Groin (inguinal) Hernia

What is an inguinal hernia?  

An inguinal hernia is a pathological, or abnormal, “bulge” in the form of a soft bump in the groin area, which occurs as a result of a weakness in the muscles of the lower abdominal wall. Typically, the intestines and/or the lining of the abdominal cavity, i.e., the peritoneum, are displaced into the groin region through that weakness. Inguinal hernias develop slowly, and early symptoms are often non-specific, therefore it is often diagnosed at a more advanced stage.

Inguinal Hernia – Types

Inguinal hernias can be:

• Acquired, meaning it occurred after birth, typically in adulthood.
• Congenital, meaning it occurred before birth.
• Indirect, or lateral hernia, where the contents of the hernia pass through the inguinal canal into the scrotum in men, or the base of the labia majora in women.
• Direct, or medial hernia, where the contents of the hernia pass directly through an anatomical landmark called the Hasselbach’s triangle in the lower abdominal wall. This variety is always acquired, smaller, and happens less frequently than an indirect hernia.
• A unique form of inguinal hernia is a recurrent hernia. It occurs in roughly 10% of patients who underwent inguinal hernia repair in the past. Often in such cases, the only method of minimally invasive surgery is robotic. This is due to the formation of postoperative adhesions, where the body heals after surgery by forming connective tissue bridges between internal anatomy and artificial meshes that were displaced after that initial surgery. Only robotic surgery offers the precision and control necessary to reach, remove, and repair these regions to minimize the risk of recurrence. Robotic surgery thus is the best alternative to open and more invasive abdominal techniques.
• Femoral hernias are more common in women. These present as painful lumps below the anatomical level of the inguinal ligament, so in the uppermost region of the thigh. Compared to other types of hernia, femoral hernias are associated with a higher risk of something called “strangulation” where a section of the intestine that protrudes through the hernia gets trapped resulting in obstruction and risk of avascular necrosis due to no blood flow. This carries a risk of death if untreated.

Inguinal Hernia – Causes 

The cause of inguinal hernia in children up to 2 years of age is a defect in the formation of the peritoneal diverticulum, which normally closes by the 20th week of pregnancy. In adults, the main cause of inguinal hernia is weakness in the abdominal muscles. Risk is increased by obesity, smoking, heavy lifting, chronic cough, sneezing, constipation, prostate diseases in men, previous trauma, and strenuous exercise without properly warming up.

Inguinal Hernia – Symptoms

Inguinal hernias are usually asymptomatic early on. Over time, however, patients develop a soft lump in the groin area that may disappear when lying down, and transient pain in the groin that increases due to exercise, coughing, or laughing. Sometimes patients also experience problems with passing stool, pain in the lower abdomen, and a sense of fullness in the lower abdomen.

Inguinal Hernia – Diagnosis  

Inguinal hernia is diagnosed during a physical exam by palpation to confirm the presence of a soft bump in the groin, i.e., scrotum in males, or labia majora in females. Sometimes, if the opening is wide enough, nothing can be palpated. In such cases, especially when there are symptoms, abdominal ultrasounds are taken to confirm the diagnosis.

Inguinal Hernia – Treatment

The gold standard for treating inguinal hernias is surgery, which can be done using open, laparoscopic, or robotic surgery. The choice of the surgical approach depends on the severity and size of the hernia, the surgeon’s experience, and the availability of appropriate tools. The goal of surgical inguinal hernia repair is to return the contents of the abdomen to their rightful place, then close the defect in the abdominal wall by suturing together muscles and ligaments with a reinforcing mesh.

Surgical inguinal hernia repair is performed using the following techniques:

• Tension-free, utilizing a special mesh to reduce the risk of recurrence and postoperative pain.
• Tension, where the opening of the inguinal hernia is closed by suturing together the muscle and tissue of the inguinal ring. This technique does not introduce artificial mesh into the body, however carries a greater risk of hernia recurrence and postoperative pain due to the tightness of the sutures necessary to close the opening.

Inguinal Hernia – Robotic Surgery

Robotic inguinal hernia repair is done under general anesthesia and utilizes a few one-centimeter incisions in the abdomen that heal with little to no visible scarring. These small incisions serve as doors for the camera and all specialized surgical tools. After precisely localizing the hernia, surgeons return the abdominal contents into their correct anatomical position then suture closed the opening using existing muscles and, if indicated, an artificial mesh to strengthen the site and reduce the risk of recurrence. Unlike open or laparoscopic surgery, the surgeon is not directly at the patient’s table, but rather controls the robotic instruments through a dedicated console in a comfortable seated position to avoid fatigue. Robotic surgery enables surgeons to operate at high magnification, which facilitates the accurate detection of nerves and blood vessels. Additionally, the robotic arms are more dexterous than the human hand, enabling surgeons to place sutures or dissect tissues with extreme precision. Robotic surgery benefits patients in many ways, namely less invasiveness, less postoperative pain, and a lower risk of complications such as infection and blood loss. Robotic surgery also shortens the duration of a procedure, lowering the risk of anesthesia-related complications, and ultimately decreasing the length of stay in hospital. Additionally, it allows patients with obesity to undergo minimally invasive bariatric surgery.

According to data from a retrospective, multicenter, non-randomized, controlled [1] clinical trial evaluating the robotic surgical approaches to inguinal hernia repair compared to open surgery, patients who were operated on robotically had a lower complication rate 30 days after surgery compared to patients who underwent open surgery. This study also reported that robotic surgery shortened both the lengths of hospital stays and postoperative recovery.

Inguinal Hernia – Postoperative Recovery

Regardless of the type of surgical technique, patients usually leave the hospital the day after the procedure. The recovery period depends on the extent of the procedure, lasting from a couple of weeks up to a month.  During this period, it is important to avoid physical activity, especially heavy lifting and cycling, that may result in sutures tearing. It is also advisable to avoid being seated for long periods.

Inguinal Hernia – Price

The price of an inguinal hernia repair depends on the stage of disease, the type of abdominal mesh used to reinforce the abdominal wall, and whether it is done classically, laparoscopically, or robotically. All details of the operation and possible treatment options are always discussed together with the attending physician during the initial consultation where you are qualified for the procedure.