Groin hernias are inguinal or femoral; inguinal hernias are either direct or indirect. Both direct and indirect hernias protrude above the inguinal ligament; a direct hernia is medial to the inferior epigastric vessels, whereas an indirect hernia is lateral. A femoral hernia protrudes below the inguinal ligament and medial to the femoral vessels.
Groin hernias are inguinal or femoral; inguinal hernias are either direct or indirect. Both direct and indirect hernias protrude above the inguinal ligament; a direct hernia is medial to the inferior epigastric vessels, whereas an indirect hernia is lateral. A femoral hernia protrudes below the inguinal ligament and medial to the femoral vessels.
Anatomy of the Groin from an Intraabdominal Perspective : Groin hernias occur through the myopectineal orifice, which is bordered by the arch formed by the termination of the aponeurotic fibers of the transversus abdominis muscle cranially, the rectus abdominis muscle medially, the iliopsoas muscle laterally, and the superior pubic ramus with attached Cooper’s ligament inferiorly. In the inset, a mesh prosthesis is shown covering the entire myopectineal orifice, as one would see in a laparoscopic inguinal herniorrhaphy. | Fitzgibbons, R. J., & Forse, R. A. (2015). Groin Hernias in Adults. New England Journal of Medicine, 372(8), 756–763. https://doi.org/10.1056/NEJMcp1404068
Introduction
Anatomy
Embryology:
Diagram of the embryologic development of the IC. A, At 7 weeks gestation, the gubernaculum passes through the developing anterior abdominal wall at the site of the future IC. The gubernaculum is attached to the lower pole of the extraperitoneally located testes. B, At 7–12 weeks gestation, the gubernaculum shortens and pulls the testes to the level of the deep inguinal ring. The PV invaginates through the anterior abdominal wall along a path formed by the gubernaculum. Extensions of the layers of the abdominal wall accompany the PV and form the walls of the IC. C, At 26–28 weeks gestation, with androgenic stimulation and increased intra-abdominal pressure, the PV and testes begin to pass through the IC. It takes 2–3 days for the testes to reach the scrotum. D, At 32–40 weeks gestation, the IC is formed, and there is downward gradual obliteration of the PV. The scrotal portion of the PV remains patent, forming the tunica vaginalis. | Revzin, M. V, Ersahin, D., Israel, G. M., Kirsch, J. D., Mathur, M., Bokhari, J., & Scoutt, L. M. (2016). US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation. RadioGraphics, 36(7), 2028–2048. https://doi.org/10.1148/rg.2016150181
Inguinal canal:
Diagram of the IC and its contents. The deep inguinal ring is formed by the transversalis fascia, and the IC is lined by the same layers that line the abdominal wall. The external superficial ring is a triangular opening in the oblique aponeurosis. The inferior epigastric artery (a.) and vein (v.) originate from the external iliac artery and vein and lie medial to the internal inguinal ring. The locations of the abdominal wall hernias in relation to the IC are as follows: The indirect inguinal hernias lie lateral to the inferior epigastric arteries (1); the direct inguinal hernias lie medial and inferior to the inferior epigastric vessels (2); the femoral hernias lie inferior and medial to the femoral vessels (3); and the spigelian hernias lie lateral to the rectus abdominus muscle (4). | Revzin, M. V, Ersahin, D., Israel, G. M., Kirsch, J. D., Mathur, M., Bokhari, J., & Scoutt, L. M. (2016). US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation. RadioGraphics, 36(7), 2028–2048. https://doi.org/10.1148/rg.2016150181
