Groin Hernias and Masses, and Abdominal Hernias

27 Groin Hernias and Masses, and Abdominal Hernias

James J. Chandler

Objectives

1. To be able to discuss the differential diagnosis of inguinal pain and the diagnosis and management of groin masses and hernias. 2. To develop an understanding of the anatomy, location, and treatment of different types of hernias; this includes the frequency, indications, surgical options, and normal postoperative course for inguinal, femoral, and umbilical hernia repairs. 3. To understand the definition and clarification of the clinical significance of incarcerated, strangulated, reducible, and Richter’s hernias. 4. To develop an awareness of the urgency of surgical referral, the urgency of treating some hernias. 5. To develop an understanding of the differential diagnosis of an abdominal wall apparent hernia or mass, including adenopathy, desmoid tumors, rectus sheath hematoma, true hernia, and neoplasm.

Cases

Case 1 A 74-year-old woman has noted an intermittent small lump in the right groin for 8 months. This has seemed to go away when she lies down, but it is present when she showers in the morning. Two nights ago, she could feel the lump when supine. It was slightly tender. Yesterday, she began feeling a steady ache in the groin and had poor appetite. The discomfort became worse, and she slept ﬁtfully last night. This morning she felt awful, had a lemon-sized tender right groin mass, and had nausea and some diarrhea. You found her moaning, holding her distended abdomen, and trying to vomit. On examination, there were intermittent

479 480 J.J. Chandler

gurgles heard in the abdomen, and a slightly pink, skin-covered, very tender lump was present in the right groin. Abdominal x-ray: dilated intestinal loops with air-ﬂuid levels. Laboratory studies: hemoglobin, 14.6; BUN, 24; electrolytes normal; urine speciﬁc gravity, 1.028.

Case 2 A male college student, age 20, presents with a 4-year history of intermittent soft mass in his groin and a large lump in the right side of the scrotum, which is now uncomfortable. He does not notice any groin mass on awakening, but he becomes aware of the groin and scrotal masses later in the morning, toward noon.

Deﬁnitions

A hernia is present when an object goes through an opening and is now in any unexpected location. There may be a covering of the object; this covering, called the sac, usually is the peritoneum. An organ, a portion of omentum, or part of the intestine, bladder, or stomach may herniate through an opening in the abdominal wall or diaphragm. This has occurred in both Case 1 and Case 2. A femoral hernia, much more common in women, presents through the femoral canal, and an indirect inguinal hernia protrudes through the abdominal wall in the spermatic cord or alongside the round ligament. Pediatric inguinal hernias are indirect. Direct inguinal hernias are rare in females and in males younger than 35 years of age. An internal hernia occurs when the intestine goes through an opening inside the abdominal cavity. In a Richter’s hernia (Case 1), only a part of the intestinal wall, covered by a sac formed by the overlying peritoneum, protrudes through an opening (usually in the femoral canal), and the intestinal lumen remains open. In Case 1, the woman has both a lump in the groin and not complete intestinal obstruction, meaning that she could have a knuckle of bowel wall caught in an opening but with an open lumen, as in a Richter’s hernia. This patient is dehydrated and seriously ill! (See Algorithms 27.1 and 27.2.) If an organ or a portion of the intestine uncovered by peritoneum protrudes through and forms part of the hernia sac, this is called a sliding hernia. When an intestinal loop comes out through an opening and this hernia does not go back by itself or cannot be gently pushed back, the hernia cannot be reduced. The hernia is incarcerated. When part of the intestine (or stomach) is incarcerated, there can be a shut- ting off of the venous drainage and/or the arterial circulation; this is now a strangulated hernia. Gangrenous changes develop, leading to possible perforation and possible death.

Groin Masses: Differential Diagnosis

These are the differential diagnoses for groin masses. • Inguinal hernia: Protrudes through the internal ring, at the level of the public tubercle; exits via the external ring (see Algorithm 27.1). 27. Groin Hernias and Masses, and Abdominal Hernias 481

Immediate surgical Groin mass Painful referral

Not reducible Reducible: it is a hernia Tender, looks Not tender Pulsatile like hernia Patient stands and strains Hard Soft ? Cancer Bulge near level of pubic Bulge next to femoral tubercle—inguinal artery—femoral Vascular— surgical referral now Surgical Surgical referral now Tender: referral looks like lymph node

Surgical referral

Algorithm 27.1. Algorithm for the evaluation of groin masses.

There may be a sausage-shaped mass going all the way down into the scrotum, as in Case 2. • Femoral hernia: Bulge/mass appears medial to the femoral vein (see Algorithm 27.1), can rise higher, and can be difficult to distinguish from an inguinal hernia. • Lymph node mass: This does not disappear with pressure on it. This usually is a nontender mass that is firm, overlying the femoral artery. Lymph nodes may be inflamed and tender from infection or enlarged and firm because of cancer, a lymphoma, or metastatic cancer (see Algorithm 27.1).

