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© Borgis - Postępy Nauk Medycznych 5/2018, s. 287-291 | DOI: 10.25121/PNM.2018.31.5.287
*Paulina Wozniewska, Piotr Golaszewski, Patrycja Pawluszewicz, Hady Razak Hady
Inguinal hernias – the review of literature
Przepukliny pachwinowe – przegląd literatury
Ist Department of General and Endocrine Surgery, University Clinical Hospital in Bialystok, Poland
Streszczenie
Spośród wszystkich schorzeń chirurgicznych, przepukliny brzuszne są jednymi z najczęściej spotykanych w praktyce klinicznej chirurgów ogólnych na całym świecie. Temat ten od wielu lat stanowi punkt zainteresowania naukowców i z każdym rokiem przybywa nam informacji odnośnie jak najlepszego zaopatrywania pacjentów z powyższym schorzeniem.
Pacjenci zazwyczaj zgłaszają się do lekarza z powodu wyczuwalnego uwypuklenia w obrębie pachwiny oraz bólu i dyskomfortu, który może pojawiać się w spoczynku bądź podczas wykonywania aktywności fizycznej. Ostry ból zazwyczaj wskazuje na uwięźnięcie przepukliny i wymaga pilnego zaopatrzenia chirurgicznego. W pozostałych przypadkach operacje powinny być wykonywane jako zabiegi planowe, co eliminuje objawy kliniczne, poprawiając jakość życia pacjentów oraz pozwala uniknąć poważnych komplikacji. Operacje naprawcze przepuklin mogą być przeprowadzone przy pomocy technik otwartych (z użyciem bądź bez użycia siatek) lub laparoskopowych.
Niniejsza praca stanowi przegląd dostępnych danych oraz piśmiennictwa na temat epidemiologii i patogenezy przepuklin pachwinowych oraz oceny klinicznej i postępowania chirurgicznego z pacjentami, u których została zdiagnozowana.
Summary
Among all surgical diseases, inguinal hernias are one of the most commonly encountered in the clinical practice of general surgeons all over the world. Although this topic has been under investigation for a long time, every year brings new information concerning the best approaches to the patients with this pathology.
Patients usually seek medical attention because of palpable mass in groin region and pain or discomfort that may appear at rest or during physical activities. Severe pain usually indicates hernia strangulation and needs immediate surgery. In other cases, hernia repair should be performed on electively in order to reduce clinical symptoms improving quality of patient's life and avoid complications. The hernia repair surgery may be performed as open (mesh or non-mesh techniques) or laparoscopic procedure.
In this study, a review of available data and literature on the epidemiology and pathogenesis of inguinal hernia has been conducted, as well as the clinical evaluation and the surgical treatment.
INTRODUCTION
Inguinal hernia repair is one of the most common procedure performed all over the world in adults. The lifetime risk of developing an inguinal hernia has been estimated at 27% for men and 3% for women (1). In general, due to easy recognition as an palpable mass in the groin region patients seek for doctor’s consultation. Usually, it is not a life-threatening condition that may be successfully treated with the surgical manipulation. The emergency operation is necessary in cases of strangulation due to the possible complications such as intestinal necrosis, diffuse peritonitis and septic shock. The “wait and watch” strategy may be applied when it refers to minimally symptomatic or totally asymptomatic patients.
REVIEW
Epidemiology and risk factors
Groin hernias account for up to 75% of all abdominal wall hernias, with the incidence of 97% for inguinal hernia and 3% for femoral hernia. Inguinal hernias are most likely to appear in men (90.2% males vs 9.8% females), whereas 70.2% of femoral hernias appear in women (2). The risk factors for hernia formation may be divided into patient-related and external risk factors. Higher incidence of inguinal hernia is associated with older age, male gender, coexistence of hiatal hernia in men, lower body mass index and Caucasian race (3). Inverse relationship between obesity and lower risk of hernia may be a result of limitations in physical examination in obese patients. Moreover, the visceral fat may act as a barrier against protrusion of the hernia sack (4, 5). Recent studies suggest that smoking may be associated with the increased risk for hernia development due to the changes in collagen metabolism (6, 7). On the other hand, some studies showed negative link between tobacco use and inguinal hernia formation, which still remains unexplained (8, 9). Other patient-related factors identified as a potential risk for the formation of groin hernia include positive family history, chronic obstructive pulmonary diseases, abdominal aortic aneurysm, patent processus vaginalis and connective tissue disorders (10-12). Patients with increased serum levels of matrix metalloproteinase 2 (MMP-2) and matrix metalloproteinase tissue inhibitor 2 (TIMP-2) comparing to general population are also at higher risk of developing hernia (13). External risk factors are identified with cumulative exposures to daily lifting activities (total load, frequent heavy lifting) and prolonged standing and walking (14).
Anatomy