Diagram of the walls of the IC. The anterior wall is formed by the aponeuroses of the external and internal oblique muscles. The posterior wall is formed by the transversalis fascia and conjoint tendon, a medial juncture of the internal oblique and transversalis fasciae at the pectineal line. The roof, or superior wall, is formed by the aponeuroses of the internal oblique and transversus abdominis muscles. The floor, or inferior wall, of the IC is formed by the inguinal ligament, a folded-up border of the external oblique aponeurosis. | Revzin, M. V, Ersahin, D., Israel, G. M., Kirsch, J. D., Mathur, M., Bokhari, J., & Scoutt, L. M. (2016). US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation. RadioGraphics, 36(7), 2028–2048. https://doi.org/10.1148/rg.2016150181
Diagrams of the contents of the IC in male and female individuals. In male individuals, the IC contains the ilioinguinal nerve and spermatic cord. The spermatic cord contains the genital branch of the genitofemoral nerve (from the lumbar plexus); vas deferens and vas deferens artery (a branch of the inferior vesicle artery); testicular artery, which originates from the infrarenal aorta; testicular veins (pumpiniform plexus), with the left testicular vein draining into the left renal vein and the right testicular vein draining directly into the inferior vena cava; cremasteric artery (a branch of the inferior epigastric artery); lymphatic vessels; and connective tissue. The external and internal spermatic fasciae and the cremasteric fascia and muscle cover the spermatic cord. In female individuals, the IC contains the ilioinguinal nerve, round ligament, and lymphatic vessels. | Revzin, M. V, Ersahin, D., Israel, G. M., Kirsch, J. D., Mathur, M., Bokhari, J., & Scoutt, L. M. (2016). US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation. RadioGraphics, 36(7), 2028–2048. https://doi.org/10.1148/rg.2016150181
Abdominal wall:
The abdominal wall at the groin is classically identified as the “nine layers”
Abdominal wall at the groin: The nine layers include the skin, subcutaneous fat, superficial fasciae (Camper’s and Scarpa’s fasciae), innominate (untitled) fascia, inguinal ligament, internal abdominal oblique muscle, transversalis fascia, preperitoneal space [superficial parietal layer (anterior subperitoneal fascia) and deeper visceral layer (posterior subperitoneal fascia)] and peritoneum. | DVL: Deeper visceral layer; IAOM: Internal abdominal oblique muscle; IL: Inguinal ligament; PPS: Preperitoneal space; SPL: Superficial parietal layer; TF: Transversalis fascia. | Yasukawa, D., Aisu, Y., & Hori, T. (2020). Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults. World journal of gastrointestinal surgery, 12(7), 307–325. https://doi.org/10.4240/wjgs.v12.i7.307
Hasselbach’s triangle:
Formed by the inguinal ligament inferiorly, inferior epigastric vessels laterally, and the rectus abdominis muscle medially
“All groin (inguinofemoral) hernias originate in a single weak area called the myopectineal orifice. This oval, funnel-like, ‘potential’ orifice formed by the following structures, makes the ‘myopectineal orifice of Fruchaud’.” -Henry Fruchaud
CHOI, B. B., STECKEL, J., DENOTO, G., VAUGHAN, E. D., & SCHLEGEL, P. N. (1999). PREPERITONEAL PROSTHETIC MESH HERNIOPLASTY DURING RADICAL RETROPUBIC PROSTATECTOMY. The Journal of Urology, 161(3), 840–843. https://doi.org/https://doi.org/10.1016/S0022-5347(01)61786-5
Trapezoid of disaster:
Triangle of doom (medial): Inverted V-shaped area bound laterally by the gonadal vessels and medially by the vas deferens in male patients, or the round ligament in female patients. The EIA, external iliac vein, deep circumflex iliac vein, genital branch of the genitofemoral nerve, and femoral nerve are involved in this area.
Triangle of pain (lateral): Involves the femoral branch of the genitofemoral nerve, lateral femoral cutaneous nerve, femoral nerve, and the anterior cutaneous branch of the femoral nerve. Even a subtle injury to the nerves located within the triangle of pain is a risk factor for intractable pain.
