performed on an outpatient basis.
Here, there is the TEP and the TAPP procedure, in which the meshes are placed in a layer between the peritoneum and the abdominal wall using the keyhole technique. In the TAPP procedure, the abdominal cavity is opened so that it can be inspected.
In both surgical procedures, a 10x15cm plastic mesh is inserted through three small incisions under general anesthesia, which does not dissolve and is not made tight to avoid nerve injury.
Patients remain inpatient for one night for monitoring and can immediately bear weight normally. We prefer this procedure for our operations.
During follow-up treatment, the wounds are inspected in the following 5 days. In the case of dissolving sutures, we recommend a plaster dressing for up to 10 days. With shower plasters you can shower from the first day after surgery. Bathing only from the 14th day.
Often a small bruise (hematoma) forms in the inguinal canal and wound fluid (seroma) collects. In men, wound secretion and blood may migrate to the testicle from day 2, resulting in a bruise in the scrotum and tenderness in the testicle. This usually goes away after 2-4 weeks.
Rarely, bleeding and subsequent infection may occur in the umbilical area. This manifests itself as pain, swelling, hyperthermia, discharge, odor.
In this case, an immediate medical presentation is required and can usually heal without problems after a small miracle opening and irrigation.
It has been shown in many studies that inguinal hernia has a very different dynamic in women than in men. Overall, it occurs less frequently and leads to significantly more problems, which is why surgical treatment should always be sought.
We have published extensively on this topic in the very prestigious surgical journal "Annals of Surgery" in 2019. more here...
Varicosis of the rotundum ligament
Shown here is a vascular nodule (varicosis) in the groin of a pregnant patient. She came to us with a suspicion of inguinal hernia because of the presentation of an easily palpable swelling in the groin that was not painful.
In contrast to the inguinal hernia, this protrusion cannot be pushed away when the patient is standing. When the patient is lying down, the increase in blood flow in the mother ligament (ligamentum rotundum) recedes markedly due to improved drainage in the veins and is often no longer palpable.
The bright colors represent the blood flow in the Doppler examination, which can be diagnosed by any doctor within a few seconds. This finding recedes completely after delivery and the resulting decrease in venous congestion and must never be operated on.
Nuck's cyst is not a hernia, but a fluid-filled swelling (cyst).
It is a fluid accumulation in the groin (cyst), which corresponds to a water hernia (hydrocele) in men.
The size can vary and there is a close connection to the so-called uterine ligament, the ligamantum teres uteri.
Here in the picture the tightly fitting blood vessels are shown in color and the Nuck's cyst is black with a suggested heart shape.
In the case of complaints such as a permanent feeling of pressure, the cyst can be operated on like an inguinal hernia using the open or keyhole technique. Since an accompanying hernia is usually also present, a mesh should be surgically inserted.
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