Introduction

About 75% of all hernias are classified as inguinal hernias, which are the most commontype of hernia occurring in men and women as a result of the activities of normal living andaging. Because humans stand upright, there is a greater downward force on the lower abdomen,increasing pressure on the less muscled and naturally weaker tissues of the groin area. Inguinalhernias do not include those caused by a cut (incision) in the abdominal wall (incisional hernia).According to the National Center for Health Statistics, about 700,000 inguinal hernias arerepaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through theabdominal wall. The inguinal canal is the normal route by which testes descend into the scrotumin the male fetus, which is one reason these hernias occur more frequently in men. Hernias are divided into two categories: congenital (from birth), also called indirect hernias, and acquired, also called direct hernias. Among the 75% of hernias classified as inguinalhernias, 50% are indirect or congenital hernias, occurring when the inguinal canal entrance failsto close normally before birth. The indirect inguinal hernia pushes down from the abdomen andthrough the inguinal canal. This condition is found in 2% of all adult males and in 12% of malechildren. Indirect inguinal hernias can occur in women, too, when abdominal pressure pushesfolds of genital tissue into the inquinal canal opening. In fact, women will more likely have anindirect inguinal hernia than direct. Direct or acquired inguinal hernias occur when part of thelarge intestine protrudes through a weakened area of muscles in the groin. The weakening resultsfrom a variety of factors encountered in the wear and tear of life.Inguinal hernias may occur on one side of the groin or both sides at the same or differenttimes, but occur most often on the right side. About 60% of hernias found in children, for example, will be on the right side, about 30% on the left, and 10% on both sides. The muscular weak spots develop because of pressure on the abdominal muscles in the groin area occurringduring normal activities such as lifting, coughing,straining during urination or bowelmovements,pregnancy,or excessive weight gain. Internal organs such as the intestines may thenpush through this weak spot, causing a bulge of tissue. A congenital indirect inguinal hernia maybe diagnosed in infancy, childhood, or later in adulthood, influenced by the same causes as directhernia. There is evidence that a tendency for inguinal hernia may be inherited.A direct and an indirect inguinal hernia may occur at the same time; this combined herniais called a pantaloon hernia. Because inguinal hernias do not heal on their own and can become larger or twisted,which may close off the intestines, the prevailing medical opinion is that hernias must be treatedsurgically when they cause pain or limit activity. Protruding intestines can sometimes be pushedback temporarily into the abdominal cavity, or an external support (truss) may be worn to holdthe area in place until surgery can be performed. Sometimes, other medical conditionscomplicate the presence of a hernia by adding constant abdominal pressure. These conditions,including chronic coughing, constipation, fluid retention, or urinary obstruction, must be treatedsimultaneously to reduce abdominal pressure and the recurrence of hernias after repair. Arelationship between smoking and hernia development has also been shown. Groin hernias occur more frequently in smokers than nonsmokers, especially in women. A hernia may becomeincarcerated, which means that it is trapped in place and cannot slip back into the abdomen.

This causes bowel obstruction, which may require the removal of affected parts of the intestines(bowel resection) as well as hernia repair.If the herniated intestine becomes twisted, bloodsupply to the intestines may be cut off (intestinal ischemia) and the hernia is said to bestrangulated, a condition causing severe pain and requiring immediate surgery. A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. Hernias by themselves may be asymptomatic (produce no symptoms) or cause slight to severe pain. Nearly all have a potential risk of having their blood supply cut off (becoming strangulated). When the content of the hernia bulges out, the opening it bulges out through can apply enough pressure that blood vessels in the hernia are constricted and therefore the blood supply is cut off. If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply. Different types of abdominal-wall hernias include the following: Inguinal (groin) hernia: Making up 75% of all abdominal-wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect. Both occur in the groin area where the skin of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area. Distinguishing between the direct and indirect hernia, however, is important as a clinical diagnosis. Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible site for a hernia in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age. Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in an area where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age. Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated. Not all hernias that are irreducible are strangulated (have their blood supply cut off ), but all hernias that are irreducible need to be evaluated by a health-care provider. Umbilical hernia: These common hernias (10%-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than half an inch), this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are pregnant or who have given birth (due to the added stress on the area).

Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness in which a hernia may develop. This occurs after 2%-10% of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return. Spigelian hernia: This rare hernia occurs along the edge of the rectus abdominus muscle through the spigelian fascia, which is several inches to the side of the middle of the abdomen. Obturator hernia: This extremely rare abdominal hernia develops mostly in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting. Because of the lack of visible bulging, this hernia is very difficult to diagnose. Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

Causes
Although abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness. Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. Examples include obesity, heavy lifting, coughing, straining during a bowel movement or urination, chronic lung disease, and fluid in the abdominal cavity. A family history of hernias can make you more likely to develop a hernia.

Symptoms and Signs

The signs and symptoms of a hernia can range from noticing a painless lump to the severely painful, tender, swollen protrusion of tissue that you are unable to push back into theabdomen (an incarcerated strangulated hernia).

Reducible hernia It may appear as a new lump in the groin or other abdominal area. It may ache but is not tender when touched. Sometimes pain precedes the discovery of the lump. The lump increases in size when standing or when abdominal pressure is increased (such as coughing). It may be reduced (pushed back into the abdomen) unless very large. Irreducible hernia It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it. Some may be chronic (occur over a long term) without pain.

An irreducible hernia is also known as an incarcerated hernia. It can lead to strangulation (blood supply being cut off to tissue in the hernia). Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting. Strangulated hernia This is an irreducible hernia in which the entrapped intestine has its blood supply cut off. Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting). The affected person may appear ill with or without fever.

Complications
Most inguinal hernias enlarge over time if they're not repaired surgically. Large hernias can put pressure on surrounding tissues in men they may extend into the scrotum, causing pain and swelling. But the most serious complication of an inguinal hernia occurs when a loop of intestine becomes trapped in the weak point in the abdominal wall (incarcerated hernia). This may obstruct the bowel, leading to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas.It can also diminish blood flow to the trapped portion of the intestine a condition called strangulation that may lead to the death of the affected bowel tissues. A strangulated hernia is life-threatening and requires immediate surgery. Diagnostic Procedures The diagnosis of inguinal hernia is usually based on your medical history and a physical exam. Tests such as ultrasound and CT scans are not usually needed to diagnose an inguinal hernia. In most cases, a doctor can identify an inguinal hernia during a physical exam. An examination of urine (urinalysis) may be done to rule out a urinary tract infection. A urinary tract infection or kidney stone may cause pain in the groin that can be mistaken for hernia pain. Further tests may be done to rule out other conditions that could be contributing to the hernia, such as colon or prostate cancer or lung diseases that cause chronic coughing.

Medical Management
The hernia truss is intended to contain a reducible inguinal hernia within the abdomen.This device fell out of favour with the advent of hernia surgery. It is not considered to provide acure, and if the pads are

hard and intrude into the hernia aperture they may cause scarring andenlargement of the aperture. In addition, most trusses with older designs are not able effectivelyto contain the hernia at all times, because their pads do not remain permanently in contact withthe hernia. The more modern variety of truss (medicine)is made with non-intrusive flat pads andcomes with a guarantee to hold the hernia securely during all activities. Although there is as yetno proof that such devices can prevent an inguinal hernia from progressing, they have beendescribed by users as providing greater confidence and comfort when carrying out physicallydemanding tasksTheir popularity is likely to increase, as many individuals with small, painlesshernias are now delaying hernia surgery due to recently published reports on the incidence of Post Herniorrhaphy Pain Syndrome.

