Martin Foster, aged 25 years, presents complaining of a lump in his groin. He reports that the lump appeared a few weeks after commencing his new job as a furniture removalist.
Causes of groin swelling include:
| Feature | Indirect | Direct |
|---|---|---|
| Patient's age | Any age but usually young | Older |
| Cause | May be congenital | Acquired |
| Bilateral | 20% | 50% |
| Protrusion on coughing | Oblique | Straight |
| Appearance on standing | Does not reach full size immediately | Reaches full size immediately |
| Reduction on lying down | May not reduce immediately | May reduce immediately |
| Descent into scrotum | Common | Rare |
| Occlusion of internal ring | Controls | Does not control |
| Neck of sac | Narrow | Wide |
| Strangulation | Not uncommon | Unusual |
| Relation to inferior epigastric vessels | Lateral | Medial |
Key Clinical Points:
Anatomy of the internal inguinal ring, showing sites of herniation from within:
Key anatomical structures in the groin region:
Processus vaginalis:
Adults with a symptomatic inguinal hernia should be offered surgery. Open mesh repair or laparoscopic repair aims to reduce post-operative pain to a minimum, enabling most procedures to be undertaken as day cases. Inguinal hernias can be controlled by a truss, but this is uncomfortable and is now seldom indicated, as repair using local or regional anaesthetic techniques can be employed in higher-risk patients.
Children: The identification of an inguinal hernia in any child is always an indication to operate. In newborns, the procedure must be carried out with some urgency because of the risk of strangulation. In very premature infants, the procedure may need to be done under regional block alone, and where general anaesthesia is used, elective post-operative ventilation may be required. In older children, elective surgery is usually undertaken on a day-case basis, with liberal use of local anaesthetic blocks for post-operative pain relief.
Lichtenstein Open Tension-Free Repair (most common):
Laparoscopic Hernia Repair (increasing in popularity):
Femoral Hernias:
Management approach:
Cochrane Review 2018 - Mesh versus Non-Mesh Repairs:
The authors conclude:
"Compared to non-mesh repairs, mesh repairs probably reduce the rate of hernia recurrence, and reduce visceral or neurovascular injuries, making mesh repair a common repair approach. Mesh repairs may result in a reduced length of hospital stay and time to return to activities of daily living, but these results are uncertain due to variation in the results of the studies. Non-mesh repair is less likely to cause seroma formation and has been favoured in low-income countries due to low cost and reduced availability of mesh materials. Risk of bias in the included studies was low to moderate and generally handled well by study authors, with attention to details of allocation, blinding, attrition and reporting."
Summary of Key Points:
Cochrane Review - Laparoscopic vs Open Techniques for Inguinal Hernia Repair:
Repair of a hernia in the groin (inguinal hernia) is the most frequently performed operation in general surgery. The most common laparoscopic technique is totally extra peritoneal (TEP) repair. TEP is different as the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the peritoneum.
Advantages of Laparoscopic Repair:
Disadvantages of Laparoscopic Repair:
Using a mesh for repair reduced the risk of recurring hernia rather than the method of placement (open or laparoscopic surgery).
| Hernia Type | Men | Women | Children |
|---|---|---|---|
| Direct | Common (indirect 4x more common than direct) | Less common | Very rare |
| Indirect | 10x more common in males; indirect 4x more common than direct | Less common than in men | Almost all inguinal hernias are indirect; 90% occur in males |
| Femoral | Uncommon | 4x more common in women | Rare |
Key Points:
Vertical incision through the linea alba (relatively avascular midline). Can be upper, lower, or extend the full length of abdomen. Most versatile incision with excellent exposure and minimal risk to vessels/nerves.
Vertical incision parallel to the midline, approximately 2-3cm lateral to it. Passes through anterior rectus sheath, retracts rectus muscle laterally, then incises posterior sheath and peritoneum. Less commonly used now.
Horizontal incision across the abdomen. Can be upper (epigastric), middle, or lower (low transverse/suprapubic). Better cosmetic result and less post-op pain than vertical incisions.
Abdominal incision parallel to the fibres of the external oblique muscle, about 1/3 of the distance along a line from ASIS to umbilicus, half the incision being above and the remainder below this point. The skin and subcutaneous fat are incised down to the external oblique muscle, the fibres of which are split; the underlying internal oblique and transversus abdominis muscles are then split and separated. Used for appendicectomy.
Oblique incision parallel and below the costal margin, typically on the right (for gallbladder/liver) or left (for spleen). Provides good access to upper abdominal organs.
A curved abdominal incision, the convexity being directed downward just above the symphysis pubis, passing through skin, superficial fascia, and aponeurosis, exposing the pyramidalis and rectus muscles, which are separated from each other in the midline, the peritoneum being opened vertically. Commonly used for C-sections and pelvic surgery. Excellent cosmetic result.
Donor nephrectomy: Typically performed laparoscopically now, but open approach uses a flank incision (lateral position with kidney rest elevated). May be subcostal or through the bed of the 11th or 12th rib.
Recipient kidney transplant: Curved lower abdominal incision in the right or left iliac fossa (extraperitoneal approach). Kidney placed in iliac fossa with anastomoses to iliac vessels.