Inguinal Hernias: Incidence, Causes, and Treatments

Inguinal hernias are one of the most common surgical conditions encountered in clinical practice, representing a significant healthcare burden worldwide. They occur when a portion of the intestine or fatty tissue protrudes through a weak spot in the abdominal wall, specifically in the inguinal canal, which is located in the groin area.

This condition can affect individuals of all ages and genders, though they are more prevalent in men. Inguinal hernias can cause a variety of symptoms, including pain, discomfort, and visible swelling in the groin area, and they may lead to complications if not treated appropriately. Here, I’ll review the causes and treatment options for inguinal hernias, with a particular focus on surgical options, including mesh and meshless techniques.

Inguinal Hernia Epidemiology and Risk Factors

Inguinal hernias represent a significant medical condition affecting approximately 7.7% of the general population,¹ with striking demographic variations in their occurrence. Boys and men face a particularly high risk, primarily due to their distinct anatomical structure — specifically, a natural weakness in the abdominal wall resulting from testicular descent during fetal development. As explained by Cincinnati Children’s Hospital:²

"Approximately 80% to 90% of inguinal hernias appear in boys. They are more common on the right side, but in about 10% of cases, they occur on both sides (bilaterally) …

An inguinal hernia can occur at any age, but one-third of hernias in children appear in the first 6 months of life … In premature infants, the occurrence of inguinal hernia is increased by up to 30%."

While women can develop inguinal hernias, their incidence is notably lower, typically occurring in conjunction with risk factors such as obesity, previous pregnancies, or chronic cough conditions.

Age plays a crucial role in hernia development, with incidence rates climbing significantly among older adults due to the natural deterioration of abdominal wall strength and connective tissue integrity over time.

The condition manifests in two primary forms: congenital and acquired. Congenital hernias, present from birth, stem from incomplete closure of the processus vaginalis — a peritoneal pouch that normally seals following testicular descent. When this closure fails, it creates a natural weakness that can lead to hernia formation.

The interplay of these demographic, anatomical, and age-related factors creates a complex risk profile that varies significantly among individuals. The recognition of these risk factors and their underlying mechanisms helps inform both preventive measures and therapeutic interventions, ultimately contributing to more effective patient care and outcomes.

Risk Factors for Acquired Inguinal Hernias

Acquired inguinal hernias develop later in life and are associated with several risk factors, including:

Potential Complications That Can Be Very Serious

Treatment for inguinal hernias typically involves surgical intervention, particularly when symptoms are present or if the hernia is at risk of complications, such as incarceration or strangulation.

Incarceration refers to a condition where the herniated contents (usually a portion of the intestine) become trapped in the hernia sac and cannot be pushed back into the abdominal cavity. Key points about incarcerated hernias include:³

• It is considered a medical emergency requiring prompt attention.
• Signs include a painful, irreducible bulge in the groin area.
• Diagnosis typically involves physical examination and may be confirmed with imaging like ultrasound or CT scan.
• Treatment often requires emergency surgery to release the trapped tissue and repair the hernia.

Strangulation is a more severe complication that can develop from an incarcerated hernia. It occurs when the blood supply to the trapped tissue is cut off, leading to tissue death. This is a life-threatening emergency requiring immediate surgical intervention. Symptoms may include severe pain, fever, nausea, vomiting, and signs of systemic illness. The affected area may appear warm, tender, or discolored.⁴

Both incarceration and strangulation are serious complications that significantly increase the risks associated with inguinal hernias. They are primary reasons why surgical repair is often recommended, even for asymptomatic hernias, to prevent these potentially life-threatening situations.

Treatments for Inguinal Hernias

There are two main surgical approaches for inguinal hernias: mesh repair and meshless repair techniques.

Comparison of Desarda Technique and Shouldice Method for Inguinal Hernia Repair

The Desarda technique represents a significant advancement in inguinal hernia repair, offering a distinctive meshless approach that prioritizes the use of the patient's natural tissues. Rather than relying on prosthetic materials, this innovative method employs a single layer of the external oblique aponeurosis to create a new internal ring and reinforce the inguinal canal, resulting in a durable repair that maintains anatomical integrity.

One of the technique's notable advantages lies in its surgical versatility, as it can be performed through both open and laparoscopic approaches. This flexibility allows surgeons to tailor the procedure to individual patient needs and their own expertise.

