27
Groin Hernias and Masses, and
Abdominal Hernias
James J. Chandler
Objectives
1. To be able to discuss the differential diagnosis of
inguinal pain and the diagnosis and management
of groin masses and hernias.
2. To develop an understanding of the anatomy, location, and treatment of different types of hernias;
this includes the frequency, indications, surgical options, and normal postoperative course for
inguinal, femoral, and umbilical hernia repairs.
3. To understand the definition and clarification of
the clinical significance of incarcerated, strangulated, reducible, and Richter’s hernias.
4. To develop an awareness of the urgency of surgical referral, the urgency of treating some hernias.
5. To develop an understanding of the differential
diagnosis of an abdominal wall apparent hernia
or mass, including adenopathy, desmoid tumors,
rectus sheath hematoma, true hernia, and
neoplasm.
Cases
Case 1
A 74-year-old woman has noted an intermittent small lump in the right
groin for 8 months. This has seemed to go away when she lies down, but
it is present when she showers in the morning. Two nights ago, she could
feel the lump when supine. It was slightly tender. Yesterday, she began
feeling a steady ache in the groin and had poor appetite. The discomfort
became worse, and she slept fitfully last night. This morning she felt
awful, had a lemon-sized tender right groin mass, and had nausea
and some diarrhea. You found her moaning, holding her distended
abdomen, and trying to vomit. On examination, there were intermittent
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J.J. Chandler
gurgles heard in the abdomen, and a slightly pink, skin-covered, very
tender lump was present in the right groin. Abdominal x-ray: dilated
intestinal loops with air-fluid levels. Laboratory studies: hemoglobin,
14.6; BUN, 24; electrolytes normal; urine specific gravity, 1.028.
Case 2
A male college student, age 20, presents with a 4-year history of intermittent soft mass in his groin and a large lump in the right side of the
scrotum, which is now uncomfortable. He does not notice any groin
mass on awakening, but he becomes aware of the groin and scrotal
masses later in the morning, toward noon.
Definitions
A hernia is present when an object goes through an opening and is now
in any unexpected location. There may be a covering of the object; this
covering, called the sac, usually is the peritoneum. An organ, a portion
of omentum, or part of the intestine, bladder, or stomach may herniate
through an opening in the abdominal wall or diaphragm. This has
occurred in both Case 1 and Case 2.
A femoral hernia, much more common in women, presents through
the femoral canal, and an indirect inguinal hernia protrudes through
the abdominal wall in the spermatic cord or alongside the round ligament. Pediatric inguinal hernias are indirect. Direct inguinal hernias
are rare in females and in males younger than 35 years of age.
An internal hernia occurs when the intestine goes through an
opening inside the abdominal cavity. In a Richter’s hernia (Case 1), only
a part of the intestinal wall, covered by a sac formed by the overlying
peritoneum, protrudes through an opening (usually in the femoral
canal), and the intestinal lumen remains open. In Case 1, the woman
has both a lump in the groin and not complete intestinal obstruction,
meaning that she could have a knuckle of bowel wall caught in an
opening but with an open lumen, as in a Richter’s hernia. This patient
is dehydrated and seriously ill! (See Algorithms 27.1 and 27.2.)
If an organ or a portion of the intestine uncovered by peritoneum
protrudes through and forms part of the hernia sac, this is called a
sliding hernia. When an intestinal loop comes out through an opening
and this hernia does not go back by itself or cannot be gently pushed
back, the hernia cannot be reduced. The hernia is incarcerated. When
part of the intestine (or stomach) is incarcerated, there can be a shutting off of the venous drainage and/or the arterial circulation; this is
now a strangulated hernia. Gangrenous changes develop, leading to
possible perforation and possible death.
Groin Masses: Differential Diagnosis
These are the differential diagnoses for groin masses.
• Inguinal hernia: Protrudes through the internal ring, at the level of
the public tubercle; exits via the external ring (see Algorithm 27.1).
27. Groin Hernias and Masses, and Abdominal Hernias
Groin mass
481
Immediate surgical
referral
Painful
Not reducible
Reducible:
it is a hernia
Tender, looks
like hernia
Not tender
Pulsatile
Patient stands and strains
Bulge next to femoral
artery—femoral
Bulge near level of pubic
tubercle—inguinal
Surgical
referral
Surgical referral now
Hard
? Cancer
Soft
Vascular—
surgical referral now
Tender:
looks like lymph node
Surgical referral
Algorithm 27.1. Algorithm for the evaluation of groin masses.
There may be a sausage-shaped mass going all the way down into
the scrotum, as in Case 2.
• Femoral hernia: Bulge/mass appears medial to the femoral vein (see
Algorithm 27.1), can rise higher, and can be difficult to distinguish
from an inguinal hernia.
• Lymph node mass: This does not disappear with pressure on it. This
usually is a nontender mass that is firm, overlying the femoral artery.
Lymph nodes may be inflamed and tender from infection or
enlarged and firm because of cancer, a lymphoma, or metastatic
cancer (see Algorithm 27.1).
Femoral
History and physical
Possible femoral hernia
Reduces spontaneously
Does not reduce
Surgical referral soon
Immediate referral
Algorithm 27.2. Algorithm for the evaluation of likely femoral hernia.