Femoral

History and physical

Possible femoral hernia

Reduces spontaneously Does not reduce

Surgical referral soon Immediate referral

Algorithm 27.2. Algorithm for the evaluation of likely femoral hernia. 482 J.J. Chandler

• Varicocele: Irregular, nontender type lump palpable in the spermatic cord superior to the left testicle. If diagnosis is uncertain, order duplex color-coded ultrasonography. • Hydrocele: “Water sac.” A fluid-filled membrane, around or above the testicle, which may extend up into the inguinal canal and may communicate with a hernia sac. A hydrocele can be transilluminated by holding a flashlight behind it. • Femoral artery aneurysm: Pulsatile, expansile mass. Refer for vascular surgery, now! • Psoas muscle abscess: Rare. Formerly more common when due to tuberculosis. Pus in the muscle sheath dissects inferiorly and bulges into the groin. If due to staphylococcus, patient is very ill and febrile, and the mass is acutely tender. • Tumor (benign) of spermatic cord: A fibroma is firm, nontender, and can be moved a little to the side, in the inguinal canal. • Seroma: Collection of serum in the groin. Edges are poorly defined. These generally follow a groin-area surgical procedure, such as groin dissection or arterial surgery. Hematomas are fairly common after hernia repair, but large ones are rare. • Abscess: This would be unlikely unless following a surgical procedure. Tender, warm skin overlying. • Cryptorchid: An undescended testicle. Duplex ultrasonography diagnosis it. See Algorithm 27.3 for a general workup for an abdominal or groin lump/mass.

Anatomy of the Groin

The layers of tissue found in the lower abdomen are the external oblique muscle, internal oblique, transversus abdomen, transversalis fascia, preperitoneal fat, and peritoneum (Fig. 27.1).

History of abdominal of groin lump/mass

Physical exam

Groin Abdominal

Consider CTs See Algorithm 27.2

Intraabdominal Abdominal wall?

Surgical referral Surgical referral

Algorithm 27.3. Algorithm for general workup for abdominal or groin lump/mass. 27. Groin Hernias and Masses, and Abdominal Hernias 483

External oblique m. Ant. rectus sheath

Internal oblique m. Rectus abd. m.

Peritoneum Post. rectus sheath Transversus abd. m. Transversalis fascia A

Anterior rectus sheath

Rectus abdominis m.

Figure 27.1. Abdominal wall layers: (A) above the semilunar line of Douglas; (B) below the semilunar line. (Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.)

The inguinal canal courses obliquely from the internal ring opening in the transversalis fascia to the pubic bone and the external ring opening in the external oblique. The spermatic cord in the male comes through the internal ring; the external ring is where the spermatic cord exits to head down into the scrotum. Included in this “cord” are super- ficial and external spermatic fascial layers, cremaster muscle, external spermatic artery (in the cremaster), internal spermatic fascia, vas deferens, testicular artery, pampiniform plexus of little veins, and some sympathetic fibers. The genital branch of the genital femoral nerve, often said to be in the spermatic cord, actually courses through the internal ring in the edge of posterior cremaster fibers and easily is sep- arated from the cord. This nerve lies posterior to the cord with its accompanying vessels in the inguinal canal. The boundaries of the inguinal canal are the transversalis fascia posterior, external oblique 484 J.J. Chandler

anterior, internal oblique muscle and rectus sheath superior, inguinal ligament inferior, pubic bone medial, and internal ring lateral. See Figure 27.2 for the relationships of the inguinal canal. A hernia going through the internal ring, outside the inferior epigastric artery, and inside the spermatic cord courses obliquely with the cord and is termed an indirect inguinal hernia (Case 2). A protrusion through thinned-out transversalis fascia comes straight out through the abdominal wall and is called a direct inguinal hernia, which is medial to the inferior epigastric artery. These hernias bulge through Hesselbach’s triangle, which is bounded by the rectus sheath, inguinal ligament, pubis, and inferior epigastric artery (Fig. 27.3). A hernia pre- senting through both the internal ring and Hesselbach’s triangle is termed a pantaloon hernia, with a “leg” of the hernia coming out on both sides of the inferior epigastric artery.

Groin Hernias

Femoral Hernia Unknown in children and relatively rare in males, this is a hernia pre- senting in the femoral sheath, through the femoral canal, medial to the nerve, artery, and vein there. The femoral ring has ﬁrm, unyielding

External oblique m.

Ext. oblique aponeurosis Int. oblique m. (reflected)

Arch of transversus abd. m.

