Inguinal hernia: new ideas for an old problem

Undoubtedly, the most frequent consultation in surgery is the pathology of the abdominal wall, and more specifically, that of inguinal hernia.

This is the appearance of a bulge in one groin (or both), usually after physical exertion. As is logical, patients with professions requiring the handling of heavy weights, as well as chronic coughers (pulmonary emphysema, smokers, etc.), or those who require a significant defecatory effort, are more prone to suffer from inguinal hernia.

However, it also affects healthy patients with excessive sporting activity, the so-called athlete’s hernia, which leads to a progressive weakening of the inguinal canal, as this is subject to traction in the opposite direction of the abdominal and adductor muscles of the thigh. This causes a tear of the groin and the appearance of chronic pain, especially after exercise.

The main diagnosis is established by physical examination, through which the increased volume of the groin and the displacement of the abdominal contents are perceived. In case of doubt, ultrasound will provide sufficient data to confirm the diagnosis.

When should surgery be performed?

In general, any patient in good physical condition should opt for surgery, as this is the treatment of choice.

However, in case of asymptomatic hernia (no pain and no limitation of activity) of small or medium size, the clinical and evolutionary observation of the patient is accepted as a treatment to be considered, although the patient should be thoroughly informed about the alarm symptoms (pain, hardening of the area, etc.) that would be in favor of complication, so that surgery would be the first option.

Which operation is the most convenient?

As for the type of surgical intervention, the techniques are multiple and varied and depend very much on the surgical team that performs them.

However, there is a worldwide consensus that reinforcement mesh should always be used, since its use significantly reduces the rate of recurrence.

On the other hand, a very different issue is the surgical approach. This decides the methodology to be used and the team’s experience and habitus sets the basis for the appropriate management.

In this sense, the Abdominal Wall Unit of the HLA Vistahermosa Hospital in Alicante proposes the following:

1. If the hernia is unilateral and not reproduced, use the anterior approach, consisting of an incision over the inguinal canal and repair of the defect by sutures and placement of a reinforcing mesh.
2. If the hernia is double or reproduced, consider a laparoscopic approach consisting of access to the abdominal cavity through the umbilicus, by means of a camera that allows exploration of both groins at the same time. In this way, the hernial content will be reduced. Finally, a mesh is placed and fixed with resorbable staples.
3. The aforementioned athlete’s hernia is a separate case. This occurs in young patients who practice intense exercise with great muscular demand, which fundamentally require laparoscopic repair, even if it is unilateral or open. The traumatologist will suture the weakened musculature, through an inguinal incision, with a section of the adductor tendon, performed below the pubis. In both cases, the stay is 24 hours in the hospital and the patient is provided with the instructions to be followed in order to be discharged immediately after surgery. This includes recommendations on what can and cannot be done during the first 10 – 15 days after the intervention, including sports activities if the patient is practicing. In these cases, referral for physiotherapy with specific exercises for 5 weeks.

What is the most appropriate reinforcement mesh?

There are multiple varieties of reinforcement mesh for the treatment of inguinal hernia, but they are mainly divided into:

• Resorbable: they are used much less, since they are prostheses that degrade over time and end up disappearing from the body. The risk of recurrence is higher than in the non-absorbable ones.
• Non-absorbable: they are made of different materials, polypropylene being the most used due to its excellent tolerance. They also offer excellent results in terms of recurrence and quality of life.

The type of mesh to be used is also influenced by the experience and affinity of the surgical team with the material, since it is the surgeon’s personal decision as to which prosthesis to implant.

What problems can a mesh cause?

As is evident, the surgical mesh is a foreign body inserted in the organism. This causes a minimal inflammatory response in 95% of the cases. However, but in a small group of patients it can manifest itself in a remarkable way. This occurs in cases in which the rate of rejection forcing it to be explanted does not exceed 2 per thousand. This inflammatory reaction can be controlled conservatively, and reoperation for this reason is exceptional.

Is a follow-up necessary?

In principle, the follow-up by the surgical team is established as a protocol, from 8 to 10 days for the removal of sutures, one month for scar control and, depending on the type of intervention, quarterly review a year after it.

What precautions should I take?

Usually, the recommendation is directed to avoid overexertion, coughing, constipation and obesity, since these are determining factors in the possible reproduction of the same.

In the group of sports patients, specific precautions are indicated as far as exercise is concerned, so we have a Physiotherapy service to advise and guide these patients.

The Abdominal Wall Unit of the HLA Vistahermosa Hospital has the most modern technology and professional experience for the treatment of inguinal hernias and their surgical medical management.