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J.J. Chandler
• Varicocele: Irregular, nontender type lump palpable in the spermatic
cord superior to the left testicle. If diagnosis is uncertain, order
duplex color-coded ultrasonography.
• Hydrocele: “Water sac.” A fluid-filled membrane, around or above
the testicle, which may extend up into the inguinal canal and may
communicate with a hernia sac. A hydrocele can be transilluminated
by holding a flashlight behind it.
• Femoral artery aneurysm: Pulsatile, expansile mass. Refer for vascular surgery, now!
• Psoas muscle abscess: Rare. Formerly more common when due to
tuberculosis. Pus in the muscle sheath dissects inferiorly and bulges
into the groin. If due to staphylococcus, patient is very ill and febrile,
and the mass is acutely tender.
• Tumor (benign) of spermatic cord: A fibroma is firm, nontender, and
can be moved a little to the side, in the inguinal canal.
• Seroma: Collection of serum in the groin. Edges are poorly defined.
These generally follow a groin-area surgical procedure, such as groin
dissection or arterial surgery. Hematomas are fairly common after
hernia repair, but large ones are rare.
• Abscess: This would be unlikely unless following a surgical procedure. Tender, warm skin overlying.
• Cryptorchid: An undescended testicle. Duplex ultrasonography
diagnosis it.
See Algorithm 27.3 for a general workup for an abdominal or groin
lump/mass.
Anatomy of the Groin
The layers of tissue found in the lower abdomen are the external
oblique muscle, internal oblique, transversus abdomen, transversalis
fascia, preperitoneal fat, and peritoneum (Fig. 27.1).
History of
abdominal of groin lump/mass
Physical exam
Groin
Abdominal
Consider CTs
Intraabdominal
Surgical referral
See Algorithm 27.2
Abdominal wall?
Surgical referral
Algorithm 27.3. Algorithm for general workup for abdominal or groin lump/mass.
27. Groin Hernias and Masses, and Abdominal Hernias
External oblique m.
Internal oblique m.
Ant. rectus sheath
Rectus abd. m.
Peritoneum
Transversus abd. m.
Post. rectus sheath
Transversalis fascia
A
Anterior rectus sheath
Rectus abdominis m.
B
Figure 27.1. Abdominal wall layers: (A) above the semilunar line of Douglas;
(B) below the semilunar line. (Reprinted from Scott DJ, Jones DB. Hernias and
abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds.
Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001,
with permission.)
The inguinal canal courses obliquely from the internal ring opening
in the transversalis fascia to the pubic bone and the external ring
opening in the external oblique. The spermatic cord in the male comes
through the internal ring; the external ring is where the spermatic cord
exits to head down into the scrotum. Included in this “cord” are superficial and external spermatic fascial layers, cremaster muscle, external
spermatic artery (in the cremaster), internal spermatic fascia, vas deferens, testicular artery, pampiniform plexus of little veins, and some
sympathetic fibers. The genital branch of the genital femoral nerve,
often said to be in the spermatic cord, actually courses through the
internal ring in the edge of posterior cremaster fibers and easily is separated from the cord. This nerve lies posterior to the cord with its
accompanying vessels in the inguinal canal. The boundaries of the
inguinal canal are the transversalis fascia posterior, external oblique
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J.J. Chandler
anterior, internal oblique muscle and rectus sheath superior, inguinal
ligament inferior, pubic bone medial, and internal ring lateral. See
Figure 27.2 for the relationships of the inguinal canal.
A hernia going through the internal ring, outside the inferior epigastric artery, and inside the spermatic cord courses obliquely with the
cord and is termed an indirect inguinal hernia (Case 2). A protrusion
through thinned-out transversalis fascia comes straight out through
the abdominal wall and is called a direct inguinal hernia, which is
medial to the inferior epigastric artery. These hernias bulge through
Hesselbach’s triangle, which is bounded by the rectus sheath, inguinal
ligament, pubis, and inferior epigastric artery (Fig. 27.3). A hernia presenting through both the internal ring and Hesselbach’s triangle is
termed a pantaloon hernia, with a “leg” of the hernia coming out on
both sides of the inferior epigastric artery.
Groin Hernias
Femoral Hernia
Unknown in children and relatively rare in males, this is a hernia presenting in the femoral sheath, through the femoral canal, medial to the
nerve, artery, and vein there. The femoral ring has firm, unyielding
External oblique m.
Ext. oblique
aponeurosis
(reflected)
Int. oblique m.
Arch of
transversus
abd. m.
Inguinal canal
floor
(transversalis
fascia)
Inguinal lig.
External ring
Spermatic cord
Figure 27.2. The left inguinal canal with external oblique aponeurosis incised
and reflected. (Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall
defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery:
Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with
permission.)
27. Groin Hernias and Masses, and Abdominal Hernias
Internal
inguinal
ring
Hesselbach’s
triangle
Femoral
canal
Figure 27.3. Indirect hernias occur through the internal ring. Direct inguinal
hernias occur through Hesselbach’s triangle, which lies between the inguinal
ligament, the rectus sheath, and the inferior epigastric vessels. Femoral hernias
occur through the femoral canal, which lies between the inguinal ligament,
the lacunar ligament, Cooper’s ligament, and the femoral vein. Fruchaud’s
myopectineal orifice refers to the entire musculoaponeurotic area through
which inguinal and femoral hernias can occur. (Reprinted from Scott DJ, Jones
DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang
AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York:
Springer-Verlag, 2001, with permission.)
borders: the superior inguinal ligament, the inferior Cooper’s ligament,
and the medial half-moon–shaped lacunar ligament. Because of this,
these hernias frequently are incarcerated and are prone to develop
strangulation, with intestinal wall gangrene, as in Case 1.