Inguinal canal floor (transversalis Inguinal lig. fascia)

External ring Spermatic cord

Figure 27.2. The left inguinal canal with external oblique aponeurosis incised and reﬂected. (Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.) 27. Groin Hernias and Masses, and Abdominal Hernias 485

Internal inguinal Hesselbach’s ring triangle

Femoral canal

Figure 27.3. Indirect hernias occur through the internal ring. Direct inguinal hernias occur through Hesselbach’s triangle, which lies between the inguinal ligament, the rectus sheath, and the inferior epigastric vessels. Femoral hernias occur through the femoral canal, which lies between the inguinal ligament, the lacunar ligament, Cooper’s ligament, and the femoral vein. Fruchaud’s myopectineal orifice refers to the entire musculoaponeurotic area through which inguinal and femoral hernias can occur. (Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.) borders: the superior inguinal ligament, the inferior Cooper’s ligament, and the medial half-moon–shaped lacunar ligament. Because of this, these hernias frequently are incarcerated and are prone to develop strangulation, with intestinal wall gangrene, as in Case 1. Diagnosis Diagnosis can be difficult because of the short distance between the inguinal canal and the medial groin presentation site of the femoral hernia. The usual history includes the awareness of a lump in the groin, but it is in the leg crease where the pelvis meets the thigh medially. Direct pain or tenderness, vague groin or lower abdominal discomfort, nausea, and discomfort on prolonged standing or while walking are frequent findings. Examination is most helpful with the patient standing. If, when she strains and increases intraabdominal pressure, a lump is seen or felt, the base of the femoral hernia will be below the level of the top of the pubic bone, as noted in Algorithm 27.1. Also, if the examiner’s forefinger is in the femoral canal when the patient strains, the fingertip can be backed away slowly, allowing the 486 J.J. Chandler

hernia to pop out of the canal. With an incarcerated hernia in a woman, there is some tissue swelling, and it can be difficult to differentiate between femoral or inguinal hernia. The gentlest pressure can be tried with the patient supine to see whether an inguinal hernia will reduce. Caution is required because an incarcerated femoral hernia usually should be diagnosed in the operating room; no significant pressure should be applied to attempt reduction (see Algorithm 27.2)! Surgical Treatment of Femoral Hernia The surgeon must know several operative methods and be able to choose the best method for the particular patient and situation. In the open, preperitoneal approach, the surgeon opens the inguinal canal and then may enter the preperitoneal space through Hesselbach’s triangle or by going above the canal and entering through the posterior rectus sheath. A piece of nonabsorbable mesh may be used for repair. In approaching the femoral hernia from below, one incises over the femoral canal, dissects through the fat and lymphatic tissue, reduces a sac found, and occludes the canal with rolled mesh or with stitched tissue adjacent. The sac is opened to check for evidence of ischemic intestine (bloody fluid). Normal postoperative course includes the following. The individual has moderate pain after the effects of local anesthetic have cleared. She/he can resume a light diet, returning to normal in 24 hours; constipation may be a problem. With return home within a few hours after the operation, the patient is up and around but requires more rest for the next week. Patients return to work from within a few days to 2 weeks after surgery.

Inguinal Hernias Diagnosis In Case 2, we are presented with a man who has had a long history of groin and associated scrotal mass. Diagnosis of an inguinal hernia is a simple matter when given a history of an inguinal bulge felt or seen, especially if it is a new discovery and if it disappears when supine, as in Case 2. This young man should be examined while he is standing, with unclothed lower body. Seat yourself before him, ask him to strain or cough, and watch the hernia roll down the inguinal ligament and into the upper scrotum. Then see if gentle upward pressure with your or the patient’s fingers can reduce the hernia; if not, have him lie down, and try again. When examining a standing male patient without an obvious bulge, the examiner’s finger pushes up through the upper scrotal skin and is placed against the external inguinal ring. As the patient strains and coughs, a soft mass coming out through the ring and pushing your finger away gives you the diagnosis of a hernia. If the hernia is continuously bulging and will not reduce with position change or gentle upward pressure, surgical referral is indicated without delay (see Algorithm 27.4). Examination of females also is best done with the patient standing, but invagination of labial skin is next to impossible. One also desires to assess whether this is an inguinal or femoral hernia, which can be difficult (see Algorithm 27.1). Whether a hernia is even present also 27. Groin Hernias and Masses, and Abdominal Hernias 487

Inguinal

History and physical Laparoscopic repair

Physical exam

Unilateral palpable Recurrent hernia Bilateral palpable Persistent pain, hernia hernia no hernia detected

Bilaterial open Staged open Reducible Incarcerated Lap repair mesh repair mesh repair

Open mesh repair Urgent: open repair, possible mesh Reexam Nerve irritation Muscle strain in 1–3 months

Preperitoneal open mesh repair Open mesh repair Local anesthetic, *steroid injection Heat—avoid (vs. refer: Pain exercise Management Service)