Triangle of doom and triangle of pain should be adequately recognized by the surgeon: Triangle of doom is an inverted V-shaped area bound laterally by the gonadal vessels and medially by the vas deferens in male patients, or the round ligament in female patients. The EIA, external iliac vein, deep circumflex iliac vein, genital branch of the genitofemoral nerve, and femoral nerve are involved in this area. Area of the triangle of pain involves the femoral branch of the genitofemoral nerve, lateral femoral cutaneous nerve, femoral nerve, and the anterior cutaneous branch of the femoral nerve. Even a subtle injury to the nerves located within the triangle of pain is a risk factor for intractable pain. | ARM: Abdominal rectal muscle; EIA: External iliac artery; EIV: External iliac vein; Gb-GFN: Genital branch of the genitofemoral nerve; IPT: Iliopubic tract; LFCN: Lateral femoral cutaneous nerve; VD: Vas deferens. | Yasukawa, D., Aisu, Y., & Hori, T. (2020). Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults. World journal of gastrointestinal surgery, 12(7), 307–325. https://doi.org/10.4240/wjgs.v12.i7.307
Importance of upward view: A: The triangle of doom and triangle of pain configure a unique rhombus around the inferior epigastric artery (IEA). Adequate change of laparoscopic view during transabdominal preperitoneal (TAPP) is very important. B and C: Although downward view requires safe preservation of the vas deferens and gonadal vessels and sure exposure of Cooper’s ligament, downward view may easily mislead surgeons causing unexpected injuries of topographic nerves and vessels. D and E: Generally, a unique rhombus around the IEA seems to be a triangle on the upward view, and the abdominal rectal muscle (ARM) is simultaneously observed at the roof. Thus, intraperitoneal anatomy including the ARM should be simultaneously recognized by upward view, for optimal mesh placement during TAPP. | ARM: Abdominal rectal muscle; VD: Vas deferens. | Yasukawa, D., Aisu, Y., & Hori, T. (2020). Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults. World journal of gastrointestinal surgery, 12(7), 307–325. https://doi.org/10.4240/wjgs.v12.i7.307
Coronal mortis “Circle of death”:
Arterial anastomosis between the obturator artery and the inferior epigastric artery via the ectopic obturator artery. The existence of the obturator artery results in annular communication between the inferior epigastric artery, common iliac artery, internal iliac artery, external iliac artery, and obturator artery. There may be several variants of anastomosing vascular branches. Brisk bleeding is difficult to control because of the dual vascular supply from the obturator and iliac vessels.
Corona mortis and complicated vascular connection between the epigastric and obturator vessels: The corona mortis is classically defined as the arterial anastomosis between the obturator artery and the inferior epigastric artery via the ectopic obturator artery. The existence of the obturator artery results in annular communication between the inferior epigastric artery, common iliac artery, internal iliac artery, external iliac artery, and obturator artery. There may be several variants of anastomosing vascular branches. Brisk bleeding is difficult to control because of the dual vascular supply from the obturator and iliac vessels. | Yasukawa, D., Aisu, Y., & Hori, T. (2020). Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults. World journal of gastrointestinal surgery, 12(7), 307–325. https://doi.org/10.4240/wjgs.v12.i7.307
Classification
Degree of inguinal hernia:
Bubonocoele: Hernia limited to inguinal canal
Funicular: Hernia stops above testes
Complete/inguinoscrotal: Hernia reaches bottom of scrotum
Nyhus classification:
Categories hernia defects by size, location, and type. M/widely accepted classification system
Gilbert classification:
European Hernia Society (EHS) classification:
EHS classification, based on Aachen system defines the location of hernia with L: lateral, M: medial, and F: femoral. The size of hernia is indicated with 1: ≤one finger, 2: one-two fingers, and 3: ≥three fingers. If the patient has two types of hernia together (e.g., direct+indirect, direct+femoral, indirect+femoral) appropriate boxes in the table are ticked. In addition, P or R letter is encircled for a primary or recurrent hernia.
The EHS groin hernia classification. | Kulacoglu H. (2011). Current options in inguinal hernia repair in adult patients. Hippokratia, 15(3), 223–231.