Diagnosis
Diagnosis can be difficult because of the short distance between the
inguinal canal and the medial groin presentation site of the femoral
hernia. The usual history includes the awareness of a lump in the
groin, but it is in the leg crease where the pelvis meets the thigh medially. Direct pain or tenderness, vague groin or lower abdominal discomfort, nausea, and discomfort on prolonged standing or while
walking are frequent findings. Examination is most helpful with the
patient standing. If, when she strains and increases intraabdominal
pressure, a lump is seen or felt, the base of the femoral hernia will be
below the level of the top of the pubic bone, as noted in Algorithm
27.1. Also, if the examiner’s forefinger is in the femoral canal when the
patient strains, the fingertip can be backed away slowly, allowing the
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J.J. Chandler
hernia to pop out of the canal. With an incarcerated hernia in a woman,
there is some tissue swelling, and it can be difficult to differentiate
between femoral or inguinal hernia. The gentlest pressure can be tried
with the patient supine to see whether an inguinal hernia will reduce.
Caution is required because an incarcerated femoral hernia usually
should be diagnosed in the operating room; no significant pressure
should be applied to attempt reduction (see Algorithm 27.2)!
Surgical Treatment of Femoral Hernia
The surgeon must know several operative methods and be able to
choose the best method for the particular patient and situation. In the
open, preperitoneal approach, the surgeon opens the inguinal canal
and then may enter the preperitoneal space through Hesselbach’s triangle or by going above the canal and entering through the posterior
rectus sheath. A piece of nonabsorbable mesh may be used for repair.
In approaching the femoral hernia from below, one incises over the
femoral canal, dissects through the fat and lymphatic tissue, reduces a
sac found, and occludes the canal with rolled mesh or with stitched
tissue adjacent. The sac is opened to check for evidence of ischemic
intestine (bloody fluid). Normal postoperative course includes the following. The individual has moderate pain after the effects of local anesthetic have cleared. She/he can resume a light diet, returning to normal
in 24 hours; constipation may be a problem. With return home within
a few hours after the operation, the patient is up and around but
requires more rest for the next week. Patients return to work from
within a few days to 2 weeks after surgery.
Inguinal Hernias
Diagnosis
In Case 2, we are presented with a man who has had a long history of
groin and associated scrotal mass. Diagnosis of an inguinal hernia is a
simple matter when given a history of an inguinal bulge felt or seen,
especially if it is a new discovery and if it disappears when supine, as
in Case 2. This young man should be examined while he is standing,
with unclothed lower body. Seat yourself before him, ask him to strain
or cough, and watch the hernia roll down the inguinal ligament and
into the upper scrotum. Then see if gentle upward pressure with your
or the patient’s fingers can reduce the hernia; if not, have him lie down,
and try again. When examining a standing male patient without an
obvious bulge, the examiner’s finger pushes up through the upper
scrotal skin and is placed against the external inguinal ring. As the
patient strains and coughs, a soft mass coming out through the ring
and pushing your finger away gives you the diagnosis of a hernia. If
the hernia is continuously bulging and will not reduce with position
change or gentle upward pressure, surgical referral is indicated
without delay (see Algorithm 27.4).
Examination of females also is best done with the patient standing,
but invagination of labial skin is next to impossible. One also desires
to assess whether this is an inguinal or femoral hernia, which can be
difficult (see Algorithm 27.1). Whether a hernia is even present also
27. Groin Hernias and Masses, and Abdominal Hernias
487
Inguinal
History and physical
Laparoscopic repair
Physical exam
Recurrent hernia
Unilateral palpable
hernia
Reducible
Incarcerated
Open mesh repair
Urgent:
open repair,
possible mesh
Preperitoneal open mesh repair
Bilateral palpable
hernia
Bilaterial open
mesh repair
Staged open
mesh repair
Reexam
in 1–3 months
Open mesh repair
Persistent pain,
no hernia detected
Lap repair
Nerve irritation
Local anesthetic,
*steroid injection
(vs. refer: Pain
Management Service)
Algorithm 27.4. Decision tree for inguinal hernia and inguinal pain.
may be especially difficult to decide in females and in any obese male.
On occasion, the examiner will admit uncertainty and recommend
follow-up exam or examination by another physician (see Algorithm
27.4). Operating and finding no hernia to repair is to be avoided.
Pain upon straining or lifting but with no appreciable bulge can be
the first evidence of inguinal hernia. The groin lump may appear some
days later after discomfort from muscle disruption and after inflammation in the muscle have subsided. Pain from inguinal hernia can be
poorly or well localized by the patient. Discomfort usually is intermittent and related to prolonged standing or walking or increased intraabdominal pressure. “Burning,” “dragging feeling,” and “ache” all have
been used as descriptions. Persistent pain and groin mass suggest
incarceration, which requires urgent surgical treatment. Fever,
nausea and vomiting, rapid heart rate, marked tenderness over the
mass, and abdominal distention must bring to mind likely bowel
ischemia, “strangulation,” and the required emergency treatment.