Algorithm 27.4. Decision tree for inguinal hernia and inguinal pain.

may be especially difficult to decide in females and in any obese male. On occasion, the examiner will admit uncertainty and recommend follow-up exam or examination by another physician (see Algorithm 27.4). Operating and finding no hernia to repair is to be avoided. Pain upon straining or lifting but with no appreciable bulge can be the first evidence of inguinal hernia. The groin lump may appear some days later after discomfort from muscle disruption and after inflam- mation in the muscle have subsided. Pain from inguinal hernia can be poorly or well localized by the patient. Discomfort usually is intermittent and related to prolonged standing or walking or increased intraabdominal pressure. “Burning,” “dragging feeling,” and “ache” all have been used as descriptions. Persistent pain and groin mass suggest incarceration, which requires urgent surgical treatment. Fever, nausea and vomiting, rapid heart rate, marked tenderness over the mass, and abdominal distention must bring to mind likely bowel ischemia, “strangulation,” and the required emergency treatment. Surgical Treatment of Inguinal Hernia Open Repair: Open repair is the term used to differentiate from a laparoscopic technique. The open repair can be via an anterior approach or via an approach from behind the inguinal canal, through the preperitoneal space, termed “preperitoneal approach.” Many hernia repair techniques have been described. General surgeons know 488 J.J. Chandler

multiple methods. The Italian surgical genius Bassini developed an elaborate anterior open and successful operation using layers of native tissue.1 The modern, currently most popular and successful open anterior technique with native tissue is the Canadian Repair developed at the Shouldice Clinic.2 This features local anesthesia and very early ambulation, after a repair utilizing running stitches in several layers of tissue. Nyhus3 is given credit both for promoting an understanding of the surgical anatomy above the pelvis and for demonstrating advan- tages in hernia repair with a preperitoneal approach. Lichtenstein4 opened the mesh repair floodgates with his introduction of a highly successful open, anterior technique using inert mesh laid onto the posterior inguinal canal, repairing a hernia without the tension caused by bringing tissues together with stitches. Repairs then were developed that featured mesh placed in the preperitoneal space and repairs in which mesh is used both in that space and over the floor of the inguinal canal. Laparoscopic repairs also have evolved. The young man in Case 2 had his hernia diagnosed through the history and the exam method described earlier. Many repair techniques could be used. With the expected small opening at the internal ring and the congenital-type indirect inguinal hernia, the sac could be ligated high or stitched, with redundant sac tissue excised, or the sac could be dissected high and inverted. A few stitches taken medially to tighten the internal ring (the Marcy repair) might suffice in a case with firm layer of transversalis fascia in Hesselbach’s triangle. A mesh plug could be used in the internal ring. After an internal ring plug is placed, onlay of mesh covering the inguinal canal provides some insurance against recurrence. The normal postoperative course is similar to the course after femoral hernia repair. However, lifting more than 35 pounds and heavy work are to be avoided for 6 postoperative weeks. Pitfalls and Perils of Open Inguinal Hernia Repair: Complication rates vary from minimal to 20%. Nerve entrapment or neuroma with virtu- ally constant pain, bleeding and large hematoma, ischemic orchitis, vas deferens injury, intestinal injury, or failure to recognize pregangrene all are known and relatively unusual, but feared. Pain after surgery has been reduced markedly by using a tension-free procedure combined with local anesthesia. Mesh sheets shrink 20% in size. Mesh plugs shrink up to 70% in volume, harden, and may allow a hernia to develop adjacent to the plug. Patient-related complications are ileus, nausea, cardiac, and respiratory. Other complications that can follow hernia

1 Wright AJ, Gardner GC, Fitzgibbons RJ Jr. The Bassini repair and its variants. In: Fitzgibbons RJ, Greenberg AG, eds. Nyhus and Condon’s Hernia, 5th ed. Philadelphia: Lippincott, 2002:105–114. 2 Bendavid R. The Shouldice repair. In: Fitzgibbons RJ, Greenberg AG, eds. Nyhus and Condon’s hernia, 5th ed. Philadelphia: Lippincott, 2002:129–138. 3 Nyhus LM, Condon RE, Harkins HW. Clinical experiences with preperitoneal hernia repair for all types of hernia in the groin: with particular reference to the importance of tranversalis fascia analogs. Am J Surg 1960;100:234–244. 4 Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery, including a new concept, introducing tension-free repair. Int Surg 1986;71:1–4. 27. Groin Hernias and Masses, and Abdominal Hernias 489 repair include chronic pain, testicular atrophy or ejaculation abnormality, wound seroma or infection, hydrocele, and scrotal or retroperitoneal hematoma. Recurrence of hernias after surgical repair is of major concern to surgeons and patients alike. Many patients are not closely followed, and many with a recurrence seek aid elsewhere, making recurrence rates difﬁcult to establish. In summary, all of the open approaches now in popular usage have acceptable rates of long- term hernia cure when the reports of centers with large numbers of repairs are reviewed. Laparoscopic Inguinal Hernia Repair: Laparoscopic repair requires general anesthesia, has been controversial, and is not widely used. However, recent reports of highly acceptable recurrence rates, lessened postoperative pain, and rapid return to regular work have caused genuine increasing interest, demonstrated in a recent compilation of prospective, randomized trials comparing open and laparoscopic repairs (Table 27.1). Pitfalls and Perils of Laparoscopic Repair of Inguinal Hernias: While some surgeons have excellent reported results, laparoscopic repair has had numerous complications related to this technique, in addition to the usual list of potential complications of open hernia surgery. These include bleeding in the retroperitoneal space, in the abdominal wall, or inside the abdomen; intraabdominal intestinal or artery injury; bladder perforation; trocar-site hernia; stapling a nerve; and small-bowel obstruction. Recurrences have resulted from inadequate mesh ﬁxation, too small a mesh, missed hernia, and mesh displacement. Cost of repairing a hernia with a laparoscopic method is greater than the costs associated with other methods.

