Inguinal hernia of the woman
General
Inguinal hernias are much rarer in women than in men; for every female patient with an inguinal hernia, there are 8 male patients with the same clinical picture. There are direct and indirect inguinal hernias that enter the inguinal canal at different points, but both leave the inguinal canal at the so-called outer inguinal ring.
In women, the indirect (or also lateral) Inguinal hernia more often, the hernial sac enters the inguinal canal at the inner inguinal ring, a muscular area of the abdominal wall, and then runs together with the uterine ligament (Lig. Teres uteri) to the outer inguinal ring and then emerges together with this band at the outer inguinal ring and can then be palpable as a protrusion in the inguinal region. Organs of the abdominal cavity such as parts of the intestine can be found in the hernial sac.
Read more on the topic: Inguinal hernia in women
causes
On the Muscle layer of the abdominal wall there is always a burden in the groin region Pressure from the organs in the abdomen. When carrying heavy things or when coughing, sneezing and using the toilet, the pressure on this muscle wall increases. Usually the muscle wall can withstand these pressures without any problems. But either the Pressure too big or the Muscle wall too weak, an inguinal hernia can occur. During pregnancy, the pressure on the muscle wall in the groin region is particularly great, which is why inguinal hernias occur more often than usual during pregnancy. Inguinal hernias in women can also occur through weak connective tissue or hormonal influencesthat lead to a breakdown of the connective tissue are favored.
Symptoms and complications
A complete hernia in women usually manifests itself through one Bulging or thickening in the lower abdomenthat can be painful. The Pain in an inguinal hernia mainly occur when lifting or using the abdominal press on. The size of the hernia does not correlate with the extent of the discomfort. An incomplete inguinal hernia also causes problems in the groin, but most of the time you cannot feel a bulge here. The pulling or pressing pains are the only symptom. Of the Hernial sac can be organs of the abdominal cavity, especially Intestines contain. An inguinal hernia can be dangerous if these parts of the intestine remain trapped in the hernia, as the intestine swells as a result of this trapping and from the Blood supply cut off becomes. This complication is called the Incarceration referred to, the affected section of the intestine may die or a Ileus (Intestinal obstruction) arise. Another possible complication is the inflammation of the contents of the hernia.
diagnosis
The examination by the doctor usually takes place while lying down. The doctor places a hand in the groin region and tries one Bulging, thickening or one Palpate a gap in the abdominal wall. In order to improve the examination conditions, the patient can to cough or the Tense the abdominal wall. Any inguinal hernias will then appear more clearly. Nevertheless, the diagnosis of an inguinal hernia can be made without a protruding hernial sac difficult in women be. The diagnosis can be confirmed by an ultrasound examination or, in more complicated cases, by magnetic resonance imaging (MRI).
Illustration of the types of an inguinal hernia
- Peritoneal cavity -
Cavitas peritonealis - Abdominal viscera
- Peritoneum -
peritoneum - Glued peritoneum protuberance
- Vas deferens -
Deferens duct - Epididymis -
Epididymis - Testicles -
Testis - Serous testicular envelope -
Tunica vaginalis testis - Scrotum - scrotum
- Inguinal ligament -
Inguinal ligament - Hernial sac
Inguinal hernia - Inguinal hernia
Inguinal hernia types:
a - Epigastric hernia
(in the upper abdomen on the midline) -
Epigastric hernia
b - umbilical hernia -
Umbilical and paraumbilical hernia
c - hernia
(at the location of a previous
surgical intervention) -
Hernia cicatrica
d - Direct inguinal hernia
(in the bar near the
Opening of the inguinal canal)
e - Indirect inguinal hernia
(in the bar at the opening
of the inguinal canal)
f - femoral fracture
(in the thigh canal) -
Femoral hernia
You can find an overview of all Dr-Gumpert images at: medical illustrations
therapy
An inguinal hernia must be treated surgically due to the risk of incarceration. In 90% of the cases, an intervention under regional anesthesia is possible, but the operation should be laparoscopic (Laparoscopy = abdominal examination), the procedure must be performed under general anesthesia. The operation of the inguinal hernia takes place in three steps. In the first step, an incision is made in the groin, the muscle wall is cut and the hernial sac is found. In the second step, the hernial sac is opened, then the contents of the hernia are shifted back into the abdomen and the hernial sac is closed with sutures. In the third step, the hernia is closed. The hernial port closure is based on the principle of reinforcing the posterior wall of the inguinal canal. The posterior wall of the inguinal canal faces the abdomen and can be reinforced by two different methods. The reinforcement can be done by a gathering suture and the doubling of the muscle fascia, this method can be found, for example, in the operation according to Bassini or in the operation according to Shouldice. In women, the inguinal canal can be tightly closed around the uterine ligament or that Lig. Teres uteri can be cut to allow closure of the inguinal canal. Another surgical technique achieves the reinforcement by a tension-free implantation of a plastic mesh, which can be done either in an open or a laparoscopic operation. This technique is used, for example, in the operating room in Liechtenstein.