Surgical Treatment of Inguinal Hernia
Open Repair: Open repair is the term used to differentiate from a
laparoscopic technique. The open repair can be via an anterior
approach or via an approach from behind the inguinal canal, through
the preperitoneal space, termed “preperitoneal approach.” Many
hernia repair techniques have been described. General surgeons know
Muscle strain
Heat—avoid
exercise
488
J.J. Chandler
multiple methods. The Italian surgical genius Bassini developed an
elaborate anterior open and successful operation using layers of native
tissue.1 The modern, currently most popular and successful open anterior technique with native tissue is the Canadian Repair developed at
the Shouldice Clinic.2 This features local anesthesia and very early
ambulation, after a repair utilizing running stitches in several layers of
tissue. Nyhus3 is given credit both for promoting an understanding of
the surgical anatomy above the pelvis and for demonstrating advantages in hernia repair with a preperitoneal approach. Lichtenstein4
opened the mesh repair floodgates with his introduction of a highly
successful open, anterior technique using inert mesh laid onto the posterior inguinal canal, repairing a hernia without the tension caused by
bringing tissues together with stitches. Repairs then were developed
that featured mesh placed in the preperitoneal space and repairs in
which mesh is used both in that space and over the floor of the inguinal
canal. Laparoscopic repairs also have evolved.
The young man in Case 2 had his hernia diagnosed through the
history and the exam method described earlier. Many repair techniques
could be used. With the expected small opening at the internal ring and
the congenital-type indirect inguinal hernia, the sac could be ligated
high or stitched, with redundant sac tissue excised, or the sac could be
dissected high and inverted. A few stitches taken medially to tighten
the internal ring (the Marcy repair) might suffice in a case with firm
layer of transversalis fascia in Hesselbach’s triangle. A mesh plug could
be used in the internal ring. After an internal ring plug is placed, onlay
of mesh covering the inguinal canal provides some insurance against
recurrence. The normal postoperative course is similar to the course
after femoral hernia repair. However, lifting more than 35 pounds and
heavy work are to be avoided for 6 postoperative weeks.
Pitfalls and Perils of Open Inguinal Hernia Repair: Complication rates
vary from minimal to 20%. Nerve entrapment or neuroma with virtually constant pain, bleeding and large hematoma, ischemic orchitis, vas
deferens injury, intestinal injury, or failure to recognize pregangrene all
are known and relatively unusual, but feared. Pain after surgery has
been reduced markedly by using a tension-free procedure combined
with local anesthesia. Mesh sheets shrink 20% in size. Mesh plugs
shrink up to 70% in volume, harden, and may allow a hernia to develop
adjacent to the plug. Patient-related complications are ileus, nausea,
cardiac, and respiratory. Other complications that can follow hernia
1
Wright AJ, Gardner GC, Fitzgibbons RJ Jr. The Bassini repair and its variants. In:
Fitzgibbons RJ, Greenberg AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia:
Lippincott, 2002:105–114.
2
Bendavid R. The Shouldice repair. In: Fitzgibbons RJ, Greenberg AG, eds. Nyhus and
Condon’s hernia, 5th ed. Philadelphia: Lippincott, 2002:129–138.
3
Nyhus LM, Condon RE, Harkins HW. Clinical experiences with preperitoneal hernia
repair for all types of hernia in the groin: with particular reference to the importance of
tranversalis fascia analogs. Am J Surg 1960;100:234–244.
4
Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery, including a new
concept, introducing tension-free repair. Int Surg 1986;71:1–4.
27. Groin Hernias and Masses, and Abdominal Hernias
repair include chronic pain, testicular atrophy or ejaculation abnormality, wound seroma or infection, hydrocele, and scrotal or retroperitoneal hematoma. Recurrence of hernias after surgical repair is of
major concern to surgeons and patients alike. Many patients are not
closely followed, and many with a recurrence seek aid elsewhere,
making recurrence rates difficult to establish. In summary, all of the
open approaches now in popular usage have acceptable rates of longterm hernia cure when the reports of centers with large numbers of
repairs are reviewed.
Laparoscopic Inguinal Hernia Repair: Laparoscopic repair requires
general anesthesia, has been controversial, and is not widely used.
However, recent reports of highly acceptable recurrence rates, lessened
postoperative pain, and rapid return to regular work have caused
genuine increasing interest, demonstrated in a recent compilation of
prospective, randomized trials comparing open and laparoscopic
repairs (Table 27.1).
Pitfalls and Perils of Laparoscopic Repair of Inguinal Hernias: While some
surgeons have excellent reported results, laparoscopic repair has had
numerous complications related to this technique, in addition to the
usual list of potential complications of open hernia surgery. These
include bleeding in the retroperitoneal space, in the abdominal wall, or
inside the abdomen; intraabdominal intestinal or artery injury; bladder
perforation; trocar-site hernia; stapling a nerve; and small-bowel
obstruction. Recurrences have resulted from inadequate mesh fixation,
too small a mesh, missed hernia, and mesh displacement. Cost of
repairing a hernia with a laparoscopic method is greater than the costs
associated with other methods.