Watchful Waiting Whether watchful waiting is ever indicated is controversial, and the conventional approach is to plan repair when a hernia is diagnosed. The conventional approach is being questioned, however, in asymptomatic hernias. Somewhere between one-half and three-quarter million hernias are operated upon yearly in the United States. It is esti- mated that an even larger number are not operated upon because in- dividuals are not choosing to have them repaired. Most surgeons recommend repair in order to avoid the higher complication rate and the greater difficulty of repair in cases of incarceration or strangulation, and because of the belief that incarceration/strangulation are likely to occur, when in fact this may be unlikely. Also, long-term complications, including chronic pain, may follow surgical repair. Data are insufficient now to develop clear indications for watchful waiting. An inguinal hernia that is asymptomatic, has a large defect or almost no bulge at all, and that reduces quickly with the patient supine should be able to be observed for some period of time. Also, with a patient who presents with possible incarceration of a hernia that you find to be easily reduced with very gentle pressure, surgical intervention can be de- layed for a few hours and, in some cases, for 1 or 2 days. 490 J.J. Chandler

Table 27.1. Prospective randomized trials comparing laparoscopic and open repairs (level I evidence). Average Complications Study follow-up No. of (not including Reference design (months) repairs recurrences) Recurrences Paganini et al TAPP vs. 28 TAPP: 52 14 (26.9%) total 2 1998, Italya Lichtenstein complications (3.8%) 4 (7.7%) hematoma 1 (1.9%) hydrocele 5 (9.6%) paresthesia 4 (7.7%) seroma* Licht.: 56 15 (26.8%) total 0 complications 8 (14.3%) hematoma 2 (3.6%) hydrocele 5 (8.9%) paresthesia 0 seroma* Zieren et al TAPP vs. Plug 25 TAPP: 80 2 (3%) intraop 0 1998, & Patch vs. bleeding* Germanyb Shouldice 15 (19%) postop complications Plug: 80 12 (15%) postop 0 complications Shouldice: 13 (16%) postop 0 80 complications

Liem et al TEP vs. open 20.2 TEP: 487 24 (5%) Conversion 17 1997, (Marcy, to TAPP or open (3%)* Netherlandsc Lichtenstein, 54 (11%) total postop Bassini, complications Shouldice, 0 deep wound McVay) infection* 10 (2%) chronic pain* 7 (1%) seroma* 3 (1%) pneumoscrotum >1 day Open: 507 99 (19.5%) total 31 postop (6%)* complications 6 (1%) deep wound infection* 70 (14%) chronic pain* 0 seroma* Champault TEP vs. Stopps 20.2 TEP: 51 4% total 3 et al 1997, complications* (6%) Franced 3 (6%) conversions to open

Stoppa: 49 20% total 1 complications* (2%) 27. Groin Hernias and Masses, and Abdominal Hernias 491

Table 27.1. Continued

Operative Return time Postoperative to work (min) Cost pain (days) Conclusions/details 66.6 Unilateral $1249 Ø pain 15 95% of Lichtenstein repairs performed primary* score under local anesthesia. 71.1 Unilateral @ 48 TAPP had less postop pain. recurrent h* TAPP should not be adopted routinely 85.7 Bilateral unless its cost can be reduced.

48.2 Unilateral $306 ≠ 14 primary* discomfort 41.2 Unilateral @ 7 d, recurrent 3mon 75.9 Bilateral

61* $1211 16 Plug & Patch and TAPP cause less pain and have faster return to work than 18 Shouldice; Plug & Patch cost less than TAPP and can be performed faster and 36 $124 under local anesthesia.

