• “No disease of the human body, belonging to the

province of the surgeon, requires in its treatment, a

better combination of accurate, anatomical
knowledge with surgical skill than Hernia in all its
varieties.”

• Sir Astley Paston Cooper, 18041

INGUINAL HERNIAS
Dr Tameshwar K. Algu
(ChM, DipSurg, MBBS)
HOD SURGERY - NEW AMSTERDAM HOSPITAL
EPIDEMIOLOGY
• Inguinal hernia repair is the most common General Surgical
operation performed worldwide.

• Internationally 20 million groin hernia repairs are performed

each year.2,3

• Annually, more than 750,000 inguinal hernia repairs are done

in the United States, and more than 80,000 in the UK.2,4,5

• The true incidence of inguinal hernias is unknown; published

statistics vary widely.
• About 5% of the population develop abdominal wall hernias with
about 75% of them occurring in the inguinal region.

• 2/3 are indirect and the remainder are direct inguinal hernias. 6

• Men are 25 times more likely to have a groin hernia than are
women.

• Regardless of gender, an indirect inguinal hernia is the most

common

• Direct hernias are very uncommon in women.

• Indirect hernias occur more on the right side due to a delay in

atrophy of the processus vaginalis after the normal slower descent
of the right testis to the scrotum during fetal development.
 CLASSIFICATION
• direct or indirect.

• The sac of an indirect inguinal hernia passes from the internal

inguinal ring obliquely toward the external inguinal ring.

• The sac of a direct inguinal hernia is medial to the internal inguinal

ring and protrudes outward and forward.

• Pantaloon hernia.6
Presumed Causes of Groin Herniation

• Coughing • Valsalva maneuvers

• Chronic obstructive • Ascites
pulmonary disease • Upright position
• Obesity • Congenital connective tissue
disorders
• Straining     • Defective collagen synthesis
• Constipation     • Previous right lower quadrant
• Prostatism incision
• Arterial aneurysms
• Pregnancy
• Cigarette smoking
• Birthweight less than 1500 g • Heavy lifting
• Family history of a hernia • Physical exertion (?)
 Symptoms depends on
reducibility
• Reducible - contents can be replaced within the
surrounding musculature

• Irreducible or incarcerated – contents cannot be

reduced.

• Strangulated hernia - compromised blood supply to its

contents, which is a serious and potentially fatal
complication.
• Strangulation occurs more often in large hernias that have
small orifices.
 Physical Examination
• best way to determine the presence or absence of an inguinal
hernia.

• The diagnosis may be obvious by simple inspection when a

visible bulge is present.

• Nonvisible hernias require digital examination of the inguinal

canal
• examiner should place the tip
of the index finger at the
most dependent part of the
scrotum and direct it into the
external inguinal ring.

• The patient is asked to strain.

• Having the patient cough is

discouraged as it results in
the overdiagnosis of a hernia
because of the difficulty of
differentiating a normal
expansile bulge of muscle
Differential Diagnosis of Groin Masses

• Inguinal hernia    • Psoas abscess   

• Hydrocele    • Lymphoma   
• Inguinal adenitis    • Metastatic neoplasm   
• Varicocele   
• Epididymitis   
• Ectopic testis   
• Testicular torsion   
• Lipoma   
• Femoral hernia   
• Hematoma   
• Sebaceous cyst    • Femoral adenitis   
• Hidradenitis of inguinal • Femoral artery aneurysm
apocrine glands    or pseudoaneurysm
DIAGNOSIS MADE – WHAT
TO DO?
• REFER FOR SURGICAL OPINION
• IMAGING UNECESSARY.
 MANAGEMENT
• The norm is that surgeons are taught that all hernias should be
fixed even if the patient is asymptomatic, to prevent the
complications of strangulation and obstruction.

• Strangulation occurs in 1% to 3% of groin hernias and is more

common at the extremes of life. 6, 7

• RISKS VS BENEFITS

• There is difficulty in finding patient population where some on the

persons do not undergo routine herniorrhaphy.

