Hernias
Questions Received:
Responses:
What is the difference between an indirect and direct inguinal hernia?
(hernia - the abnormal protrusion of an organ, or part of an organ, through an aperture in the surrounding structures.)
The short answer is this: in an indirect inguinal hernia the protruding loop of bowel passes obliquely through the abdominal wall, while in a direct inguinal hernia the herniating bowel pushes directly forward through the abdominal wall, taking a shorter course to the outside.
The reasons for these different modes of herniation will now be considered in more detail.
< Diagram showing inguinal region and position of inguinal canal
The inguinal region lies just above the crease between the abdomen and thigh [above diagram]. In this region, the the anterior wall of the abdomen consists of three major muscle layers and their associated fibrous attachments and planes of fascia:
The external oblique muscle
Internal oblique muscle
Transversus abdominis muscle
< Diagram showing normal arrangement of inguinal canal in the male
On the outside is the skin and subcutaneous fat, and inside is a lining of peritoneum. Passing obliquely through these layers is the inguinal canal. This canal is present in both sexes: in the female it is narrow and conveys the round ligament of the uterus (a remnant of the gubernaculum) as it extends from the uterus to the labium majus. In the male, the inguinal canal conveys the more bulky spermatic cord which contains the vas deferens and associated blood vessels [< diagram]. (It is along the pathway provided by the inguinal canal that the testis descends from the abdomen into the scrotum at about the time of birth.)
Inguinal
hernia is more likely to happen in males, partly because the presence of the
larger inguinal canal produces a potential weak point in the anterior abdominal
wall. When pressure within the abdomen rises, as for example during lifting,
defecating, or coughing, there is the possibility that a loop of small intestine
will be forced into the internal opening ('deep ring') of the inguinal canal,
preceded by a pouch of peritoneum and connective tissue, and traverse the canal
to the outside (through the 'superficial ring') where it forms a swelling [<
diagram]. This swelling may extend downwards towards the scrotum. This is called
an indirect inguinal hernia. The herniated loop of intestine is also wrapped in
the coverings of the spermatic cord. There is the danger that the blood supply
of the affected part of the intestine will be impaired due to the constriction
of the surrounding structures - a ‘strangulated’ hernia. This can lead to
necrosis and gangrene.
Alternatively,
in the case of a direct inguinal hernia the loop of intestine may push through
the abdominal wall slightly more medially where the wall is less strong and then
emerge at the outside via the superficial ring [< diagram]. In this case, the
coverings of the herniation are fewer than number compared with an indirect
hernia. This form of herniation is much less common than indirect inguinal
hernia.
The inferior epigastric artery - a branch of the external iliac artery - crosses the inguinal region just medial to the deep ring as it courses towards the back of the rectus abdominis muscle. Thus, an indirect inguinal hernia leaves the abdominal cavity lateral to the artery, while a direct inguinal hernia exits medial to the artery. These relationships are borne in mind during surgical correction of an inguinal hernia to avoid damage to the artery.
A 24 year-old male comes to me with pain and a lump in his left groin. My task is to assess his problem and find out what is wrong with him. My guess is that it's a hernia. How would I know if it's direct/indirect? How would I know if it's something other than a hernia, like swollen lymph nodes
25th May 1999
To diagnose your patient’s condition, you will need to determine the precise location of the lump in relation to the inguinal ligament, using palpation and observation. Recall that the inguinal ligament extends from the anterior superior iliac spine to the pubic tubercle, approximately in the line of the skin crease between the abdomen and thigh. If the lump originates above the inguinal ligament, it is likely to be an inguinal hernia, as you suggest. An alternative would be an incisional hernia, where the protrusion is through a surgical wound that has not healed successfully. If the lump is below the ligament, it may be a femoral hernia (although unusual in males) or enlargement of one or several inguinal lymph nodes. If the lymph nodes are inflamed, then look for potential causes, particularly within the lower limb. You must also rule out the possibility that the swelling is originating from within the scrotum, in which case it may be a hydrocele, spermatocele, or tumour of the testis. Difficulty in diagnosis can arise if the swelling is both inguinal and scrotal - this includes large inguinal herniae which descend into the scrotum, and hydroceles which occasionally extend from the tunica vaginalis into the inguinal canal. Transillumination allows the detection of fluid extending from a large hydrocele into the inguinal canal. When the swelling can be reduced by the application of pressure towards the abdomen, the presence of an inguinal hernia is confirmed.