47 $69 ≠ pain 26* score * 45* — Ø pain 14* TEP has more rapid recovery and fewer score recurrences than open repairs, but * takes slightly longer to perform.

40* — 21*

“Signiﬁcantly — Ø pain 17* 45% bilateral, 43% recurrent. longer”* score Mesh for TEP was not ﬁxed in place; * mesh size increased from 6 ¥ 11cm to Ø 12 ¥ 15cm due to early recurrences. meds Single piece of mesh for bilateral hernias * believed to reduce recurrence rates. — 35* TEP has the same long-term recurrence rate as the Stoppa procedure, but confers a real advantage in the early postop period. Continued 492 J.J. Chandler

Table 27.1. Continued Average Complications Study follow-up No. of (not including Reference design (months) repairs recurrences) Recurrences Kald et al TAPP vs. 12 TAPP: 122 8 (6.6%) total 0* 1997, Shouldice complications Swedene

Shouldice: 9 (10.1%) total 3 89 complications (3.4%) * Bessell et al TEP vs. 7.3 TEP: 39 6 conversion to open 2 1996, Shouldice 3 conversion to TAPP (5.1%) Australiaf 4 (10%) postop complications

Shouldice: 7 (9.5%) postop 0 Wright et al TEP vs. open — 74 complications — 1996, (Lichtenstein or TEP: 67 6 (9%) conversion to Scotlandg preperitoneal) open 15 (22%) postop complications 1 (1%) hematoma* 0 seroma*

Open: 64 46 (72%) postop — complications 20 (31%) hematoma* 7 (11%) seroma* Tschudi et al TAPP vs. 6.7 TAPP: 52 6 (12%) total 1 1996, Shouldice complications (1.9%) Switzerlandh

Shouldice: 9 (16%) total 2 56 complications (3.6%) Barkun et al TAPP or IPOM 14 TAPP: 33 10 (22.5%) total 0 1995, vs. open complicaions Canadai (Bassini, McVay, IPOM: 10 Shouldice, Lichtenstein, Plug & Patch) Open: 49 6 (12.2%) total 1 (2%) complications Vogt et al IPOM (with 8 IPOM: 30 5 (17%) total 1 1994, USj meshed PTEE) complications vs. open 1 (3.3%) bladder (3.3%) (Bassini, McVay) perforation Open: 31 5 (16%) total 2 complications (6.5%) 27. Groin Hernias and Masses, and Abdominal Hernias 493

Table 27.1. Continued Operative Return time Postoperative to work (min) Cost pain (days) Conclusions/details 72* + $483 — 10* TAPP had faster recovery and return to direct work with comparable complication cost rates. TAPP more cost-effective if indirect cost 62* + $1364 — 23* compared, which included income lost indirect by a delay in return to work. cost 87.5* — Ø pain 30.5 Study biased because of larger crossover score to open group. * Substantial conversion rate to open and Ø TAPP repairs. meds TEP has significant decrease in pain, equivalent return to work, but longer operative time. TEP alleviates the inherent dangers associated with TAPP, but further studies needed. 50* — 32 58* — Ø pain — Acute study focusing on early outcome. score No data for length of follow-up or * recurrences. Significant decrease in pain but increased OR time for TEP. Significant conversion rate. Ø Very high complication rates for both groups. meds Also looked at pulmonary and metabolic measures; no differences found. 45* — —

87 unilateral* — Ø pain 25 Study biased because patients 124 bilateral score undergoing open repairs told not to * resume activity for 4–6 weeks. Ø Signiﬁcantly less pain with TAPP, but meds longer OR time. * Long-term follow-up needed for analysis of recurrences. 59 unilateral* — 48 79 bilateral 43 $1718 Ø 9.6 Improved quality of life and decreased meds pain with laparoscopic repairs, but at * increased cost. Laparoscopic repairs are feasible and comparable to open repairs.

$1224 10.9

62.5 — Ø 7.5 Less pain and faster return to work with med IPOM, with comparable efﬁcacy and morbidity. Longer follow-up needed. 80.9 — 18.5 Two patients had IPOM under local anesthesia. Continued 494 J.J. Chandler

Table 27.1. Continued Average Complications Study follow-up No. of (not including Reference design (months) repairs recurrences) Recurrences Stoker et al TAPP vs. open 7 TAPP: 83 6 (7%) total 0 1994, UKk (nylon darn complications* plication) 1 deep wound infection 3 persistent pain 1 hematoma

Open: 84 16 (19%) total 0 complications* 5 deep wound infection 6 persistent pain 3 hematoma Payne et al TAPP vs. 10 TAPP: 48 6 (13%) total 0 1994, USl Lichtenstein complications 0 groin pain >1mon. 2 (4%) conversions to open 1 (2%) incarcerated omentum in peritoneal ﬂap Licht: 52 9 (17%) total 0 complications 4 (8%) groin pain >1mon.