Watchful Waiting
Whether watchful waiting is ever indicated is controversial, and the
conventional approach is to plan repair when a hernia is diagnosed.
The conventional approach is being questioned, however, in asymptomatic hernias. Somewhere between one-half and three-quarter
million hernias are operated upon yearly in the United States. It is estimated that an even larger number are not operated upon because individuals are not choosing to have them repaired. Most surgeons
recommend repair in order to avoid the higher complication rate and
the greater difficulty of repair in cases of incarceration or strangulation,
and because of the belief that incarceration/strangulation are likely to
occur, when in fact this may be unlikely. Also, long-term complications,
including chronic pain, may follow surgical repair. Data are insufficient
now to develop clear indications for watchful waiting. An inguinal
hernia that is asymptomatic, has a large defect or almost no bulge at
all, and that reduces quickly with the patient supine should be able
to be observed for some period of time. Also, with a patient who presents with possible incarceration of a hernia that you find to be easily
reduced with very gentle pressure, surgical intervention can be delayed for a few hours and, in some cases, for 1 or 2 days.
489
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J.J. Chandler
Table 27.1. Prospective randomized trials comparing laparoscopic and open repairs (level
I evidence).
Reference
Study
design
Paganini et al
1998, Italya
TAPP vs.
Lichtenstein
Average
follow-up
(months)
No. of
repairs
28
TAPP: 52
Licht.: 56
Zieren et al
1998,
Germanyb
TAPP vs. Plug
& Patch vs.
Shouldice
25
TAPP: 80
Plug: 80
Shouldice:
80
Liem et al
1997,
Netherlandsc
TEP vs. open
(Marcy,
Lichtenstein,
Bassini,
Shouldice,
McVay)
20.2
TEP: 487
Open: 507
Champault
et al 1997,
Franced
TEP vs. Stopps
20.2
Complications
(not including
recurrences)
Recurrences
14 (26.9%) total
complications
4 (7.7%) hematoma
1 (1.9%) hydrocele
5 (9.6%) paresthesia
4 (7.7%) seroma*
15 (26.8%) total
complications
8 (14.3%) hematoma
2 (3.6%) hydrocele
5 (8.9%) paresthesia
0 seroma*
2
(3.8%)
2 (3%) intraop
bleeding*
15 (19%) postop
complications
12 (15%) postop
complications
13 (16%) postop
complications
0
24 (5%) Conversion
to TAPP or open
54 (11%) total postop
complications
0 deep wound
infection*
10 (2%) chronic
pain*
7 (1%) seroma*
3 (1%)
pneumoscrotum
>1 day
99 (19.5%) total
postop
complications
6 (1%) deep wound
infection*
70 (14%) chronic
pain*
0 seroma*
0
0
0
17
(3%)*
31
(6%)*
TEP: 51
4% total
complications*
3 (6%) conversions
to open
3
(6%)
Stoppa: 49
20% total
complications*
1
(2%)
27. Groin Hernias and Masses, and Abdominal Hernias
491
Table 27.1. Continued
Operative
time
(min)
Cost
Postoperative
pain
Return
to work
(days)
66.6 Unilateral
primary*
71.1 Unilateral
recurrent
85.7 Bilateral
$1249
Ø pain
score
@ 48
h*
15
48.2 Unilateral
primary*
41.2 Unilateral
recurrent
75.9 Bilateral
$306
≠
discomfort
@ 7 d,
3 mon
14
61*
$1211
16
18
36
$124
47
$69
45*
—
40*
—
“Significantly
longer”*
—
—
≠ pain
score
*
26*
Ø pain
score
*
14*
Conclusions/details
95% of Lichtenstein repairs performed
under local anesthesia.
TAPP had less postop pain.
TAPP should not be adopted routinely
unless its cost can be reduced.
Plug & Patch and TAPP cause less pain
and have faster return to work than
Shouldice; Plug & Patch cost less than
TAPP and can be performed faster and
under local anesthesia.
TEP has more rapid recovery and fewer
recurrences than open repairs, but
takes slightly longer to perform.
21*
Ø pain
score
*
Ø
meds
*
17*
35*
45% bilateral, 43% recurrent.
Mesh for TEP was not fixed in place;
mesh size increased from 6 ¥ 11 cm to
12 ¥ 15 cm due to early recurrences.
Single piece of mesh for bilateral hernias
believed to reduce recurrence rates.
TEP has the same long-term recurrence
rate as the Stoppa procedure, but
confers a real advantage in the early
postop period.
Continued
492
J.J. Chandler
Table 27.1. Continued
Reference
Kald et al
1997,
Swedene
Study
design
TAPP vs.
Shouldice
Average
follow-up
(months)
12
Bessell et al
1996,
Australiaf
TEP vs.
Shouldice
7.3
Wright et al
1996,
Scotlandg
TEP vs. open
(Lichtenstein or
preperitoneal)
—
Tschudi et al
1996,
Switzerlandh
Barkun et al
1995,
Canadai
Vogt et al
1994, USj
TAPP vs.
