Overview

An inguinal hernia is a bulge of tissues such as part of the intestine that protrudes through the lower abdominal wall. It is estimated that 96% of all groin hernias are inguinal. They can occur on either side of the two passages in the lower abdominal wall which are called the inguinal canals.

In some cases, inguinal hernias also occur in the deeper passages in the groin called femoral canals. Hernia protruding in these canals are called femoral hernia.

When an inguinal hernia occurs, a sac is formed around the hernia by a part of the peritoneum. Inguinal hernias can slide in and out of the abdominal walls. It mostly occurs on the right side of the groin compared to the left side. Studies indicate that individuals who develop inguinal hernia on one side are likely to develop on the other side too.

Risk Factors of Inguinal Hernia

An inguinal hernia may arise at any time between infanthood and adulthood. Research studies indicate that inguinal hernia is more likely to arise in males (27%) than females (3%).

The common risk factors are listed below.

  • Age: Adults between the ages of 75 to 80 and children between the ages of 0 to 5 are highly prone to inguinal hernia.
  • Weaker connective tissues
  • Genetic factors
  • Family history
  • Obesity
  • Prior abdominal surgery
  • Increased pressure in the abdomen walls due to health conditions like chronic cough and constipation
  • Excessive pressure in the abdomen walls due to standing for a long time or lifting heavy weights or walking for hours
  • Inguinal hernia is more common in premature infants when the lining of the abdomen does not fully close during their development
  • In some cases, pregnancy is found to be a cause for inguinal hernia due to the excessive pressure on the abdomen that weakens the muscles

Symptoms of Inguinal Hernia

Although the symptoms may vary between individuals, the following are the common inguinal hernia symptoms.

  • A bulge on either side of the pubic bone area which becomes more apparent when the individual is upright, particularly during a cough or strain
  • A sensation of pain or burning in the bulge
  • Discomfort and a sensation of heaviness in the groin
  • Pain and weakness in the groin especially when bending over, coughing, or lifting weights
  • Pain and swelling around the scrotum

Types of Inguinal Hernia

1. Indirect Inguinal Hernia

In a growing fetus, the inguinal canals have openings that are supposed to close before the birth of the infant. When the inguinal canal does not fully close by the time the baby is born, it causes weakness in the abdominal wall.

A piece of fat or intestine may slip through the abdominal wall causing an indirect inguinal hernia. It is more common in male fetuses. Premature infants are at higher risk for this type of hernia since there is less time for the closure of the inguinal canal.

In women, the female organs or the small intestine slide into the groin through a weakness in the abdominal wall, causing an indirect inguinal hernia.

2. Direct Inguinal Hernia

It is the most common inguinal hernia. The contents of the abdomen bulge out through the weaker muscles in the lower abdomen wall developing a hernia. This type of hernia is mostly seen in men than women and children.

3. Incarcerated Inguinal Hernia

Incarcerated inguinal hernia is developed when the herniated tissue gets trapped in the groin or scrotum and cannot be pushed back to their place by massage. This condition can lead to bowel obstruction or strangulation.

Incarcerated external hernias are reported to be the second most common cause of small-intestinal obstructions. It contributes to about 5-15 % of all operated hernias.

4. Strangulated Inguinal Hernia

After the fatty tissue or a portion of the small intestine pushes through the weakened abdominal wall, the surrounding muscles are loosened around the tissue. This obstructs the blood flow to the intestine which may even end up in a life-threatening situation.

Strangulated inguinal hernia is often found to be associated with incarcerated inguinal hernia or may also be present at birth.

Complications of Inguinal Hernia

Complication occurs when the contents of the hernia bulging through the abdominal wall cannot be massaged back inside the abdominal wall. When a hernia causes strangulation of the intestinal tissues, it can even lead to the death of the patient. When left untreated, inguinal hernias may enlarge. In men, this could extend into the scrotum, causing severe pain and swelling.

Diagnosis of Inguinal Hernia

The preliminary diagnosis of inguinal hernia would be based on the medical records and physical examination of the patient. The physician would perform a physical examination of the abdomen during which the patient is asked to cough, stand, or strain to identify the bulge caused by the hernia. Diagnosis is proceeded by massaging on the bulge of the tissues to restore them to their original position.

Further diagnosis would be based on the reports of imaging studies of the abdomen like ultrasound scan, MRI scan and CT scan.

Management of Inguinal Hernia

Watchful waiting is one suggestion given to inguinal hernia patients who don’t exhibit many symptoms or complications.

 1. Muscle Strengthening Exercises

Exercises for inguinal hernia may be advised to patients with very mild symptoms. This may help to strengthen the abdominal muscles. These exercises may be suggested after an inguinal hernia surgery also. Since strenuous physical activity can trigger inguinal hernia, exercises should be approached with caution. Medical attention should be sought if pain is felt while doing these exercises.

2. Surgical Repair

 Surgery is another strategy followed in inguinal hernia treatment. Inguinal hernia surgery would be an open inguinal herniorrhaphy, a laparoscopic inguinal herniorrhaphy or a robotic-assisted surgery. The type of inguinal hernia repair surgery would be based on the following criteria

  • Size of the hernia
  • Type of the hernia
  • Age and health condition of the patient
  • Medical history of the patient

Open Inguinal Herniorrhaphy

In open inguinal hernia surgery, the patient is sedated with either general anesthesia or local anesthesia.