Duration of the operation
Exactly how long the operation of an inguinal hernia takes depends on the type of procedure. A distinction is made between open and laparoscopic (minimally invasive) procedures. On average, the operation takes about half an hour. It should be noted, however, that the patient must initiate the operation before the operation and that additional time in the recovery room is required after the operation. This means that the overall duration of the operation is significantly longer.
Do you always need an operation?
Surgery is not always necessary for an inguinal hernia. For example, if the break is an incidental finding and shows no or only very few symptoms, so-called “watchful waiting” can take place. Regular checks of the symptoms and the hernial sac are carried out in order to rule out any deterioration. Symptomatic inguinal hernias are usually operated on. An exception is the trapping of a hernial sac, which is always operated on immediately.
The choice of surgical procedure depends primarily on whether a hernia has already occurred in the past. A distinction is made between open and minimally invasive (laparoscopic) surgical techniques:
- an open, surgical treatment of hernias is usually done with a mesh insert that supports the breakthrough in addition to the suture (Liechtenstein procedure).
- Laparoscopic procedures are the so-called Tapp (transabdominal preperitoneal plastic) and the TEP (total extraperitoneal plastic).
forecast
The The prognosis is good, the recurrence rate is between 2-10% depending on the surgical method.
Inguinal hernia in pregnancy
There is an increased risk of an inguinal hernia during pregnancy. The reason for this is the increased pressure within the abdominal cavity and a weakness in the abdominal wall muscles. The constant pressure in the abdomen, which increases steadily, leads to a decrease in the abdominal wall through which the intestines emerge. Furthermore, the typical weak points are additionally weakened by a decrease in the strength of the muscles. Therefore, a hernia occurs more often in pregnant women, which is usually noticeable during a prenatal check-up or by a given symptomatology.
Inguinal hernias during pregnancy are usually not treated surgically or only after the birth. Since such an inguinal hernia is almost always caused by pregnancy, this trigger disappears after the birth, which is why one often waits. If the symptoms do not improve after the birth, an operation is appropriate.
If complications or severe pain occur during pregnancy, the hernia is operated on early.
Different forms of hernia in women
Indirect inguinal hernia
In indirect or "lateral" (external) inguinal hernias, the hernial sac enters the canal through the inner ring of the inguinal canal. There the hernial sac accompanied, among other things, the uterine ligament (ligamentum teres uteri), which extends from the uterus to the labia. The hernial sac then exits through the outer ring of the inguinal canal, above the inguinal ligament, and is usually palpable there.
Indirect inguinal hernias can be congenital or acquired during life. In contrast to men, the hernia accompanies the uterine ligament and not the spermatic duct. Since men have larger structures within the inguinal canal, the inner ring, i.e. the entry portal, is enlarged. This is why an inguinal hernia is much more common in men.
