Inguinal Hernias: Causes, Types, Repair & Surgery Options

What is a hernia?

A hernia is a protrusion of a tissue, structure, organ or part of an organ through the surrounding structures that contain it.

In most cases, when you mention hernia, people think about abdominal wall hernias such as groin hernias or umbilical hernias.

It is possible to have internal hernias through defects within the abdomen, either congenital or acquired. Another common area for hernias is the passage of organs through defects in the diaphragm.

Again, these can be congenital, i.e. something you are born with, or they can be acquired. For example, it is possible to develop a diaphragmatic hernia some time after a seemingly relatively benign road traffic accident.

The mechanism here is the sudden increase of intra-abdominal pressure from the restraining seatbelt. This is felt to cause a tear in the diaphragm and over time this progressively enlarges enough to allow organs to pass through from the abdomen into the chest and cause a hernia.

Types of hernias

For the majority of people, the most common hernias they experience are groin hernias. Of these, inguinal hernias are by far the most common, making up up to 75% of cases.

Inguinal hernias are more common in men than women, although inguinal hernias remain the most common type of hernia seen in women. There are several ways of classifying inguinal hernias but the commonest is to divide them into indirect and direct.

Indirect inguinal hernias

Indirect inguinal hernias are frequently seen in children. In this case, the testicles start development adjacent to the kidneys and then move down the back of the abdominal wall before exiting through the groin and travelling down into the scrotum.

In a small percentage of cases, this process can leave some abnormal connections between the abdomen and scrotum, leading to the early presentation of an inguinal hernia.

In addition, in children, the internal and external openings of the inguinal canal are close together, giving a much more direct route for part of the bowel to travel through this opening and into the scrotum.

In children, removal of this abnormal connection or sac is usually sufficient to resolve the hernia and then as the child grows, the two openings, the deep and superficial rings as they are called, move apart, giving a more oblique path from the abdomen into the scrotum and thus reducing the chance of developing a hernia.

Direct inguinal hernias

Direct inguinal hernias occur when there is a weakness in the muscles of the groin. This is typically seen in older patients. All of our muscles tend to lose tone as we get older and our muscles become weaker.

In addition, previous surgery, particularly for appendicectomy, can lead to nerve damage to the nerves supplying the muscles, therefore causing further weakness.

As well as this, excess abdominal weight and coughing due to chronic lung conditions also puts more stress on the abdominal muscles, leading to weakness and ultimately to hernia.

Difference between direct and indirect inguinal hernias

In adults, whether an inguinal hernia is direct or indirect, this does not really make very much difference to the surgeon in terms of repairing it.

What are the indications to have a hernia fixed?

Traditionally, if you had a groin hernia, the recommendation was always to have it fixed.

However, some recent studies, predominantly of male patients in the United States, have shown that the risk of a complication from groin hernias, in particular the risk of obstruction or strangulation, is not as high as we have previously thought.

Therefore, many hernia surgeons would suggest that the main reason to have a hernia fixed is if it is interfering with your lifestyle, rather than having it fixed for fear of developing a serious complication.

Obviously, the earlier you have the hernia fixed, the smaller it is likely to be and the easier the operation will be to perform.

In addition, as you get older, the risks of all types of surgery increase. So therefore, most surgeons would recommend that most patients should have their hernias fixed but the hernias can be fixed at a time and place of the patient’s choosing to fit in with work or social commitments.

More elderly patients with limited mobility do not necessarily have to have their hernias fixed.

How are hernias repaired?

In virtually all cases of hernia repair, we use prosthetic mesh to reinforce the muscles of the abdominal wall and prevent further hernia occurring.

There are increasing numbers of mesh available and equally, several different ways of utilising that mesh for hernia repairs.

Mesh can be divided into two types; synthetic and biological.

Synthetic mesh

The most common  synthetic mesh is polypropylene but in Europe, polyester has been used for some time and it may have some theoretical advantages as it is less likely to shrink than polypropylene.

Biological mesh

More recently, biological meshes have come onto the market. There are two main biological meshes; one made from pigs and the other from human cadavers.

It is likely going forward that more biological type meshes will become available and their use is likely to become more widespread.

Types of hernia operations

The decision whether to have a hernia fixed laparoscopically or by open operation comes down to a combination of personal preference and surgeon experience.

Operating procedures can be broadly divided into open operations and keyhole (laparoscopic) operations.

Open operations

Open operations have various different types, depending on where the incisions are made and how the mesh is placed.

Obviously, the open operation has been around longer than keyhole surgery and particularly open operations with the placement of mesh have a very good result in terms of a low risk of long term recurrence.

Keyhole (laparoscopic) operations

Keyhole surgery is increasing in popularity and again, there are a couple of different ways of placing the mesh using keyhole surgery. These different types of keyhole surgery have different levels of popularity in various parts of the world.

Keyhole surgery is felt to be less painful, have more rapid patient recovery and return to work.

However, apart from these benefits, in the long term, there does not appear to be too much difference between an open or laparoscopic operation.

Should I have my hernia fixed laparoscopically or by open operation?

This choice comes down to a combination of personal preference and surgeon experience.

Most general surgeons can be expected to carry out an open mesh hernia repair with a low risk of complication and a low risk of recurrence. Laparoscopic hernia repair requires a higher level of skill and experience.

In experienced hands, laparoscopic repair can produce excellent long term results with little risk of recurrence. However, in my opinion, it is not an operation that should be done on an occasional basis.

Therefore my advice would be to pick your surgeon carefully and if you want to have a laparoscopic keyhole hernia repair, then take the time to seek out a surgeon with experience and an interest in laparoscopic hernia repair.

By Dr Phil Lockie – Specialist Bariatric Surgeon

This article is for informational purposes only and should not be taken as medical advice. If in doubt, HealthEngine recommends consulting with a registered health practitioner.