• It may be that the risk of complications may be overstated as the

natural history of asymptomatic hernias has not been evaluated.
42 Y.O. M – STRANGUALTED
RISH
54 Y.O. – INCARCERATED RISH
PRINCIPLES IN HERNIA
REPAIR
• Initial Incision

• Proper handling of tissues –nerves and cord structures

• Management of sac - High Ligation of Sac vs Complete excision vs

eversion

• Repair of Inguinal Floor

• +/-Relaxing incision

• Closure
7/12/20 Surgery M&M
Surgery M&M
• There has been quite a lot of progress in the field of
hernia surgery.

• We have come a far way, from recurrence rates after 1

year of 30-40 % in the mid to late 1800s. In those days
most hernias would have recurred by 4 years. Even
mortality was as high as 10%.

• There are numerous techniques in inguinal hernia

surgery which are accepted and these are clearly
described in surgical texts.

• >80 techniques described since 1800s

 • Much of the credit to
modern hernia surgery
should go to Bassini.

• He was the first to

describe clear anatomical
dissection and
reconstruction of the
inguinal canal.
Edoardo Bassini - Italian Surgeon
Father of hernia surgery
REPAIR OPTIONS
• Bassini
• Maloney
• Mesh and Plug
• Mesh (Lichtenstein)
 SPORTSMAN’S HERNIA - athletic pubalgia
• In patients with a classical hernia presentation but with the
absence of clinical findings.

• These are commonly seen in athletes, which results from a

weakness or tearing of the posterior inguinal wall.

• Sometimes found in non-athletes due to an abrupt motion.

• These patients may present with acute or gradual worsening

of deep groin pain after increased activity.

• The pain is aggravated by movements and sudden increases in

intra-abdominal pressure.
 SPORTSMAN’S HERNIA
• Initial management is conservative, which also allows time
to rule out other possible conditions such as muscle strain.

• Conservative therapy consists of rest, cold compress,

NSAIDs and physiotherapy.

• Surgical exploration is necessary if the pain returns when

the patient resumes normal activities after 6 to 8 weeks of
conservative management.

• This yields successful resolution of pain and return to

physical activity. 7
 COMPLICATIONS OF OPEN
REPAIR
Recurrence Hematoma Bladder injury
Chronic groin pain   Wound Wound infection
Cord and testicular   Scrotal Seroma
  Hematoma   Retroperitoneal General
  Ischemic orchitis Prosthetic complications   Urinary
  Testicular atrophy   Contraction   Paralytic ileus
  Dysejaculation   Erosion   Nausea and vomiting
  Division of vas   Infection   Aspiration pneumonia
  Hydrocele   Rejection   Cardiovascular and
respiratory insufficiency
  Testicular descent   Fracture Osteitis pubis
 RECURRENCE RATES
• Studies have shown that the recurrence rate is approximately
<1% for mesh repairs and as high as 15 to 20% for suture
repairs.10

• The recurrence rate for the nylon darn is 2-9%.9

• Some studies have demonstrated good results with the

Moloney Darn.

• One RCT with 651 patients with a mean follow up of 33 months

showed similar recurrence rates (1%) between mesh and
darn.11

• Another study of 322 patients with a mean follow up of 56

months found a recurrence rate of 0.6% in the Litchenstien
group and no recurrence in the modified darn repair.12
• To really assess recurrence there is the need for long
term follow up, since approximately 50% of inguinal
hernia recurrences do not present until after three to
five years.9,13

• Recurrence continues to develop even after ten years.

Of note 20% may not be apparent for 15-25 years. 9,13
INGUINODYNIA
• persistent groin pain after inguinal hernia surgery
for a period of over three months, and is usually a
result of nerve entrapment, scar tissue, or mesh
adherence.

• inguinodynia seems to have become the major

complication facing surgeons.2

• Patients who experience groin pain before

operation have a higher incidence of inguinodynia. 9

• The incidence of inguinodynia ranges from 6% to as

high as 23%.9,14
Chronic post-herniorrhaphy pain can be one of three
syndromes:

• Somatic pain is usually secondary to injury to ligaments

and muscles. It can be reproduced with exertion or
movement of the abdominal wall.

• Visceral pain is experienced during a visceral function

such as ejaculation and may result from injury to a
sympathetic nerve plexus.