The surgeon first makes a single long incision in the groin. In a direct inguinal hernia, where the hernia is bulging out of the abdominal wall, it is pushed back into place. In the case of an indirect inguinal hernia, the hernia sac is either pushed back through the inguinal canal or tied off and removed.

In either case, after repairing the hernia, a synthetic mesh is stitched or glued to the weaker abdomen wall to close and to strengthen it. This prevents the reoccurrence of the hernia. Another method is the primary closure of the surgical site with sutures.

Laparoscopic Inguinal Herniorrhaphy

In laparoscopic surgery, the patient is sedated with general anesthesia. It is a minimal invasive procedure where the surgeon makes tiny, half-inch incisions or punctures in the lower abdomen. The laparoscope and the surgical tools are inserted into the intestine through the small cuts.

The hernia is repaired, and the weaker muscles are stitched with a synthetic mesh to reinforce the weakened abdominal wall.

Laparoscopic inguinal herniorrhaphy is less painful with speedy recovery when compared to the open surgery.

Robotic-Assisted Inguinal Hernia Repair

Robotic laparoscopic surgery provides a high definition, critical view of the surgical site. Seated at a console in the operating room, the surgeon directs the robotic arms and performs the surgery. Since the robotic instruments are flexible and wristed, making incisions and placing the mesh would be much precise in a robotic-assisted hernia repair.

According to the U.S. Food and Drug Administration, hernia surgeries implanting surgical meshes are reported to have the following complications like pain, infection, mesh migration etc.

Testicular Torsion Following Inguinal Hernia Surgery

Testicular torsion is a urological emergency occurring due to the torsion of the spermatic cord structures. This leads to reduced blood flow to the testicles which gradually leads to the death of the testicles. Sudden shooting pain in one side of the scrotum is the most common symptom of testicular torsion. Color doppler ultrasonography is the commonly implied diagnostic imaging study used to study testicular torsion.

Though not common, testicular torsion is reported as a side effect of hernia surgery using synthetic surgical mesh. The mesh repair procedure may induce an inflammatory response that lead to the enclosure of the spermatic cord by scar tissue. This may rarely block the blood supply that may cause acute scrotum.

It is very important to note that mesh independent testicular torsion is also reported in some patients post inguinal hernia surgery. In such cases, there is a chance for the hernia mesh to be misinterpreted as the cause of testicular torsion.

Case Study of Inguinal Surgery Complication

A 60-year-old male was diagnosed with a right inguinal hernia. A general surgeon performed robotic- assisted laparoscopic right inguinal hernia repair. During the procedure, the inferior epigastric vessels were displaced anteriorly. The overlying peritoneum was taken down anteriorly, and the vessel was inadvertently transected.

Four days later, the patient visited the general surgeon with complaints of pain and swelling in the groin. Patient’s physical examination revealed extensive ecchymosis from right to left and into the scrotum. Scrotum was purple as well as exhibited hematoma in the cord. General Surgeon refilled the pain medication and advised the patient to follow up in a month.

On the following day, the patient’s spouse called the doctor’s office with patient’s complaints of pain, difficulty to walk and his testicles were black.

Next day, the patient was taken to the emergency room with continuing testicle pain. Ultrasound showed no blood flow to the right testicle and emergency physician diagnosed the patient with right testicular torsion and testicular infarction. The emergency physician opined that the previous inguinal hernia repair with large third bard mesh was complicated by injury to epigastric vessels and eventually needed right orchiectomy.

Subsequently, the patient was subjected to scrotal exploration and an emergency right orchiectomy was done by another surgeon. Surgical findings noted no evidence of any torsion of the cord. Pathology of the right testicle revealed infarction in the testis and epididymis.

Final Thoughts

In the above case study, primary treating surgeon had accidentally cut down the patient’s inferior epigastric vessels during the laparoscopic inguinal hernia surgery. When the patient reported pain in the testicles, as per the standard of care, the surgeon had to order for a detailed diagnosis with a Color Doppler Ultrasonography. Instead, he just refilled the pain medication and asked the patient to follow up in one month. The issue was diagnosed by the physician when the patient was presented in the emergency room. Ultimately it ended up in orchiectomy.

The medical negligence of the general surgeon during the hernia surgery and the failure to diagnose the complication on time caused medical complications in the patient. This resulted in removal of his testicle.

Medical error which happened during the surgery and the negligence caused in timely diagnosis of the complication is evidently a medical malpractice.

A patient who become victim of such medical errors could make potential claim for medical malpractice. An experienced medical malpractice attorney could help the victim to pursue the lawsuit. The medical records of the plaintiff would act as concrete evidence in such cases. The medical chart would contain the data regarding the symptoms and complications of the patient, diagnosis done and the medications prescribed.

Offshoring the medical chart review process to an expert medical record review company would result in precise medical chart reviews to support the lawsuit. Skilled medical professionals in such outsourcing companies could identify the strength and weakness of the medical chart within no time.