Let us assume that you are satisfied that the lump is an inguinal hernia - the next step is to decide whether it is an indirect hernia (along the full course of the inguinal canal from deep to superficial rings) or a direct hernia (pushing forwards through the anterior abdominal wall in the region of the superficial inguinal ring). Most inguinal hernias are indirect - only 10 to 20 per cent are direct. Examine your patient in the standing position after the swelling has been reduced (reduced in size by pressing it back towards the plane of the abdominal wall). Ask him to cough while you press your finger first over the deep inguinal ring and then over the superficial ring. To do this you will need to be clear about the exact position of both rings. Alternatively the contents of the inguinal canal may be palpated: if a sac comes down the inguinal canal when the patient coughs, an oblique or indirect hernia is present. The detection of an impulse coming through the canal from behind indicates that a direct hernia is more likely. An indirect hernia tends to descend more readily into the scrotum and may extend as far as the testis, while a direct hernia remains outside most of the coverings of the spermatic cord and often presents as a more limited swelling close to the pubic tubercle.
< Diagram of the inguinal canal showing the
different layers of the abdominal wall and the composition of the spermatic cord
<
Test for direct/indirect inguinal hernia - pressure over the deep inguinal ring
does not control a direct hernia but controls an indirect hernia
<
Test for direct/indirect inguinal hernia left: pressure over the superficial
inguinal ring controls a direct hernia but not an indirect one
I had 2 hernias repaired 5 months ago and I have never been without pain since. I think that the surgery failed, but I have not seen my Dr. about it. I have had a rough time recovering. I can do pretty everything right now but not without considerable pain. My testicles still hurt (after 5 months) and I don't know what to do. My question is....If I have to have a 2nd surgery is the recovery time longer...and is the operation more difficult than the 1st? Thank You!
20th June 1999
Hernia repair can be painful (and bilateral repair particularly so) but the experience of pain can be lessened if the correct analgesics are used, and used regularly. This is an important point as a range of analgesics may have to be tried before the correct one is found. Patients should therefore monitor their response to the analgesics that are prescribed and inform the doctor or nurse if the pain which they are experiencing does not settle with the prescribed drug. Another important point is compliance. This means that it is important to take the prescribed drug regularly and not to stop suddenly if the pain has subsided, or wait for the pain to appear before taking the drug.
Were you relatively pain free whilst in hospital? Did the pain surface following your discharge? What are the analgesics that have been prescribed for the remainder of your recovery period? Were you able to try these before your discharge? Also it is important that whatever was prescribed for you is taken, regularly and in accordance with the instructions provided by your doctor or those on the package.
It could be that you feel hesitant about discussing this persistent pain with your doctor because you are worried that there may be a need for further surgery. However, there may be other options and your doctor will be able to discuss these with you. Explain the pain and discomfort that you have been experiencing so that your analgesic regime can be reviewed. Many people are prepared to tolerate pain following surgery and some, particularly the elderly, can be remarkably stoical. There is now such a wide range of analgesics available that pain relief is achievable for the majority of people. Non-pharmacological measures also make an equal contribution to post operative pain management. Open discussion with your doctor should settle many of the problems which you have expressed.
I am going to have direct inguinal hernia surgery and I like to know if I could have a bloating feeling in my stomach?
29th March 2000
The doctors and nurses caring for you will aim to minimise any pain and discomfort that you may experience postoperatively. You use the term ‘bloating’ - this is normally used to describe feelings of abdominal discomfort due to the accumulation of gas, food, or non-digestible food residue within the stomach and intestines. If you are to be given a general anaesthetic you will be given nil by mouth for up to about four hours prior to your operation. This means that your stomach will be empty at the time of the operation. However, partially digested food will still be present further along your digestive tract. Some of the drugs used to achieve anaesthesia and reduce pain can also inhibit peristalsis and impede the onward movement of food, so some feelings of distension may be experienced for about the first 24 to 48 hours postoperatively.
These feelings often settle though, providing effective pain control and early mobilisation is achieved. The gradual return to a normal diet and movement of the bowels also enables any feelings of distension to be kept to a minimum.
Inguinal hernia repair can be performed laparoscopically (minimal access surgery). This technique involves inflating the lower abdominal region with carbon dioxide gas to give better visibility for the surgeon. The gas is removed following the repair. One of the advantages of this approach is that the amount of post-operative pain experienced is said to be less compared with a conventional open operation. Some temporary discomfort can arise from retained carbon dioxide but this usually settles when full mobility is achieved.