• Neuropathic pain result from nerve damage or

entrapment and is usually a localized sharp pain that
may impart a sensation of burning or tearing.7
 SSI
• Primary inguinal hernias, which are considered clean
cases, are subject to a low wound infection rate, usually 1
to 2%.

• The prostheses used for inguinal herniorrhaphies rarely

become infected.

• With the risk of an infected prosthesis in mind the routine

use of prophylactic antibiotics but not a complete course
for treatment is recommended.
RESULTS
• 112 patients had an Inguinal Hernia Repair during the
study period.

• 101 subjects were completely analyzed.

• There were 88 surgeries for primary hernias.

• 29 patients underwent clinical evaluation.

THE DISTRIBUTION OF PATIENTS BY AGE
GROUP
30 28

NUMBER OF PATIENTS
25
19 18
20 16
15
10 8
10
5 2
0
<30 30-39 40-49 50-59 60-69 70-79 >80
AGE GROUP
Emergent Operations
• Ten (9.9%) cases were emergency surgeries, with
incarceration in 6 and strangulation in 4.

• Viable bowel and omentum was found in the six cases

that had incarceration.

• The four cases that were operated on for strangulation

required bowel resection, with primary anastomosis in
2, colostomy in 1 and anastomosis at second look
laparotomy in the other.
 CHART SHOWING THE PROPORTION OF TYPES OF HERNIAS

70 65.3%

60

50
NUMBER OF PATIENTS

40
66
29.7%

30

20 30

10 5.0%
5
0
B/L LIH RIH

TYPE OF HERNIA
• Overall there were ten (10) direct hernias, seventy six
(76) indirect hernias, two (2) pantaloon hernias and
thirteen (13) cases were not specified.

• Of the hernia types that could be identified, 11.4%

were direct, 86.4% were indirect and 2.3% were
pantaloon.
 PATIENTS ACCORDING TO PROCEDURE

72.3%

73

27.7%

28

SUTURE REPAIR MESH REPAIR

PERIOPERATIVE COMPLICATIONS IN PATIENTS ACCORDING TO URGENCY OF SURGERY

TOTAL
NUMBER (%)

NUMBER OF NUMBER OF
PATIENTS (%) IN PATIENTS (%) IN
COMPLICATION ELECTIVE GROUP EMERGENCY GROUP
16 (15.8)
Excessive pain 14 (15.4) 2 (20)
4 (4)
Urinary retention 4 (4.4) 0
1 (1)
Scrotal Haematoma 1 (1.2) 0
2 (2)
Paralytic ileus 0 2 (20)
0
Seroma 0 0
PERIOPERATIVE COMPLICATIONS IN PATIENTS ACCORDING TO TYPE OF SURGERY

NUMBER OF PATIENTS NUMBER OF PATIENTS

COMPLICATION (%) IN MESH GROUP (%) IN SUTURE GROUP

Excessive pain 12 (16.4) 4 (14.3)

Urinary retention 2 (2.7) 2 (7.1)

Scrotal Haematoma 1 (1.4) 0

Paralytic ileus 0 2 (7.1)

Seroma 0 0
 COMPLICATIONS

MESH COMPLICATIONS 0.0%

0

CORD OR TESTICULAR COMPLICATIONS 00.0%

SCROTAL HAEMATOMA 1 1.0%

SURGICAL SITE INFECTIONS 8 7.9%

CHRONIC PAIN 22 21.8%

RECURRENCE 1 1.0%

0 5 10 15 20 25
 NUMBER OF
NUMBER OF PATIENTS (%) IN
PATIENTS (%) IN EMERGENCY
COMPLICATION ELECTIVE GROUP GROUP

RECURRENCE 1 (1.1) 0

CHRONIC PAIN 22 (24.2) 0

SSI 8 (8.8) 0

SCROTAL HAEMATOMA 1 (1.1) 0

CORD OR TESTICULAR 0 0

MESH COMPLICATIONS 0 0

OSTEITIS PUBIS 0 0
THE LONG TERM COMPLICATIONS ACCORDING TO THE TYPE OF REPAIR

NUMBER OF NUMBER OF
PATIENTS (%) IN PATIENTS (%) IN
COMPLICATION MESH GROUP SUTURE GROUP
RECURRENCE 1 (1.3) 0
CHRONIC PAIN 14 (19.2) 8 (28.6)
SSI 5 (6.8) 3 (10.7)
SCROTAL HAEMATOMA 1 (1.3) 0
CORD OR TESTICULAR 0 0
MESH COMPLICATIONS 0 0
OSTEITIS PUBIS 0 0
DISCUSSION
• The purpose of this study was to evaluate whether the
post-operative complication rate of these procedures was
higher than those done at tertiary or specialized centres.

