Examining modern approaches to inguinal and femoral herniorrhaphy: the newest hernia repair techniques, including the various laparoscopic approaches, require continued learning and practice by the surgeon to develop and maintain proficiency.(SURGICAL REVIEW)

Publication: JAAPA-Journal of the American Academy of Physicians Assistants

Publication Date: 01-JUN-08

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COPYRIGHT 2008 Haymarket Media, Inc.

Groin hernias are the most common clinical problem addressed by surgeons, with more than 700,000 repairs performed annually in the United States alone. (1,2) This article reviews the basics of hernia repair in 2008. The authors describe the anatomic features that differentiate groin hernias and provide factors the PA should consider when evaluating a patient with a hernia. Discussion of the various classification systems for hernias shows proper methods for documenting the type of hernia. A chronologic review of types of hernia repair helps the reader to visualize how techniques have progressed and where the future of hernia surgery lies. After completing this article, the reader will gain a better understanding of how best to educate patients, whether in a primary care or surgical setting, about the various treatment options for groin hernias.

DEFINITIONS

The word hernia comes from the Latin for rupture and the Greek for bud? A groin hernia is any protrusion of the intraabdominal contents through a muscular defect. Hernias may occur in areas devoid of striated muscle. They are a common cause of bowel obstruction. Hernias may be chronic or may incarcerate and lead to strangulation of bowel. Strangulation occurs in 1% to 3% of all hernias and results in compromised blood flow to the entrapped contents?

It is important to realize that although an incarcerated hernia is irreducible or "stuck," patients may have chronically incarcerated hernias without strangulation. (4) However, incarcerated hernias increase the risk of later strangulation as a result of swelling of the trapped contents. In patients who present acutely with a hernia, the greatest risk of strangulation is in the first 3 months. (3) Strangulated hernias have a 10% operative mortality rate, which is 10 times higher than the mortality rate for an elective hernia repair)

ANATOMY AND PATHOPHYSIOLOGY

Hernias of the groin comprise approximately 75% of all hernias and are more common in men. (2) Inguinal hernias may be classified as indirect or direct. Indirect hernias represent the most common type of hernia in both men and women and are termed such because of their indirect route of passage through the internal ring. (6)

Indirect hernias that occur in men are the result of a congenital defect called a patent processus vaginalis. The processus vaginalis is an outpouching of the peritoneum, which may be viewed much like the finger of a glove, that allows for descent of the testicle into the scrotum, as directed by the gubernaculum, during fetal development. (4) The processus vaginalis typically doses by age 2 years in male children, but retained patency is found in 20% of adult males, providing potential for communication with the abdominal cavity. (3) Although retained patency is common and increases risk for indirect herniation, the lifetime incidence of inguinal hernia is estimated to be as low as 5%. (4)

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The internal ring is a natural opening, formed by the external oblique (external ring) and the transversus abdominus (deep ring), allowing for the passage of the spermatic cord in men and the round ligament in women. Stretching or muscle deficiency surrounding this opening also provides opportunity for indirect herniation to develop. Indirect hernias are more commonly found on the right, which is attributed to delayed descent of the right testicle in men and subsequent delay in the atrophy of the processus vaginalis that normally follows this descent. (3)

Direct hernias result from a weakened transversalis...

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