Special inguinal hernias:
Gibbon hernia: Inguinal hernia + hydrocele
Pantaloon hernia: Direct + indirect inguinal hernia
Sliding hernia ‘Hernia en Glissade’: Posterior boundary formed by viscera
Sportsman hernia ‘Gilmore groin’: Painful hernia due to teat in posterior wall muscle
Spigelian hernia (hernia of linea semilunaris): Hernia occurs though spigelian fascia (aponeurosis of transverse abdominis), behind an intact external oblique aponeurosis (thus no mass on presentation, only local pain)
Oglive’s hernia: Hernia through conjoint tendon
Maydl’s hernia/Hernia-en-W/retrograde hernia: 2 loops of bowel remain in sac with connecting loop inside abdomen
Richter’s hernia: Small portion of antimesenteric wall of intestine trapped within hernia
Special femoral hernias:
All are prone to strangulation
Laugier’s hernia: Through lacunar (Gimbernat’s) ligament
Narath’s hernia: Femoral hernia in congenital dislocation of hip (CDH), occuring behind femoral vessels
Cloquet’s hernia: Sac lies under pectineus fascia
Hasselbach’s hernia: Hernia lies lateral to femoral artery
Velpeau (prevascular/Teale’s) hernia (prevascular hernia): Lies anterior to femoral vessels
Beclard’s hernia: Through saphenous opening
Aetiology
Risk factors:
9:1 male predominance with a higher incidence among men 40 to 59 years of age.
Diagnosed hiatal hernia (2x risk of an inguinal hernia)
Taller height
Chronic cough
Neither smoking nor alcohol use has been shown to affect hernia occurrence.
Low BMI (overweight/obese are at a lower risk)
Clinical features
Inguinal hernias present with a lump in the groin that goes away with minimal pressure or when the patient is lying down. Most cause mild to moderate discomfort that increases with activity. A third of patients scheduled for surgery have no pain, and severe pain is uncommon.
Bulge in groin area made more prominent by actions that increase intra-abdominal pressure (i.e., coughing, straining, lifting, standing) [2].
Stretching/tearing of tissue around the hernia: Localized burning, aching, and dragging sensation
Pain worse at the end of the day or after extended activity and further aggravated by defecation, urination or sexual intercourse.
Physical examination:
Deep ring occlusion test (single best test)
Ziemann 3-finger test
Ring invagination test
Diagram illustrates the imaging landmarks used for localization of the deep inguinal ring of the IC, as shown on the transverse view through the right side of the abdomen. The deep inguinal ring is lateral to the origins of the inferior epigastric artery (IEA) and inferior epigastric vein (IEV). These vessels are posterior to the lateral border of the rectus abdominis muscle, approximately 2 cm below the umbilicus. | ASIS = anterior superior iliac spine, EIA = external iliac artery, EIV = external iliac vein, ST = soft tissues. | Revzin, M. V, Ersahin, D., Israel, G. M., Kirsch, J. D., Mathur, M., Bokhari, J., & Scoutt, L. M. (2016). US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation. RadioGraphics, 36(7), 2028–2048. https://doi.org/10.1148/rg.2016150181
Complications
Strangulation (M/C complications, 1-3% of groin hernias): More commonly seen in extremes of life
Incidence: Femoral (M/C) >> Indirect inguinal > Direct inguinal
C/F: Tenderness (first sign)
℞: Immediate surgical repair
Diagnosis
Ultrasonography:
(a, b) Ultrasound images of direct/indirect inguinal hernias (From Ultrasound of the gastrointestinal tract, abdominal hernias, volvulus, and intussusception, 2012, Vijayaraghavan SB, Fig. 5b,c. , Springer Science and Business Media
Differential diagnosis:
Varies according to the clinical presentation.
Groin mass: Lymphadenopathy, a soft-tissue tumor, or an abscess
Scrotal masse: Hydrocele or testicular tumor
Symptoms consistent with groin hernia but without a mass: Epididymitis, local musculoskeletal abnormalities (e.g., arthritis of the hip, osteitis pubis, or tenosynovitis), nerve-root compression, and renal calculi.
Syndromes in Athletes (have symptoms suggestive of a hernia): Athletic pubalgia, femoral acetabular impingement, and adductor longus tendinopathy.
