Dr. Vilius Kontenis

Many abdominal wall hernias are asymptomatic or cause only mild pain and discomfort, but acute complications can sometimes develop and require urgent surgical intervention. Most patients first consult general practitioners, who diagnose the majority of hernias and refer patients for further treatment. Prompt and timely diagnosis is crucial, as groin hernia surgery is one of the most commonly performed operations in Western Europe.

Epidemiology

The most common abdominal wall hernias are external abdominal wall hernias, with a prevalence of around 1.7% across all age groups and approximately 4% among individuals older than 45 years. In these hernias, a hole or defect forms in the weakened abdominal wall, allowing fatty tissue or abdominal organs covered by the peritoneum to protrude outward.

External abdominal wall hernias include groin, femoral, and ventral hernias, such as umbilical, linea alba (paraumbilical, epigastric, and hypogastric) hernias, excluding postoperative hernias and, less commonly, lateral hernias (2).

Groin hernia surgery is the most common operation performed on men in Western Europe and the third most common operation worldwide. Groin hernias include inguinal and femoral hernias that develop within the myopectineal orifice of the groin region. Inguinal hernias are more common than femoral and other abdominal wall hernias, although femoral hernias are associated with a higher rate of complications (1).

Hernias occur more frequently in men and Caucasians compared with women and other racial groups (3). Men are approximately eight times more likely to develop a hernia than women and require treatment around 20 times more often. The lifetime risk of developing a hernia is estimated to be up to 25% in men and less than 5% in women.

Hernias in women also tend to appear later in life. One review reported that the average age of women diagnosed with hernias was 60–79 years, while for men it was 50–69 years (4).

Types Of Groin Hernias

Groin hernias are anatomically classified as inguinal (direct or indirect) or femoral hernias. Clinical reviews provide several notable findings:

• Approximately 96% of groin hernias are inguinal, while only 4% are femoral;
• Inguinal hernias, particularly indirect inguinal hernias, are the most common type in both men and women (4);
• Direct inguinal hernias are found in 30–40% of men, while inguinal hernias overall are found in 14–21% of women (4);
• Femoral hernias account for less than 10% of all groin hernias, while only 2–4% of all surgically treated groin hernias are femoral;
• Surgical treatment for femoral hernias in women accounts for 20–31% of cases, while in men it accounts for only around 1%;
• In patients older than 70 years, surgical treatment for femoral hernias is performed in 52% of women and 7% of men (4, 5).

Risk Factors That Promote Hernia Development

Researchers have identified several important risk factors associated with hernia development (3, 5):

• Previous hernias;
• Older age;
• Male sex;
• Caucasian ethnicity;
• Prolonged cough;
• Chronic constipation;
• Smoking;
• Family history;
• Abdominal wall injury.

These factors may weaken connective tissue or repeatedly increase intra-abdominal pressure, making hernia formation more likely over time.

Classification And Pathogenesis

Groin hernias can be classified according to both etiology and anatomical location. Hernias may be congenital, meaning they develop because of abnormalities during fetal development, or acquired later in life after weakening of the abdominal wall.

Congenital hernias occur most commonly in the groin area, accounting for approximately 95% of congenital hernias. However, they may also develop in other areas, including the umbilical region, femoral canal, or linea alba.

The simplest and most commonly used anatomical classification divides groin hernias into:

• Indirect inguinal hernias;
• Direct inguinal hernias;
• Femoral hernias.

These hernias arise from different anatomical openings in the muscular and aponeurotic structures of the abdominal wall.

An indirect inguinal hernia begins in the lateral triangle area. The hernia sac passes through the internal inguinal ring and is associated with the spermatic cord in men or the round ligament in women.

A direct inguinal hernia develops in the medial triangle area. In this case, the hernia sac passes directly through the posterior wall of the inguinal canal and is not associated with the spermatic cord.

Femoral hernias originate in the femoral triangle region, where the hernia sac passes through the femoral canal.

How Congenital Hernias Develop

Congenital inguinal hernias occur when the processus vaginalis fails to close completely because of abnormalities during embryonic development.

In boys, the testes descend through the inguinal canal, forming a temporary peritoneal protrusion known as the processus vaginalis. Once the testes descend into the scrotum, this protrusion normally closes. If it remains open, it stays connected to the abdominal cavity, creating a pathway through which a hernia can protrude.

In girls, the round ligament passes through the inguinal canal. If the peritoneal protrusion does not close properly, the hernia sac may even contain an ovary (6, 7).

Why Early Diagnosis Matters

Although many hernias remain painless or cause only mild discomfort, untreated hernias may eventually become incarcerated or strangulated. In such cases, blood supply to the protruding tissue may become compromised, creating a surgical emergency.

Doctors therefore emphasize the importance of early diagnosis and timely referral for surgical evaluation. Prompt treatment can significantly reduce the risk of complications and improve long-term outcomes, especially in older adults and patients with femoral hernias, which carry a higher complication risk.

Hernia: Causes, Symptoms, Diagnosis, And Treatment

A hernia is a condition in which a weakened or damaged area of the abdominal wall forms an opening through which fatty tissue or abdominal organs covered by the peritoneum can protrude into the subcutaneous tissue. This may occur because of connective tissue disorders, previous abdominal wall injuries, or other factors that weaken the abdominal muscles.

