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Updated: Jun 14 2022



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  • Snapshot
    • A 35-year-old man presents to the general surgeon's office with pain in his right groin. He recently noticed a bulge in this region after performing heavy weight lifting at the gym. The pain and bulge comes and goes sporadically and he thinks it is associated with his workouts. He denies any change in bowel or bladder function.
  • Overview
  • Introduction
    • Clinical definition
      • a protrusion of peritoneum through an opening or weakness into another body cavity
    • Increased risk with structural weakness or increased intra-abdominal pressure
    • Classification based on the anatomy of Hesselbach's triangle
      • borders
        • lateral - inferior epigastric artery
        • medial - lateral border of rectus abdominis
        • inferior - inguinal ligament
    • Types
      • indirect inguinal
        • travels the entire length of the inguinal canal following descent path of the testes
          • enters internal inguinal ring lateral to inferior epigastric artery and exits external inguinal ring
          • may enter scrotum
        • covered by all 3 layers of spermatic fascia
        • most commonly seen in male infants
          • due to patent processus vaginalis
            • peritoneal connection between inguinal canal and tunica vaginalis
      • direct inguinal
        • bulges through the inguinal (Hesselbach's) triangle
          • directly through abdominal wall (transversalis fascia) through the external inguinal ring
          • medial to inferior epigastric artery
        • covered only by external spermatic fascia
        • most commonly in older men
      • femoral
        • protrudes below inguinal ligament through femoral canal
          • lateral to pubic tubercle
        • more common in women
      • umbilical
        • most commonly in adults
          • associated with pregnancy, ascites, and obesity
      • incisional
        • occurs at previous surgical sites
  • Treatment
    • Indirect and direct inguinal hernia
      • surgical placement of mesh over Hesselbach's triangle/inguinal canal and reinforce abdominal wall
    • Femoral
      • surgical joining of Cooper's ligament to transversalis fascia
    • Incisional
      • associated with previous incision through the fascia
      • goal is to achieve primary fascial closure with mesh reinforcement
      • number of different repairs are possible including mesh underlay, inlay, overlay or bridging repairs
  • Prognosis, Prevention, and Complications
    • Incarceration and strangulation
      • seen in all hernia types where hernia contents get stuck within the defect
      • the larger the hernia defect the smaller risk of incarceration
        • femoral hernia has greatest risk
    • Post-herniorrhaphy neuropathy
      • chronic neuropathic pain in the ilioinguinal and/or genitofemoral nerve distribution
      • caused by injury to the respective nerve during surgery
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