Shouldice
TAPP or IPOM
vs. open
(Bassini, McVay,
Shouldice,
Lichtenstein,
Plug & Patch)
IPOM (with
meshed PTEE)
vs. open
(Bassini, McVay)
6.7
14
No. of
repairs
TAPP: 122
Complications
(not including
recurrences)
8 (6.6%) total
complications
Shouldice:
89
9 (10.1%) total
complications
3
(3.4%)
*
TEP: 39
6 conversion to open
3 conversion to TAPP
4 (10%) postop
complications
2
(5.1%)
Shouldice:
7 (9.5%) postop
0
74
TEP: 67
complications
6 (9%) conversion to
open
15 (22%) postop
complications
1 (1%) hematoma*
0 seroma*
—
Open: 64
46 (72%) postop
complications
20 (31%) hematoma*
7 (11%) seroma*
—
TAPP: 52
6 (12%) total
complications
1
(1.9%)
Shouldice:
56
9 (16%) total
complications
2
(3.6%)
TAPP: 33
10 (22.5%) total
complicaions
0
Open: 49
6 (12.2%) total
complications
1 (2%)
IPOM: 30
5 (17%) total
complications
1 (3.3%) bladder
perforation
5 (16%) total
complications
1
Recurrences
0*
IPOM: 10
8
Open: 31
(3.3%)
2
(6.5%)
27. Groin Hernias and Masses, and Abdominal Hernias
493
Table 27.1. Continued
Operative
time
(min)
72*
Cost
+ $483
direct
cost
Postoperative
pain
—
Return
to work
(days)
10*
62*
+ $1364
indirect
cost
—
23*
87.5*
—
Ø pain
score
*
Ø
meds
30.5
50*
—
58*
—
—
meds
—
87 unilateral*
124 bilateral
—
59 unilateral*
79 bilateral
—
43
$1718
—
80.9
—
Acute study focusing on early outcome.
No data for length of follow-up or
recurrences.
Significant decrease in pain but increased
OR time for TEP.
Significant conversion rate.
Very high complication rates for both
groups.
Also looked at pulmonary and metabolic
measures; no differences found.
—
Ø pain
score
*
Ø
meds
*
25
Study biased because patients
undergoing open repairs told not to
resume activity for 4–6 weeks.
Significantly less pain with TAPP, but
longer OR time.
Long-term follow-up needed for analysis
of recurrences.
48
Ø
meds
*
$1224
62.5
Study biased because of larger crossover
to open group.
Substantial conversion rate to open and
TAPP repairs.
TEP has significant decrease in pain,
equivalent return to work, but longer
operative time.
TEP alleviates the inherent dangers
associated with TAPP, but further
studies needed.
32
Ø pain
score
*
Ø
45*
Conclusions/details
TAPP had faster recovery and return to
work with comparable complication
rates.
TAPP more cost-effective if indirect cost
compared, which included income lost
by a delay in return to work.
9.6
Improved quality of life and decreased
pain with laparoscopic repairs, but at
increased cost.
Laparoscopic repairs are feasible and
comparable to open repairs.
10.9
Ø
med
7.5
18.5
Less pain and faster return to work with
IPOM, with comparable efficacy and
morbidity.
Longer follow-up needed.
Two patients had IPOM under local
anesthesia.
Continued
494
J.J. Chandler
Table 27.1. Continued
Reference
Stoker et al
1994, UKk
Payne et al
1994, USl
Study
design
TAPP vs. open
(nylon darn
plication)
TAPP vs.
Lichtenstein
Average
follow-up
(months)
7
10
No. of
repairs
TAPP: 83
Complications
(not including
recurrences)
6 (7%) total
complications*
1 deep wound
infection
3 persistent pain
1 hematoma
Recurrences
0
Open: 84
16 (19%) total
complications*
5 deep wound
infection
6 persistent pain
3 hematoma
0
TAPP: 48
6 (13%) total
complications
0 groin pain >1 mon.
2 (4%) conversions
to open
1 (2%) incarcerated
omentum in
peritoneal flap
9 (17%) total
complications
4 (8%) groin pain
>1 mon.
0
Licht: 52
0
TAPP, transabdominal preperitoneal approach; IPOM, intraperitoneal onlay mesh repair; TEP, totally extraperitoneal
approach; PTEE, polytetrafluoroethylene.
*, Statistically significant.
a
Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled, clinical study of laparoscopic vs open tensionfree inguinal hernia repair. Surg Endosc 1998;12:979–986.
b
Zieren J, Zieren H, Jacobe CA, et al. Prospective randomized study comparing laparoscopic and open tension-free
inguinal hernia repair with Shouldice’s operation. Am J Surg 1998;175:330–333.
c
Liem MSL, Van Der Graff Y, Van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic
surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541–1547.
d
Champault G, Rizk N, Catheline JM, et al. Inguinal hernia repair: totally pre-peritoneal laparoscopic approach
versus Stoppa operation, randomized trial: 100 cases. Hernia 1997;1:31–36.
e
Kald A, Anderberg B, Carlsson P, Park PO, et al. Surgical outcome and cost-minimization analyses of laparoscopic
and open hernia repair: a randomized prospective trial with one year follow-up. Eur J Surg 1997;163:505–510.
f
Bessell JR, Baxter P, Riddell P, Watkin S, et al. A randomized controlled trial of laparoscopic extraperitoneal hernia
repair as a day surgical procedure. Surg Endosc 1996;10:495–500.