Management
Observation:
Watchful waiting is a safe approach for asymptomatic male patients with inguinal hernia, but data from randomized trials suggest that the majority of men will ultimately be referred for surgery, primarily because of pain, within 10 years.
Herniotomy:
Involves reduction/removal of the hernial sac only. It is performed in pedriatic cases as hernia occurs due to presence of patent processus vaginalis and not due to the wekening pf abdominal muscles or ligaments.
The steps of the subcutaneous endoscopic assisted ligation (SEAL) technique.
Open suture/tissue herniorrhaphy:
Open surgery using sutures to repair the weakness in the muscles and fascia through which the hernia sac has protruded.
Bassini procedure: Suture conjoint tendon with reflected portion of inguinal ligament
McVay procedure (Cooper’s ligament repair) (only one that can be used with femoral hernias, but also used for direct inguinal hernias, large indirect hernias, recurrent hernias)
Prosthetic repairs are preferred over native tissue repair due to lower incidence of recurrence. Open surgery in which a synthetic mesh is inserted across the posterior wall of the inguinal canal to repair the weakness in the muscles and fascia through which the hernia sac has protruded. Mesh repairs are contraindicated in a contaminated field due to the high rate of infection.
Lichtenstein tension-free repair (M/C worldwide, and preferred)
Prolene hernia system (PHS)
Stoppa procedure: Open preperitoneal repair (forms the basis of laparoscopic TEP procedure) in which a large mesh is placed in retrimuscular space over posterior rectus sheath or peritoneum. The mesh isn’t sutured and is held in place by expanding intra-abdominal pressure as per Pascal’s law
Choice of mesh: Low-weight, thin fibre, large pored mess preferred (polene, M/C used)
Open mesh repair of an inguinal hernia | Jenkins, J. T., & O’Dwyer, P. J. (2008). Inguinal hernias. BMJ (Clinical research ed.), 336(7638), 269–272. https://doi.org/10.1136/bmj.39450.428275.AD
Uses mesh to repair the weakness in the muscles and fascia through which the hernia sac has protruded. This technique involves entering the peritoneum with the laparoscope, although the repair itself (done with a mesh) is undertaken anterior to the peritoneum.
Useful for bilateral hernia repair, large hernia defects, and recurrence after open repair.
Laparoscopic view at the groin. A: Laparoscopic view focused on the relation between the plicae and the hernial defect. B and C: The actual view (B) and schema (C) are shown. Laparoscopic view with pneumoperitoneum has a significant advantage for easy, accurate diagnosis without any missed evaluations because the plicae and fossae precisely indicate hernia defects. | DIH: Direct inguinal hernia; IIH: Indirect inguinal hernia; MUP: Medial umbilical plica; LUP: Lateral umbilical plica; VD: Vas deferens. | Yasukawa, D., Aisu, Y., & Hori, T. (2020). Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults. World journal of gastrointestinal surgery, 12(7), 307–325. https://doi.org/10.4240/wjgs.v12.i7.307
Uses mesh to repair the weakness in the muscles and fascia through which the hernia sac has protruded. This technique does not involve entering the peritoneum with the laparoscope
Laparoscopic Totally extraperitoneal
(TEP) herniorrhaphy: The creation of a preperitoneal working space for a laparoscopic totally extraperitoneal herniorrhaphy with the use of a dissecting balloon is shown. Some surgeons prefer to perform the dissection directly, to avoid the expense of the disposable dissecting balloon. | Fitzgibbons, R. J., & Forse, R. A. (2015). Groin Hernias in Adults. New England Journal of Medicine, 372(8), 756–763. https://doi.org/10.1056/NEJMcp1404068
Femoral hernia surgery:
Lockwood’s low inguinal surgery: Simplest surgery for femoral hernias, suitable only when no risk of bowel resection is present.
McEvedy’s high inguinal surgery: Preferred in emegencies where risk of bowel infarction is high
Lotheissen’s inguinal surgery
Henry procedure: Mid abdominal extraperitoneal femoral hernioplasty
McVay procedure: Can be performed for both inguinal & femoral hernias
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