Case Study: Direct Inguinal Hernia Reniell Iniguez, Katie Rissmann, Timothy Halbesma

Department of Surgery, University of Illinois at Chicago, Chicago IL, United States

Chief Complaint: Right-sided groin pain

History of Present Illness:52 y/o male with a family history of hernias presented with right-sided pain in the groin area for three months.Patient began an online exercise program about a year ago but doesn’t recall overexerting himself. Hedescribes the pain in his right groin as aching and persistently burning. He came into clinic because the paingradually worsened over past few months. His pain was initially 4/10 but now is rated 7/10. Coughing andbending over worsens his pain. He relieves discomfort by laying down flat on his back and taking two 500 mgibuprofen. He denies fever, headache, chills, or weight fluctuations. He is concerned that he has a hernia andwill lose his construction job as a result of time off.

Past Medical History:Hypertension

Past Surgical History:None

Medications:Lisinopril 20 mg QD oral

Allergies: NKDA

Social History:● Drinks alcohol 3x a week● Smoked tobacco for 5 years in his 20s● Denies illicit drug use● Works in Construction● Happily married for 25 years with two children● Exercises _● Eats a lot of poultry and meat, usually 4 meals a day

Review of Systems:● General: Denies weight changes, fever, appetite changes, and fatigue● HEENT: No vision changes, difficulty hearing, tinnitus, tonsillitis, voice changes● Respiratory: No dyspnea, cough, or sputum● Cadiac: No SOB, palpitations, or pain● Gastrointestinal: Discomfort when passing stool but no irregularities in BM● Urinary: No dysuria, urgency, no incontinence or hematuria● Genital: No penile discharge, no decrease in libido● Musculoskeletal: No stiffness in back, joint pain, or swelling in extremities● Endocrine: No heart or cold intolerance, no hx of thyroid disease

Vitals:Temp 36.5C, BP 13/84, Pulse 82, RR 24, O2 sat 99% room air

Physical Exam:Groin examination revealed 3.5 cm right sided irreducible inguinal swelling. Area is tender to the touchand non-erythematous. Examination of all other body systems was unremarkable.

Imaging:CT abd/pelvis revealed a direct, nonstrangulated, incarcerated inguinal hernia.

DiagnosisDifferential diagnosis included muscle strain and inguinal lymphadenopathy. The diagnosis of direct inguinal hernia was made primarily via physical exam, but confirmed with a CT scan. Patient was scheduled for a direct hernia repair procedure, with an estimated recovery of about 3 weeks to return to light activity.

ConclusionsSummary: A direct inguinal hernia was repaired and reinforced with a mesh. Surgery was open and patient was discharged a few hours after case.

Key Clinical Presentation: ● History of exercise or heavy lifting ● Abdominal pain or protrusions ● Pain increases with bending or coughing ● Weakness in groin area● Burning or aching pain

Immediate Actions Taken by Patient One who feels groin discomfort after extraneous exercise or lifting should schedule an appointment to see their general physician. Physical exam and history is often sufficient for diagnosis; however, a confirmatory scan will most always be used. The physician will refer patient to surgical consultation if an operation is required.

REFERENCES1. https://step1.medbullets.com/gastrointestinal/110018/inguinal-canal2.Suárez-Grau, J.M., Rubio Chaves, C., Morales-Conde, S. et al. Could we reduce adhesions to the intra-abdominal mesh in the first week? Experimental study with different methods of fixation. Hernia (2019). https://doi-org.proxy.cc.uic.edu/10.1007/s10029-019-02005-83.Tuma, F., & Varacallo, M. (2019). Anatomy, Abdomen and Pelvis, Inguinal Region (Inguinal Canal). In StatPearls [Internet]. StatPearls Publishing.4. Chowbey, P. (2020). Complications Inguinal Hernias: Strangulated Incarcerated and Obstructed Hernias. In Techniques of Abdominal Wall Hernia Repair (pp. 163-168). Springer, New Delhi.5. Berger, D., M. Bientzle, and A. Müller. "Postoperative complications after laparoscopic incisional hernia repair." Surgical Endoscopy And Other Interventional Techniques 16.12 (2002): 1720-1723.6.Lehman D, Gilstrap J, Georges A. Pediatrics. In: Dangleben DA, Lee J, Madbak F. eds. ABSITE Slayer New York, NY: McGraw-Hill.

Direct Inguinal Hernia Definition: Abdominal Protrusion through the inguinal canal.

Direct: Indicates that the hernia is medial to the inferior epigastric artery. In addition, the sac usually protrudes directly through the posterior wall of the inguinal canal and exits out the external

inguinal ring. Irreducible: Manual pressure cannot push the herniation back into abdominal cavity.

Anatomy: Inguinal Canal Boundaries ● Anterior: Aponeurosis of external oblique● Posterior: Transversalis fascia (herniations often occur through the posterior wall)● Roof: Transversalis fascia, internal oblique, transversus abdominis● Floor: Inguinal ligament

Current Research and New TreatmentsChoice of Mesh in Hernia Repair

When the mesh from the surgical repair is exposed to the viscera, adhesion formation is common which could lead to bowel occlusions, fistulas, or abscesses 2. A recent study from 2019 compared the effectiveness of conventional polypropylene mesh to one with a sponge on the visceral surface containing thrombin, fibrinogen, and clotting factors (called Tachosil) 2. In mouse studies, it was found that the treated prostheses led to less edema and angiogenesis as well as a lower degree of necrosis. There are many different mesh choices and surgical techniques that can be used and should be discussed on a case-to-case basis. However, in a study looking at 150 different surgical laparoscopic hernia repair procedures, all complications were due to surgical mistakes except for one, which was due to the material used5.

Inguinal Hernia Considerations in the Pediatric PopulationIn the pediatric population, especially infants under 1 yr. of age, it is necessary to distinguish an inguinal hernia from an acute, noncommunicating hydrocele6. A hydrocele can be differentiated by the lack of bowel obstruction and the ability to palpate normal cord structures above the scrotal mass and transilluminate the hyrdocele6 . In children, the most common complications of an inguinal hernia repair are complications from anesthesia, recurrence of the hernia, wound infection, or injury to the vas deferens or testicular vessels6.

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EMBRYOLOGICAL CONTRIBUTION IN MALES: The inguinal canal connects the testes with the abdominal wall. This canal is an inherent weak spot in the abdomen of males due to its concurrent embryological descent with the scrotum. The testes descend from the posterior abdominal cavity to the scrotal cavity. The testes must traverse various abdominal wall layers to reach its destination. As result, the anterior portion of the abdomen at the inguinal canal is less supported and prone to hernias 3.

STRANGULATION OF HERNIATED SAC: Strangulation occurs when the blood supply of the herniated tissue is compromised. This is a feared complication that can cause necrosis of the tissue. Dead tissue can release toxins into the bloodstream and cause sepsis. Be aware of patients that present with herniation symptoms and increase WBC count, temperature, nausea or vomiting. Delay in Dx for 6-12 hr increases chances of necrosis of bowel and need for resection in 15% of cases 4.

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