It will be helpful to discuss your pending operation with the surgeon who is going to carry it out. If possible, visit the ward where you will be nursed before your admission. Nursing staff on the ward will no doubt be willing to explain how your preoperative and postoperative care is likely to be conducted. At the same time you will be able to get to know the staff and the hospital environment.
We should like to thank Mrs. Laura Jackson, staff nurse, for her help with this answer.
My seven year old son has developed a hernia in his groin. I have been told this will require a minor op, it is a very small hernia [I am told]. However I am extremely nervous about him having a general anaesthetic as out of the four children I have two of them, including the son in question, have reacted badly to vaccination. I have lost faith in the medical profession as a result.
I have now found after surfing the web that there are different methods with the op and now feel I should question the method they may intend to use. I only want the best for my son, I have read that a mesh method is favoured without stitching into the muscle, can you help?
28th March 2000
Your feelings of anxiety over your son's pending hernia repair are understandable. All parents' want the best for their children and when anaesthesia and surgery is anticipated feelings of uncertainty can easily predominate.
Try to keep your concerns into perspective. Whilst it is true that every anaesthetic carries some risk these have to be balanced against the benefits to your son of having the hernia repair, particularly whilst he is young and before any potential complications arise. Your family doctor will be able to discuss the implications of the operation, and what delay might mean, with you. The fact that two of your children developed adverse reactions to vaccinations may or may not be significant. However, this should be explained to both your family doctor and the anaesthetist well before your little son has his operation.
Keep in mind that the medical and nursing teams will aim to provide safe, soundly based treatment and care for your son. Trust is a 'key' issue here, try to see each member of the team as wanting the best for your son and that any information provided is designed to enable you to retain and enhance your investment in your son's care. With a professional team and a caring parent both working in unison what risks there are should, in theory, be capable of being kept to a minimum.
A non-absorbable mesh is sometimes used for hernia repair. The use of a mesh avoids the need for suturing muscle and fascial layers together (Burkitt et al, 1996).
Reference
Burkitt, H.J., Quick, R.G., and Gatt, D. (1996) Inguinal herniorrhaphy and herniotomy. In: Essential surgery problems, diagnosis and management (2nd edition). Edinburgh: Churchill Livingstone (pp 364-65).
I am a young man 34 years old. I had quite sound health before five years ago. I was operated two times due to hernias but unfortunately it has happened once more and the doctors advise to re-operate but I am not satisfied because I do not want to get operated every time and spoil my life. I want to get it examined or checked in U.K. as the U.K. is one of the well known countries for hernia treatment.
26th June 2001
We are very sorry to hear that your hernia operations were unsuccessful and that you are still suffering as a result. Unfortunately we are not in a position to recommend a surgeon or a hospital here in the UK. As you suggest it is probable that you could obtain good treatment here, but this would be expensive given the travel costs and the costs of private medicine - I don't think you would be eligible for free treatment by the National Health Service because you are living in Pakistan. However, if you have access to the internet you may find some help from the NHS Direct website at www.nhsdirect.nhs.uk
We assume that your hernias are inguinal hernias - in the groin region. An indirect inguinal hernia is the most common type in someone of your age. Some surgeons still use traditional methods of repair which involve pulling together the muscles and ligaments and stitching them in place. These repairs are often painful because of the strain caused by pulling the tissue into place and this same tension can cause the repair to separate in time. One in ten hernias repaired in this way come back again, and this may explain why you have been experiencing difficulty. Some surgeons use the Canadian (also known as the Shouldice) technique, which involves stitching through three overlapped layers rather than one, as in the traditional method. In expert hands, this technique can be performed as a day case and the hernia rarely recurs.
An increasing number of doctors now prefer the new tension-free mesh hernia repair. It involves placing a piece of strong polypropylene mesh over the weakened abdominal wall. The body tissue then grows through the mesh, combining with it to form a strong and permanent repair. The hernia rarely comes back. Many people can have a tension-free mesh repair under local anaesthetic as day case patients. This means they may be able to go home within a few hours of the operation. There is much less pain after a tension-free mesh repair, and many people resume an active life soon after the operation. Perhaps there is a surgeon in Pakistan who can carry out this type of operation? We hope that you will soon be able to find effective treatment for your problem.