Source: Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang
AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.
Abdominal Wall Hernias
Ventral hernias are those protruding through the anterior wall of the
abdomen. Umbilical hernias are ventral, but they are placed in their
own category because etiology and repair techniques are so different
from those used for ventral incisional hernias. With a weakened area
of the wall or with significant increased intraabdominal pressure,
hernia develops. At the umbilicus, hernia usually is congenital, but
hernia can follow childbirth, increased weight, or be at the upper or
27. Groin Hernias and Masses, and Abdominal Hernias
495
Table 27.1. Continued
Operative
time
(min)
50 unilateral*
92 bilateral
Cost
+£168
Postoperative
pain
Ø
pain
score
*
Ø
meds
*
35 unilateral*
60 bilateral
Return
to work
(days)
14*
Conclusions/details
TAPP has less pain, faster return to work,
and fewer complications, but increased
operative time.
Substantial economic savings in lost
work days.
28*
68 unilateral
87 bilateral
67 recurrent
$3093
*
—
9 unilat.*
7.5 bilat.
11.4
recurr.
56 unilateral
93 bilateral
73 recurrent
$2494
*
—
17
unilat.*
25 bilat.
26
recurr.
TAPP can be performed with similar
operative times and short-term
recurrence rates, with faster return to
work, but an increased cost.
90% of Lichtenstein’s used local
anesthesia.
Biggest impact on faster return to work
and increased ability to perform
straight leg raises seen in manual labor
population.*
g
Wright DM, Kennedy A, Baxter JN, et al. Early outcome after open versus extraperitoneal endoscopic tension-free
hernioplasty: a randomized clinical trial. Surgery (St. Louis) 1996;119:552–557.
h
Tschudi J, Wagner M, Klaiber C, Brugger JJ, et al. Controlled multicenter trial of laparoscopic transabdominal
preperitoneal hernioplasty vs Shouldice herniorrhaphy. Surg Endosc 1996;10:845–847.
i
Barkun JS, Wexler MJ, Hinchey EJ, Thibeault D, et al. Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial. Surgery (St. Louis) 1995;118:703–710.
j
Vogt DM, Curet MJ, Pitcher DE, et al. Preliminary results of a prospective randomized trial of laparoscopic onlay
versus conventional inguinal herniorrhaphy. Am J Surg 1995;169:84–90.
k
Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomized prospective trial. Lancet 1994;343:1243–1245.
l
Payne JH, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994;129:973–981.
Source: Reprinted from Scotl DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang
AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.
lower end of a healed incision (an incisional umbilical hernia).
Preperitoneal fat, omentum, or gut may protrude, causing a bulge,
symptoms of pain, and nausea. A huge umbilical hernia may allow a
large portion of bowel to enter the sac, to become twisted and compromised, and to perforate. Some umbilical hernias can be repaired
using local anesthesia, but most require general anesthesia and muscle
relaxation. Asymptomatic hernias may be able to be controlled with an
abdominal binder. Symptomatic umbilical hernias are repaired by
incising halfway around the umbilical skin, dissecting down to the
496
J.J. Chandler
fascia, separating the overlying skin from the hernia sac, separating the
fascial ring from the sac, reducing the sac and contents, and closing the
fascial defect with permanent suture. A piece of prosthetic mesh often
is placed just under the fascial closure, held in place with one or more
of the closure stitches.
Epigastric hernias occur in the upper abdomen through a defect in
the linea alba and are repaired with simple closure with permanent
suture, often buttressed with a piece of mesh in the preperitoneal
space. Abdominal wall mass differential diagnosis includes metastatic
cancer at the navel (“Sister Mary Joseph” tumor) or dermal metastasis, varicose veins (umbilical, secondary to portal hypertension),
lymph node groin mass encroaching onto the abdominal wall, rectus
sheath hematoma (usually in an anticoagulated patient: the hard,
tender mass is confined to one entire rectus sheath), and desmoid
tumor. Desmoids are seen in patients with familial polyposis syndrome
and, although benign, can be a problem and difficult to remove surgically. Biopsy is diagnostic, and imaging studies aid in management
decision.
Incisional hernias may be small or large and enlarging. Huge symptomatic hernias in an obese patient can be very difficult to repair, carrying the risks of intestinal injury (while freeing adhesions in the
abdomen) and of major pulmonary, cardiac, and wound complications
postoperatively. Numerous operations have been developed. Almost
all repairs used today involve the use of mesh placement somewhere.
(For more information, see the chapter “Hernias and Abdominal Wall
Defects” by D.J. Scott and D.B. Jones in Surgery: Basic Science and Clinical Evidence) edited by J.A. Norton, et al, published by Springer-Verlag,
2001.) Of particular interest for repair of large and complex incisional
hernias are techniques using a giant piece of mesh. The newer laparoscopic methods seem promising, with fewer reported complications
and less pain postoperatively.
Other Abdominal Hernias
In a spigelian hernia, fat or an intestinal loop comes through a weak
point in the lateral posterior rectus sheath at the semilunar line (in the
lower abdomen). This hernia is in the abdominal wall between muscles
and fascia, which makes the hernia difficult to locate. It usually is
reducible, but it is intermittently painful. Laparoscopic repair works
well for these, as does an incision directly onto the palpable lump or
through the midline. When a midline incision is used, the site of the
abdominal wall is lifted up so that the opening can be seen from underneath and the hernia defect repaired.