TAPP, transabdominal preperitoneal approach; IPOM, intraperitoneal onlay mesh repair; TEP, totally extraperitoneal approach; PTEE, polytetraﬂuoroethylene. *, Statistically signiﬁcant. a Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled, clinical study of laparoscopic vs open tension- free inguinal hernia repair. Surg Endosc 1998;12:979–986. b Zieren J, Zieren H, Jacobe CA, et al. Prospective randomized study comparing laparoscopic and open tension-free inguinal hernia repair with Shouldice’s operation. Am J Surg 1998;175:330–333. c Liem MSL, Van Der Graff Y, Van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541–1547. d Champault G, Rizk N, Catheline JM, et al. Inguinal hernia repair: totally pre-peritoneal laparoscopic approach versus Stoppa operation, randomized trial: 100 cases. Hernia 1997;1:31–36. e Kald A, Anderberg B, Carlsson P, Park PO, et al. Surgical outcome and cost-minimization analyses of laparoscopic and open hernia repair: a randomized prospective trial with one year follow-up. Eur J Surg 1997;163:505–510. f Bessell JR, Baxter P, Riddell P, Watkin S, et al. A randomized controlled trial of laparoscopic extraperitoneal hernia repair as a day surgical procedure. Surg Endosc 1996;10:495–500. Source: Reprinted from Scott DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.

Abdominal Wall Hernias

Ventral hernias are those protruding through the anterior wall of the abdomen. Umbilical hernias are ventral, but they are placed in their own category because etiology and repair techniques are so different from those used for ventral incisional hernias. With a weakened area of the wall or with signiﬁcant increased intraabdominal pressure, hernia develops. At the umbilicus, hernia usually is congenital, but hernia can follow childbirth, increased weight, or be at the upper or 27. Groin Hernias and Masses, and Abdominal Hernias 495

Table 27.1. Continued Operative Return time Postoperative to work (min) Cost pain (days) Conclusions/details 50 unilateral* +£168 Ø 14* TAPP has less pain, faster return to work, 92 bilateral pain and fewer complications, but increased score operative time. * Substantial economic savings in lost Ø work days. meds * 35 unilateral* 28* 60 bilateral

68 unilateral $3093 — 9 unilat.* TAPP can be performed with similar 87 bilateral * 7.5 bilat. operative times and short-term 67 recurrent 11.4 recurrence rates, with faster return to recurr. work, but an increased cost. 90% of Lichtenstein’s used local anesthesia. Biggest impact on faster return to work and increased ability to perform 56 unilateral $2494 — 17 straight leg raises seen in manual labor 93 bilateral * unilat.* population.* 73 recurrent 25 bilat. 26 recurr. g Wright DM, Kennedy A, Baxter JN, et al. Early outcome after open versus extraperitoneal endoscopic tension-free hernioplasty: a randomized clinical trial. Surgery (St. Louis) 1996;119:552–557. h Tschudi J, Wagner M, Klaiber C, Brugger JJ, et al. Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Surg Endosc 1996;10:845–847. i Barkun JS, Wexler MJ, Hinchey EJ, Thibeault D, et al. Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial. Surgery (St. Louis) 1995;118:703–710. j Vogt DM, Curet MJ, Pitcher DE, et al. Preliminary results of a prospective randomized trial of laparoscopic onlay versus conventional inguinal herniorrhaphy. Am J Surg 1995;169:84–90. k Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomized prospective trial. Lancet 1994;343:1243–1245. l Payne JH, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994;129:973–981. Source: Reprinted from Scotl DJ, Jones DB. Hernias and abdominal wall defects. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.

lower end of a healed incision (an incisional umbilical hernia). Preperitoneal fat, omentum, or gut may protrude, causing a bulge, symptoms of pain, and nausea. A huge umbilical hernia may allow a large portion of bowel to enter the sac, to become twisted and com- promised, and to perforate. Some umbilical hernias can be repaired using local anesthesia, but most require general anesthesia and muscle relaxation. Asymptomatic hernias may be able to be controlled with an abdominal binder. Symptomatic umbilical hernias are repaired by incising halfway around the umbilical skin, dissecting down to the 496 J.J. Chandler