• The mean duration of follow up for this study was 33.7

months (range 21.0 to 44.5).

• The essential findings are a recurrence rate of 1%,

incidence of inguinodynia at 21.8%, and surgical site
infections found in 7.9% of cases.
COMPLICATION INCIDENCE (%)
Inguinodynia 21.8
Excessive pain 16.9
Surgical Site Infection 7.9
Urinary retention 4
Paralytic ileus 2
Recurrence 1
Scrotal haematoma 1
Seroma 0
Cardiovascular complications 0
Mesh complications 0
Cord and testicular complications 0
Osteitis pubis 0
STUDY INCIDENCE OF
INGUINODYNIA (%)

Menakuru et al 5 6.2
Bay-Nielson et al3 23.6
Shouldice 21.9
Marcy 23.0
Litchenstein 24.8

This study 21.8

Mesh repair 17.8
Moloney darn (modified) 32.1
• The mean time to return to normal activity in this study
was 9.5 weeks. There was an earlier return to normal
activity in the mesh group (mean 8.9 weeks) than the
suture group (mean 11 weeks).

• Koukourou et al found the mean time to return to

normal activity was 5.13 weeks in both the mesh and
suture repair group.8

• The time to return to normal activity was used instead of

the time to return to work because not all patients had
jobs and sometimes due to socioeconomic states and
compensation, some patients may have prolonged
absence from work.
 RECURRENCE
STUDY MEAN FOLLOW RECURRENCE MESH (%) SUTURE
UP (MONTHS) (%) (%)
Koukourou et al8 12 3.8 3.7 3.9
Kaynak et al11 33 1 1.1 1
THIS STUDY 33.7 1 1.4 0

• This study has demonstrated that there is no benefit of

prolene mesh repair over suture (modified Moloney darn) in
terms of recurrence at a mean follow up of 33.7 months.

• For a non-specialist unit our recurrence rate is comparable to

a specialist hernia unit.
• Our surgical site infection rate was 7.9% (5.1 in the
prophylactic antibiotic group vs 18.2% in those who did
not receive prophylactic antibiotic).

• Inguinal hernia surgery has low infection rate, usually 1

to 2%.
 LIMITATIONS
• Major difficulties in obtaining patient records. (only 58.9% charts
that were located from filing system).

• Poor documentation. No discharge summaries.

• Comparisons to similar studies in the least-developed countries are

lacking.

• Our nation’s tertiary hospital lacks the information with which to

compare our statistics

• Some of the patients were lost to follow up.

• Reluctance of patients to share info

 WHERE DOES THIS STUDY
FIT IN?
• This type of study is by no means new to the surgical
community, but it is almost non-existent in poor countries.
This study was the first audit of inguinal hernia repairs in
Guyana.

• This audit has identified several problems along its way –

poor record system, poor documentation, inappropriate
antibiotics, mesh not being provided universally in the public
health care system, and an alarmingly high infection rate.

• It is hoped that these problems would be rectified

accordingly by the relevant authorities.
• This paper will act as a reference point for others. This
initial audit should stimulate other such research and
audits at other hospitals.

• This could start a database for inguinal hernias repaired

at this hospital.

• THIS AUDIT HAS SHOWN THAT A LOCALLY TRAINED

GENERAL SURGEON IN A DEVELOPING COUNTRY CAN
ACHIEVE ACCEPTABLE RESULTS DESPITE WORKING IN
A RESOURCE POOR SETTING.
CONCLUSION

• The complications of inguinal herniorrhaphy

excepting SSI are similar or better than those
documented in published studies.

• The SSI rate is significantly higher than the norm.

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