In a lumbar hernia, a posterior-lateral bulge is noted, possibly following trauma, through one of the two muscular lumbar triangles.
Pelvic floor hernias are rare, and a computed tomography (CT) scan
is useful for diagnosis and in planning the operative approach. Parastomal hernias usually develop alongside a colostomy, but they can
occur next to an iliostomy. These are common and may require correction, but the recurrence rate is high.
27. Groin Hernias and Masses, and Abdominal Hernias
Congenital and Diaphragmatic Hernias
Infants born with congenital diaphragmatic hernia constitute a pediatric and pediatric surgical emergency. While prenatal diagnosis with
ultrasound and prenatal treatment is desirable, when not done, a rapid
postnatal diagnosis can be crucial. The child has a huge opening in the
posterolateral diaphragm (foramen of Bochdalek), the abdominal contents are up in the chest; the child has a scaphoid abdomen, and may
have easily heard bowel sounds in the chest. After an abnormality is
noted in the child’s breathing and a rapid chest radiograph is ordered,
one often can make the diagnosis from seeing gut in the chest and a
shift of the mediastinum. A very small amount of contrast put through
a tiny nasogastric tube should help clarify the diagnosis. With rapid
diagnosis and appropriate treatment (neonatal intensive care before
and after surgical correction), formerly high mortality rates have been
reduced to acceptable levels.
A sliding hiatal hernia (widened esophageal hiatus with part of
the stomach in the chest) exists in almost all patients with gastroesophageal reflux disease. Wrapping some upper stomach around the
esophagogastric junction and holding it there with stitches (Nissen
repair) has excellent results in those requiring surgical intervention.
This procedure lends itself well to a laparoscopic approach, with rapid
return home and to work. Preoperative evaluation includes manometry and endoscopy.
In a paraesophageal hiatal hernia, the gastric fundus herniates up
through the diaphragm and is superior to the location of the most distal
point of the esophagus. Reflux symptoms, possible mild or severe pain,
and even gangrenous changes in the herniated portion of the stomach
can result. A lateral chest radiography usually is diagnostic; an upper
gastrointestinal study always is. If at all symptomatic, a paraesophageal hernia always should be corrected surgically without delay.
Traumatic hernia through the diaphragm always requires repair.
Summary
Evaluation of a suspected or definite groin mass and evaluation of
groin pain can be a challenge to any primary physician. History and
physical examination, while keeping the different etiologic possibilities
in mind, frequently clarify the diagnosis. The most commonly performed general surgical procedure is groin hernia repair. General surgeons are referred for many patients with groin area pains of all types.
Almost all patients with groin mass or groin pain are, sooner or later,
referred to a surgeon. The sooner this is done, the better.
The transition in hernia surgery to widespread use of local anesthesia and rapid return to home and normal activities has been aided by
shorter operating times and use of some type of inert, nonabsorbable
mesh. Outcomes and patient satisfaction have improved. Types of
hernia repairs and their pros and cons have been presented, along with
discussion of definitions, differential diagnoses, and anatomic and
497
498
J.J. Chandler
special considerations. Abdominal wall hernias as well as congenital
and diaphragmatic hernias have been briefly discussed.
Selected Readings
Bendavid R. Complications of groin hernia surgery. Surg Clin North Am
1998;78(6):1089–1103.
Cunningham J, Fry DE, Richards AT, et al. Part IV: complications of groin
hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s
Hernia, 5th ed. Philadelphia: Lippincott, 2002:279–324.
Felix E, et al. Causes of recurrence after laparoscopic hernioplasty. A multicenter study. Surg Endosc 1998;123:226–231.
Gilbert AI, Graham MF. Tension-free hernioplasty using a bilayer prosthesis.
In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th ed.
Philadelphia: Lippincott, 2002:173–180.
Hair A, et al. What effect does the duration of an inguinal hernia have on
patient symptoms? J Am Coll Surg 2001;193:125–129.
Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery, including a new concept, introducing tension-free repair. Int Surg 1986;71:1–4.
Loham AS, et al. Mechanisms of hernia recurrence after preperitoneal mesh
repair. Traditional and laparoscopic. Ann Surg 1997;225(4):422–431.
Neuhauser D. Elective inguinal herniorrhapy versus truss in the elderly. In:
Bunker JP, Barnes BA, Mosteller F, eds. Costs, Risks and Benefits of Surgery.
New York: Oxford University Press, 1977:223–239.
Nyhus LM, Condon RE, Harkins HN. Clinical experiences with preperitoneal
hernia repair for all types of hernia in the groin: with particular reference to
the importance of tranversalis fascia analogs. Am J Surg 1960;100:234–244.
Payne JH, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal
herniorrhaphy? A randomized prospective trial. Arch Surg 1994;129:973–981.
Scott DJ, Jones BJ. Hernias and abdominal wall defects. In: Norton JA, Bollinger
RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New
York: Springer-Verlag, 2001:727–823.
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inguinal hernia: results of 3,019 operations from five diverse surgical sources.
Am Surg 1992;58:255–257.
Stassen, et al. Reoperation after recurrent groin repair. Ann Surg 2001;234:
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