Surgical Treatment
Herniorrhaphy. In this procedure, also called "open" hernia repair, your surgeon makes an incision in your groin and pushes the protruding intestine back into your abdomen. Then your surgeon repairs the weakened or torn muscle by sewing it together. Often the weak area is also reinforced and supported with a synthetic mesh, a procedure called hernioplasty. After the operation, you'll be encouraged to move about as soon as possible, but it may be as long as four to six weeks before you're able to fully resume your normal activities. Laparoscopy. In laparoscopic surgery, your surgeon uses several small incisions rather than one large one. A fiber-optic tube with a tiny camera is inserted into your abdomen through one incision, and miniature instruments are inserted through the other incisions. Your surgeon then performs the operation using the video camera as a guide. In laparoscopic surgery, synthetic mesh is always used to repair the hernia (hernioplasty). Advantages of laparoscopic repair include less discomfort and scarring after surgery and a quicker return to normal activities most people are back to work within a few days. The procedure is a good choice for people whose hernias recur following traditional hernia surgery because laparoscopic methods allow surgeons to work around scar tissue from earlier repair. It's also good for people who have hernias on both sides of the body (bilateral inguinal hernias). Disadvantages of laparoscopic repair include an increased risk of complications and of recurrence following surgery. These risks are reduced if the procedure is performed by a surgeon with extensive experience in these kinds of repairs.

Pathophysiology

Increased pressure in the compartment Of the abdomen is develop

Intra abdominal wall( containing membrane or muscle) Of inguinal canal into the scrotum becomes weakened

Causing the inguinal ring not to close

Evolves into a hole or defect

Fat or part of the small intestine slides Through the inguinal canal

Swollen or enlarge of scrotum

feeling of weakness or pressure in the groin

pain or discomfort

Indirect inguinal hernias usually occur because of a persistent processus vaginalis. As the hernia emerges through the deep internal ring, it carries with it fascial linings of the tissue it transverses. The hernia courses along the inguinal canal lateral to the epigastric arteries and emerges through the external ring slightly lateral to the pubic tubercle. Contents of this hernia then follow the tract of the spermatic cord down into the scrotal sac in men, or follows the round ligament in females.

Direct hernias are always acquired and therefore unusual in the young. They typically affect middle-aged or older patients. A direct inguinal hernia occurs because of degeneration and fatty changes in the aponeurosis of the transversalis fascia in the Hesselbach triangle area. The Hesselbach triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries and medially by the lateral border of rectus abdominus.

Because of the wide neck of a direct hernia, it rarely strangulates. Strangulation is more common with indirect hernia, which has a narrow neck. As segments of the intestine prolapse through the defect in the anterior abdominal wall, they cause sequestration of fluid within the lumen of the herniated bowel. This initially impairs the lymphatic and venous drainage, which further compounds the swelling, and over time the arterial supply becomes involved. The increased intraluminal pressure causes the wall of the affected segment to become congested, which leads to extravasations of blood into the hernia sac. The normal pinkish and shining colour of the bowel wall is lost and replaced with a dull congested bowel segment, followed by loss of tone within the bowel wall. This favours bacterial proliferation and subsequent infection of the blood-stained fluid in the hernia sac. Gangrene ensues and, if left untreated, perforation occurs. Peritonitis occurs initially within the sac and then spreads to the peritoneal cavity.

Anatomy and physiology

The most common type of abdominal hernia is an inguinal or groin hernia. Patients usually bring these hernias to the attention of their physicians when they either feel a lump in their groin or develop pain or soreness with certain activities.The activities that tend to exacerbate hernia pain include prolonged standing, lifting, and straining to have a bowel movement. Hernias are essentially holes in the abdominal wall through which abdominal organs can protrude through causing a bulge or lump when looking at the skin. During in uterine development, the testes descend out of the abdomen into the scrotum. They pass out of the abdominal cavity into the inguinal canal via the deep (internal) ring and then into the scrotum via the superficial (external) ring. In females, the same tract develops as well. This tract normally withers and disappears. In some adults, the path they take remains and is called the processus vaginalis. In adult life, the processus vaginalis allows abdominal organs such as the intestine, bladder, or intraabdominal fat to migrate through the abdominal wall. This is known as an indirect inguinal hernia. A direct inguinal hernia does not go through the inguinal canal but directly through the abdominal wall and develops in men via wear and tear of the abdominal wall from older age or from excessive activity. Intra-abdominal contents bulge directly out of the abdominal wall.Indirect inguinal hernias are more common than direct inguinal hernias overall.