The knowledge of the anteroinferior abdominal wall anatomy is essential for proper understanding of inguinal hernia and its repair. The abdominal wall in groin region is composed of peritoneum, transversalis fascia, internal and external oblique muscles, subcutaneous tissue and skin. Among the structures involved in hernias formation the anatomical area known as myopectineal orifice is considered to have a crucial role. The myopectineal orifice was first described by Dr Henri Fruchaud in 1956 as an area containing natural openings that was additionally weakened during the evolutionary process of human beings (15). This part of abdominal wall is supported only by two thin layers made of the transversalis fascia and the tendinous insertion of transversalis muscle. The orifice is known to be divided into three anatomical triangles: femoral, lateral and medial, that are potential sites for groin hernias formation. The lateral triangle is defined by inguinal ligament inferiorly, the deep inferior epigastric vessels medially and the internal oblique muscle superiorly. The medial triangle, also known as Hesselbach’s Triangle or Hessert’s Triangle, is supported by the fibers of internal oblique muscle superiorly, the rectus abdominis muscle medially, the inguinal ligament inferiorly and deep inferior epigastric vessels laterally. The femoral triangle is bordered by Cooper’s (iliopectineal) ligament inferiorly, inguinal ligament and iliopubic tract superiorly and iliopsoas muscle laterally. The inguinal ligament divides the orifice into two halves. The suprainguinal area of myopectineal orifice contains the internal inguinal ring that allows the passage of spermatic cord in men and the round ligament in women. Whereas, the subinguinal region is opening for the femoral canal and allows the transition of femoral vessels and nerve from abdomen to the lower limb and inversely (fig. 1) (16).
Fig. 1. Anatomy of inguinal region (source: californiaherniaspecialists.com)
Definition and classification
Groin hernia is defined as a protrusion of abdominal content through the area of weakness in groin region. Many different classifications have been described so far, with the Nyhus classification, being the most widely used, especially in the United States. According to anatomy, the Nyhus classification divides groin hernias into femoral and inguinal, which are subdivided into direct (medial) and indirect (lateral) based on their anatomical position towards the inferior epigastric vessels (17). The femoral hernia protrudes into the femoral canal through the fascia transversalis, medially to the femoral vein and below the inguinal ligament. A direct inguinal hernia protrudes trough the transversalis fascia within the Hesselbach’s triangle, medially to the inferior epigastric vessels. Whereas, an indirect inguinal hernia comes out through the internal inguinal ring and is located laterally to the inferior epigastric vessels. Lateral hernia may extend into the scrotum in men or labium majus in women (tab. 1).
Tab. 1. Nyhus classification (1993)
Type of herniaAnatomical defect
Type 1Indirect inguinal hernia with a normal ring
Sac in the canal
Type 2Indirect hernia with an enlarged internal ring but the posterior wall is intact; inferior deep epigastric vessels not displaced, sac not in scrotum
Type 3aDirect hernia with a posterior floor defect only
Type 3bIndirect hernia with enlargement of internal ring and posterior floor defect
Type 3cFemoral hernia
Type 4Recurrent hernia
A – direct; B – indirect; C – femoral and D – combinations of A-B-C
The Nyhus classification was modified in 1998 by Stoppa, who added the aggravating factors dividing them into local (i.e. recurrence and size of hernia), general (i.e. activity, age, obesity, bladder or prostate pathology and pulmonary disease) and final factors involving particular surgical image such as risk for the infection or technical difficulties. The presence of above risk factors upgrade the hernia type by one in comparison to Nyhus system (18). As there is many different classifications available and there has been no consensus on the dominance of any of them, The European Hernia Society (EHS) decided to review all systems and simplify them. Their proposal is the classification that includes the anatomic location (L – lateral, M – medial, F – femoral) and the size of the hernia orifice based on the finger index as reference. In addition, every hernia may be described as primary (P) or recurrent (R) (19). Additionally, hernias may be classified as reducible or irreducible. A reducible hernia occurs when the sac is pushed back to the abdominal cavity with doctor’s manipulation or spontaneously, whereas irreducible cannot be fully reduced (tab. 2).
Tab. 2. EHS Groin Hernia Classification
EHS Groin Hernia ClassificationPrimary/Recurrent
0123x
L (lateral)     
M (medial)     
F (femoral)     
0 – no hernia detectible; 1 – < 1.5 cm (one finger); 2 – < 3 cm (two fingers); 3 – > 3 cm (more than two fingers); x – not investigated
Clinical evaluation

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otrzymano: 2018-09-12
zaakceptowano do druku: 2018-10-03

Adres do korespondencji:
*Paulina Wozniewska
Ist Department of General and Endocrine Surgery University Clinical Hospital in Bialystok
24A M. Skłodowskiej-Curie Str., 15-276 Bialystok, Poland
Phone: +48 (85) 8318672
E-mail: pwozniewska@gmail.com

Postępy Nauk Medycznych 5/2018
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