Classification Of Inguinal Hernias

• Asymptomatic inguinal hernia;
• Minimally symptomatic inguinal hernia;
• Symptomatic inguinal hernia.

Clinical Classification Of Groin Hernias

• Asymptomatic inguinal hernia;
• Minimally symptomatic inguinal hernia;
• Symptomatic inguinal hernia.

Clinical Signs

Many abdominal wall hernias may remain asymptomatic or cause only mild pain and discomfort. However, acute complications such as incarceration or strangulation can develop, requiring urgent surgical intervention.

Diagnosis

In most cases, inguinal hernias are diagnosed based on medical history and physical examination, making additional tests unnecessary. According to one study, the specificity of surgeons’ examinations for diagnosing inguinal hernias is 75%, while sensitivity reaches 96% (11).

Diagnosing small hernias or hernias in obese patients is more challenging, especially when differentiating them from other abdominal wall conditions. In cases of diagnostic uncertainty, instrumental imaging tests are recommended to identify occult hernias, distinguish inguinal hernias from femoral hernias, and differentiate hernias from other possible pathologies.

Imaging tests are particularly important when complications are suspected. In the absence of intra-abdominal complications, inguinal ultrasound is recommended because it is non-invasive, cost-effective, highly sensitive, and highly specific, while also helping differentiate hernias from other inguinal conditions (15).

Computed tomography (CT), magnetic resonance imaging (MRI), and herniography may also be useful in selected cases.

Ultrasound is considered the best initial diagnostic method for identifying occult inguinal hernias in patients who have symptoms suggestive of a hernia but no detectable hernia during physical examination. A systematic review and meta-analysis found that ultrasound and herniography are the most commonly used methods for diagnosing occult hernias (12).

Herniography involves transcutaneous puncture and injection of contrast material into the peritoneal cavity. This technique can identify the hernia and define the shape of the hernia sac. The method has high sensitivity and specificity with a relatively low complication rate.

In cases of unclear groin pain where hernia diagnosis remains uncertain, the recommended diagnostic sequence is:

• Ultrasound performed by an experienced radiologist;
• If ultrasound findings are inconclusive, MRI with a Valsalva maneuver is recommended;
• If MRI is also inconclusive, herniography is recommended.

One meta-analysis reported that ultrasound had a sensitivity of 86% and specificity of 77% (6 studies), herniography had sensitivity and specificity of 91% and 83% respectively (16 studies), while CT showed sensitivity of 80% and specificity of 65% (2 studies) (12).

Diagnostic laparoscopy may also be performed to definitively diagnose or remove a hernia.

Differentiating inguinal hernias from femoral hernias may be difficult, especially in obese patients presenting with clinical symptoms. Watchful waiting may be appropriate for asymptomatic or minimally symptomatic inguinal hernias, but it is generally not recommended for femoral hernias because of their higher complication risk.

If a femoral hernia cannot be confidently excluded, additional radiological tests are recommended.

Patients experiencing hernia complications may present with nausea, vomiting, abdominal distension, groin pain, or a palpable lump. These symptoms may indicate intestinal obstruction or strangulation.

Most patients with incarcerated and/or strangulated hernias do not require additional imaging before surgical treatment begins. However, for patients with signs of bowel obstruction but without a confirmed hernia diagnosis or urgent indications for surgery, CT is often more useful than ultrasound.

Differential Diagnosis

The differential diagnosis of groin pathologies includes any condition capable of causing pain or a mass in the groin area involving soft tissue, lymphatic tissue, blood vessels, bone structures, or the reproductive system.

Doctors often need to differentiate groin masses from:

• Inguinal hernia;
• Femoral hernia;
• Inguinal lymphadenitis;
• Ectopic testicle;
• Lipoma;
• Varicocele;
• Hematoma;
• Psoas abscess;
• Hydrocele;
• Lymphoma;
• Metastases;
• Epididymitis;
• Femoral artery aneurysm or pseudoaneurysm.

Diagnosing hernias in pregnant patients may be especially challenging because not every groin mass is necessarily a hernia. Pain involving the round ligament during pregnancy may closely resemble hernia symptoms (13).

During physical examination, distinguishing between direct and indirect inguinal hernias is less important because final differentiation is usually confirmed during surgery.

Treatment

Special bandages, corsets, and orthopedic support belts may be used in hernia management. Although these measures can help slow hernia progression, they do not protect against possible complications.

The primary treatment method for hernias is surgery (14).

Hernioplasty has relatively few contraindications, which may include:

• Terminal chronic illness;
• Immunosuppression;
• Advanced age.

Asymptomatic or minimally symptomatic inguinal hernias may sometimes be monitored carefully and operated on later if symptoms worsen.

Symptomatic inguinal hernias, excluding incarcerated hernias requiring urgent care, are usually treated with elective surgery through hernioplasty.

Inguinal hernia operations are generally divided into two major groups:

• Posterior wall reconstruction of the inguinal canal using the patient’s own tissues;
• Tension-free repair using synthetic materials such as meshes, plugs, and other prosthetic devices.

Publication "Internistas" No. 4-5, 2018.

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