fascia, separating the overlying skin from the hernia sac, separating the fascial ring from the sac, reducing the sac and contents, and closing the fascial defect with permanent suture. A piece of prosthetic mesh often is placed just under the fascial closure, held in place with one or more of the closure stitches. Epigastric hernias occur in the upper abdomen through a defect in the linea alba and are repaired with simple closure with permanent suture, often buttressed with a piece of mesh in the preperitoneal space. Abdominal wall mass differential diagnosis includes metastatic cancer at the navel (“Sister Mary Joseph” tumor) or dermal metas- tasis, varicose veins (umbilical, secondary to portal hypertension), lymph node groin mass encroaching onto the abdominal wall, rectus sheath hematoma (usually in an anticoagulated patient: the hard, tender mass is confined to one entire rectus sheath), and desmoid tumor. Desmoids are seen in patients with familial polyposis syndrome and, although benign, can be a problem and difficult to remove surgically. Biopsy is diagnostic, and imaging studies aid in management decision. Incisional hernias may be small or large and enlarging. Huge symptomatic hernias in an obese patient can be very difficult to repair, car- rying the risks of intestinal injury (while freeing adhesions in the abdomen) and of major pulmonary, cardiac, and wound complications postoperatively. Numerous operations have been developed. Almost all repairs used today involve the use of mesh placement somewhere. (For more information, see the chapter “Hernias and Abdominal Wall Defects” by D.J. Scott and D.B. Jones in Surgery: Basic Science and Clin- ical Evidence) edited by J.A. Norton, et al, published by Springer-Verlag, 2001.) Of particular interest for repair of large and complex incisional hernias are techniques using a giant piece of mesh. The newer laparoscopic methods seem promising, with fewer reported complications and less pain postoperatively.

Other Abdominal Hernias In a spigelian hernia, fat or an intestinal loop comes through a weak point in the lateral posterior rectus sheath at the semilunar line (in the lower abdomen). This hernia is in the abdominal wall between muscles and fascia, which makes the hernia difﬁcult to locate. It usually is reducible, but it is intermittently painful. Laparoscopic repair works well for these, as does an incision directly onto the palpable lump or through the midline. When a midline incision is used, the site of the abdominal wall is lifted up so that the opening can be seen from under- neath and the hernia defect repaired. In a lumbar hernia, a posterior-lateral bulge is noted, possibly following trauma, through one of the two muscular lumbar triangles. Pelvic ﬂoor hernias are rare, and a computed tomography (CT) scan is useful for diagnosis and in planning the operative approach. Para- stomal hernias usually develop alongside a colostomy, but they can occur next to an iliostomy. These are common and may require correction, but the recurrence rate is high. 27. Groin Hernias and Masses, and Abdominal Hernias 497

Congenital and Diaphragmatic Hernias

Infants born with congenital diaphragmatic hernia constitute a pediatric and pediatric surgical emergency. While prenatal diagnosis with ultrasound and prenatal treatment is desirable, when not done, a rapid postnatal diagnosis can be crucial. The child has a huge opening in the posterolateral diaphragm (foramen of Bochdalek), the abdominal contents are up in the chest; the child has a scaphoid abdomen, and may have easily heard bowel sounds in the chest. After an abnormality is noted in the child’s breathing and a rapid chest radiograph is ordered, one often can make the diagnosis from seeing gut in the chest and a shift of the mediastinum. A very small amount of contrast put through a tiny nasogastric tube should help clarify the diagnosis. With rapid diagnosis and appropriate treatment (neonatal intensive care before and after surgical correction), formerly high mortality rates have been reduced to acceptable levels. A sliding hiatal hernia (widened esophageal hiatus with part of the stomach in the chest) exists in almost all patients with gastro- esophageal reﬂux disease. Wrapping some upper stomach around the esophagogastric junction and holding it there with stitches (Nissen repair) has excellent results in those requiring surgical intervention. This procedure lends itself well to a laparoscopic approach, with rapid return home and to work. Preoperative evaluation includes manome- try and endoscopy. In a paraesophageal hiatal hernia, the gastric fundus herniates up through the diaphragm and is superior to the location of the most distal point of the esophagus. Reﬂux symptoms, possible mild or severe pain, and even gangrenous changes in the herniated portion of the stomach can result. A lateral chest radiography usually is diagnostic; an upper gastrointestinal study always is. If at all symptomatic, a paraesophageal hernia always should be corrected surgically without delay. Traumatic hernia through the diaphragm always requires repair.

Summary

Evaluation of a suspected or deﬁnite groin mass and evaluation of groin pain can be a challenge to any primary physician. History and physical examination, while keeping the different etiologic possibilities in mind, frequently clarify the diagnosis. The most commonly performed general surgical procedure is groin hernia repair. General surgeons are referred for many patients with groin area pains of all types. Almost all patients with groin mass or groin pain are, sooner or later, referred to a surgeon. The sooner this is done, the better. The transition in hernia surgery to widespread use of local anesthesia and rapid return to home and normal activities has been aided by shorter operating times and use of some type of inert, nonabsorbable mesh. Outcomes and patient satisfaction have improved. Types of hernia repairs and their pros and cons have been presented, along with discussion of deﬁnitions, differential diagnoses, and anatomic and 498 J.J. Chandler

special considerations. Abdominal wall hernias as well as congenital and diaphragmatic hernias have been brieﬂy discussed.

Selected Readings

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