In its broadest sense, a hernia is simply a defect of the innermost layer of fascia of the abdominal wall. This definition encompasses all types of abdominal wall hernias including inguinal and femoral groin hernias, hiatal hernias  , diaphragmatic, obturator, lumbar and post-operative incisional hernias as well as others. The presence of a hernia allows intra-abdominal contents such as intestines to pass through this defect into the subcutaneous tissue. Here the intestines may become incarcerated or strangulated, which will be discussed below. The following discussion will be limited to hernias of the groin of which there are two main types; inguinal and femoral, the more common of which is the inguinal hernia.

A femoral hernia is a hernia that penetrates the femoral ring.   This is the path that the femoral vessels take to exit the pelvis and enter the leg.

An inguinal hernia is a hernia occurring in the inguinal canal;   a natural defect in the abdominal wall fascia which allows passage of the spermatic cord in the male and analogous non functional structures in the female. The entrance of the inguinal canal from within the abdomen is called the internal ring, and the exit into the scrotum (or labia majora), the external ring.   Hernias which follow the path of the spermatic cord through the internal ring into the inguinal canal are called indirect inguinal hernias and are congenital in origin. Hernias which directly penetrate the innermost layer of abdominal fascia to enter the inguinal canal are called direct inguinal hernias and usually occur later in life. This latter type of hernia is more commonly related to years of straining or heavy exertion.

In contrast, direct inguinal hernias more commonly occur in older men with a history of strenuous activity or heavy lifting. It often takes years to develop. At surgery, the abdominal fascia involved with the hernia is attenuated and weak. Of course, this type of hernia can be seen in younger people and in women as well. Many times, an inguinal hernia is found to have both direct and indirect components where there is a hernia sac or intestines penetrating the internal ring and entering the inguinal canal, in addition to a weakness in the fascia of the floor of the canal with ballooning of the fascia and a large direct inguinal hernia.

Incarceration of a hernia means that the contents of the hernia sac, usually intestine or fat, but occasionally other organs such as bladder or ovary, are trapped in the hernia and cannot be reduced into their normal intra-abdominal position. This may cause obstruction of the intestine with the symptoms of abdominal distention, vomiting, and inability to have a bowel movement. Incarceration of the hernia contents may lead to strangulation of the hernia contents.

Strangulation occurs most typically when intestine protrudes through a relatively small hernia defect and either twists upon itself or becomes edematous and compromises its own blood supply. If not corrected emergently this may result in infarction and gangrene of that intestinal segment or organ. Symptoms at this stage include all of those previously mentioned plus severe abdominal pain, fever, confusion, obtundation and shock.

This progression from simple reducible hernia to incarcerated hernia with strangulation can happen unpredictably and suddenly. It has occasionally happened that I have seen a patient in my office with an uncomplicated hernia and have had him scheduled for elective surgery only to have him present within the next few days in the emergency room with incarceration. Thus, my usual recommendation to patients who have hernias is that they should be repaired as soon as is conveniently possible.

There are several described tissue repairs and a discussion of these is beyond the scope of this paper. I have occasionally been questioned by some patients about the "Canadian" method and I wish only to state that this is one form of tissue repair. All of these repairs are good and have good recovery and acceptable recurrence rates (<5%). However, the disadvantage of all tissue repairs is that they create some degree of tension on the tissues and recovery tends to be somewhat more painful with these repairs compared with mesh hernia repairs. In patients with bilateral hernias, I do no think that both should be repaired at the same time in adults if a tissue repair is to be the procedure of choice. In small children the technique of repair is somewhat different and bilateral repairs are much better tolerated.

Additionally, in patients with recurrent hernias or large direct hernias, the nature of the hernia is such that the patients tissues are weak and a repair involving direct suture of these weakened tissues would be expected to have a higher hernia recurrence rate. For this reason, I usually recommend hernia repair with mesh in patients with large direct hernias or recurrent hernias. Recovery from a unilateral mesh hernia repair is usually uneventful and relatively pain free because the repair is done without tension. The down side of a mesh hernia repair is that of a slightly higher risk of infection because of the prosthetic material left in the patient. I have not found this to be a significant factor and I believe most surgeons would agree.

Laparoscopic Hernia Repair is a procedure I reserve for patients with non-incarcerated bilateral hernias and multiply recurrent hernias. The main advantage of this procedure is rapid recovery after bilateral hernia repair which is impressive. In the case of a multiply recurrent hernia laparoscopic repair provides access to the hernia through tissues which have not already been operated upon and therefore the anatomy is clear and undistorted since the hernia is being approached from the inside rather than the outside. Performing a laparoscopic hernia repair on a patient who has had a recurrence after a previous laparoscopic repair is a formidable task and is ill advised.

The other advantage of laparoscopic hernia repair is visibility.   One can see the internal ring, the floor of the inguinal canal and the femoral ring all at once and can lay a mesh over all these structures such that any possible point of groin hernia formation is repaired.

The main disadvantage of this procedure is the need for general anesthesia which is certainly necessary for the trans-abdominal approach and usually necessary for the extra-peritoneal approach. Other forms of hernia repair can usually be performed with spinal anesthesia and can even be performed with local anesthesia in selected cases.

The other disadvantage of laparoscopic hernia repair, at least with the trans-abdominal method is the need to go through the abdomen. This, at least in theory, carries an increased risk of post-operative adhesion formation and possible risk of later bowel obstruction. This procedure has not been around long enough to tell if this theoretical concern will turn out to be a real disadvantage. Of course, on going into the abdomen there is always a risk of causing an injury to some organ which would have not been at risk during a standard open hernia repair with or without mesh. This risk, of course, is very low.

I welcome discussion on any of the topics discussed at this web site.