Proponents of the Desarda method particularly emphasize its reduced risk profile for post-operative complications. By eliminating the need for prosthetic materials, patients typically experience lower rates of chronic pain and favorable recovery trajectories.

These outcomes, combined with the technique's documented success in preventing hernia recurrence, have established the Desarda approach as a compelling option in modern hernia repair, especially for patients seeking alternatives to mesh-based procedures.

The Shouldice method is another well-established technique in inguinal hernia repair, distinguished by its meticulous, four-layered reconstruction approach that eschews artificial mesh in favor of the patient's native tissue. However, despite a proven track record of success, the Shouldice method does present certain notable drawbacks.

As an open surgical procedure, it requires a larger incision to access the abdominal wall, resulting in significantly longer recovery times compared to modern laparoscopic approaches. Additionally, the technique relies on stainless steel sutures to secure the tissue layers, introducing a permanent metal presence in the body — a factor that some medical professionals consider less than optimal for long-term health outcomes.

Nevertheless, the method's enduring popularity stems from its extensive clinical history and documented efficacy. The careful dissection and precise re-approximation of tissue layers, while time-consuming, creates a robust repair that has demonstrated excellent long-term durability with minimal complications.

This balance of proven success against its inherent limitations makes the Shouldice method a significant, albeit somewhat controversial, option in the modern surgeon's arsenal of hernia repair techniques.

Both the Desarda technique and the Shouldice method demonstrate low recurrence rates, but the Shouldice method often boasts slightly better long-term outcomes in larger studies. However, both methods are generally regarded as effective.

In terms of postoperative pain and recovery, studies suggest that both techniques result in manageable pain levels, though individual experiences vary. Some patients report less discomfort with the Desarda technique due to its less invasive nature. However, the Shouldice method’s reputation for a comprehensive, meticulous repair may contribute to better long-term results, balancing initial pain with later effectiveness.

The choice between these two techniques often depends on the surgeon's experience and preference. Some surgeons trained in the Shouldice method advocate for its thorough approach, while others favor the Desarda technique for its innovative use of local tissue and potentially quicker recovery.

Mesh Options for Inguinal Hernia Repair

Inguinal hernia repair with mesh involves several techniques and types of mesh that are tailored to the patient’s health condition, hernia type, and surgical preferences. Here’s a comprehensive look at the common approaches, including their advantages and disadvantages.

[At this point Dr J. Mercola does a comparison - advantages vs disadvantages - between the various surgical methods that are presently used. Not able to post these here.]

Conclusion

Navigating the various surgical options for inguinal hernia repair can seem daunting, but understanding the pros and cons of each approach can empower both patients and surgeons to make informed decisions about the best course of action. The advances in surgical techniques, particularly the integration of robotic systems like Da Vinci, represent significant progress in hernia repair technology, allowing for more precise and less invasive options.

For most patients, the ideal choice will often lean towards the closed laparoscopic approach, particularly utilizing the TEP technique, which minimizes harm and complications. However, it’s important to note that this method does not include meshless options, which cannot be performed laparoscopically.

While traditional meshes have raised concerns due to potential endocrine-disrupting chemicals, alternatives like Surgisis have emerged as favorable options. This newer mesh is biocompatible and promotes tissue integration, with clinical evidence suggesting that it is replaced by favorable type I collagen within the body. This advancement allows for enhanced healing and reduced complications.

Additionally, if you choose to use Surgisis, that is mostly collagen, consider incorporating therapies such as photobiomodulation with near-infrared light. Applying 10 to 100 milliwatts per square centimeter can significantly enhance the integration of the mesh into your tissue, supporting healing and improving overall outcomes.

There are several devices on the market that provide this treatment, just be sure that the energy irradiance of 10 to 100 milliwatts is confirmed. Ideally use that for about 8 minutes twice a day over the area where the mesh was installed as this will help integrate the collagen into your body.

As you prepare for your hernia repair journey, keep these insights in mind. Collaborate closely with your surgeon to discuss your options and preferences and consider their comfort level with the chosen technique. The path to recovery can be streamlined and effective when guided by the latest surgical innovations and a personalized approach to your health.

More at this link: https://articles.mercola.com/sites/articles/archive/2024/11/14/inguinal-hernias.aspx

 

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