Direct inguinal hernia
With a direct or "medial" (central ") inguinal hernia, the hernial sac emerges through a weak point in the abdominal muscles. The hernia does not enter the inguinal canal through the inner ring, but only accompanies it in its course. Since the hernial sac does not break through the inguinal canal but directly through the abdominal wall, this hernia is also known as a "direct inguinal hernia".
Direct hernias are always acquired, usually due to increased pressure. Your classic entry point is the so-called "Hesselbach triangle". This is the name given to the weak point in the muscles that typically exists in humans, which is projected relatively centrally on the stomach.
Congenital inguinal hernia
Congenital inguinal hernias occur primarily in newborns and young children. During embryonic development, structures that pull into the inguinal canal and traverse it sink. The peritoneum is carried along, creating a natural connection between the abdominal cavity and the groin. The connection usually grows together very early. However, if it persists, an inguinal hernia occurs early on, which is usually noticeable by a reddened swelling.
Congenital inguinal hernias are therefore always indirect hernias, as they work their way through the inner ring of the inguinal canal.
Which inguinal hernia is more common in women: right or left?
Women make up only about 10-20% of the total number of inguinal hernias. About two thirds are indirect inguinal hernias and one third are direct inguinal hernias.
In indirect and / or congenital inguinal hernias, the right side is affected significantly more often. This is probably due to embryonic development-related causes and is probably related to the width of the inguinal canal.
In the case of direct inguinal hernias, the probability of occurrence is not differentiated between right and left.
Examination for an inguinal hernia
The examination of an inguinal hernia is carried out both in a lying position and in a standing position and is divided into an inspection (appraisal) and a palpation (palpation).
First of all, it is observed whether there is any protrusion or asymmetry when standing. This is then examined under increased pressure by the patient coughing or pressing.
Then the hernia is examined by feeling for its consistency, its position, any pain and possible reduction (pushing it back into the abdomen). The same examinations are then carried out again in a lying position, whereby it is also observed whether the hernia regresses by itself when lying down.
What are the typical signs?
The typical sign of an inguinal hernia is a visible and palpable swelling. This is usually located in the groin region, but can show up in the later stages in women in the labia. The protrusion of a hernial sac, which can be felt through the skin, is usually expressed as soft, elastic and easy to move.
In addition to the swelling, there is often a pulling in the groin area that is aggravated by increased pressure in the abdomen (e.g. from coughing, sneezing, lifting heavy loads or during bowel movements). More rarely, stronger resting pains are also described, which also occur in the groin.
Can I recognize an inguinal hernia myself?
Whether an inguinal hernia can also be recognized by a medical “layperson” depends on the extent of the hernia and the level of knowledge of the person concerned. Inguinal hernias are usually recognized by themselves, especially in younger patients. In toddlers and babies, they are often noticed by the mother or father.
It is very useful to pay attention to changes in your own body, as you always have the best overview yourself and therefore small changes can be noticed early on. In order to be able to infer an inguinal hernia from this, the above criteria are well suited to get a first impression. However, a final diagnosis can only be made by the doctor, which is why a doctor's visit should always be made within a shorter period of time.
Pain from an inguinal hernia
Inguinal hernia pain usually manifests itself as pulling pain that radiates into the entire groin and increases with manipulation. A manipulation takes place, for example, by touching the hernia or by pressing attempts, which increase the pressure in the abdomen.
If there is an increase in pain within a short period of time with possibly additional nausea and vomiting, a doctor or an emergency room should be consulted immediately, as the hernial sac could become trapped and thus an emergency.
Which doctor is responsible for an inguinal hernia in women?
As a rule, the doctor responsible for inguinal hernias is the general or visceral surgeon. However, hernias are usually discovered by the family doctor or gynecologist. They either decide for themselves whether an operation is necessary and refer the affected person to the surgeon if necessary, or refer the patient directly to the surgeon. The latter selects the procedure and performs the operation.
Follow-up care is in turn taken over by the respective family doctor.
