Groin hernia, inguinal or femoral: diagnosis, when to consult, when and how to operate?
140,000 groin hernias are operated on each year in France. Hernia surgery is one of our privileged areas of expertise, the intervention most often takes place on an outpatient basis (hospitalization for a few hours) .
The cause of the hernia is not easy to demonstrate, contrary to popular belief, it is not physical exertion that creates the groin hernia. see our blog post: “Hernia and physical effort: no cause and effect!” voir notre billet de blug:”Hernie et effort physique: pas de cause à effets !”
A hernia is the passage, through an area of weakness in the abdominal wall, of part of the contents of the abdominal cavity.
Groin hernia is the appearance of a bulge above the fold of the groin.
The presence of a bulge in the groin is often the first manifestation of hernia. Discomfort at this level can also be a telltale sign.
When there is an groin area discomfort, especially after physical exertion, but in the absence of a visible or palpable lump, it is probably not a hernia. Even if an ultrasound of the groin "shows" a weakness at this level. It is then recommended to be examined by a surgeon at least partially specialized in parietal surgery in order to establish a "good" diagnosis. Surgery for groin pain with the presence of an “ultrasound” hernia, but in the absence of true parietal weakness, would lead to poor functional results with the risk of chronic pain, for example. A French study has demonstrated the uselessness of ultrasound (https://www.club-hernie.com/fr/publications/hernies-de-l-aine-l-echographie-un-examen-inutile) demonstrating that it is the clinical examination by the specialist that makes the diagnosis.
Once diagnosed, it is accepted that most hernias need to be treated surgically. Some hernias are dangerous in the short term and must be operated on without delay, others can be programmed, some simply monitored (small asymptomatic hernia). Any suspicion of hernia (detected by the patient himself, or by the General Practitioner, etc.) must therefore give rise to a consultation with a specialized surgeon.
Too often, inguinal hernias are operated on too late, in an emergency, in a context of hernial strangulation (intestinal obstruction, etc.), sometimes requiring intestinal resections and posing vital risks to patients, especially the elderly or the more fragile. Moreover, parietal repair performed in an emergency often does not allow the use of prosthetic material. The repair is then less reliable, exposing the patient to an increased risk of recurrence. In this emergency context the intervention carried out by a non-specialist surgeon could have a less good result.
The hernia bandage, a principle of protection that was useful before the advent of effective surgical techniques, is today very poorly adapted, and most often restrictive, it has practically no place anymore.
The purpose of the consultation with the specialist is to assess the benefit/risk ratio of the surgical cure of the hernia, knowing that there is no alternative treatment in this context.
The decision to operate may be based, if necessary, on a consultation in cardiology or pulmonology or geriatrics or another specialty, sometimes with the prescription of biological assessments. A second surgical consultation analyzing these results may be necessary.
Of course in all cases a thorough anesthesiology consultation will make the synthesis.
The notion of the care pathway is essential, (See Ref. Blog post on the care pathway, Le parcours de soins pour le traitement d’une hernie de l’aine) and in all cases, in addition to the detailed information given to the patient during the first preoperative consultation, we provide the patient a information with very precise information concerning the aims of the intervention, the types of techniques, and the surgical consequences usually expected, the information gives him indications on the general behavior to adopt in the days and weeks following the intervention in terms of activities physical… The form accompanied by the prescription and the duplicate of the letter addressed to the general practitioner indicate the simple local treatments to be carried out most often by the patient himself. The patient is thus instructed on the events which could worry him but which do not constitute a complication, or on the contrary on those which must give rise to a specific unscheduled postoperative consultation (the personal telephone number of the surgeon being always accessible in particular in the context of outpatient surgery) either in the surgeon's office or in the emergency department of the clinic (open 24 hours a day) where the intervention was carried out. See the sheet dedicated to groin hernia (https://www.fcvd.fr/wp-content/uploads/2022/01/FICHE-D_INFORMATION-PATIENT-HERNIES-DE-LAINE.pdf fiches patients téléchargeables)
The possible stoppage of work is precisely organized during the preoperative consultation.
In our practice, the patient is systematically seen again on the 10th and 30th postoperative day, information is collected at 3 months by phone, sms, email or other… The patient is reviewed in the office for a complete clinical examination at one year. A patient call is scheduled at 2 years by an independent clinical research assistant. A prolonged follow-up can even be planned (5 years) within the framework of our long-term prospective studies.
This program was designed to collect useful data allowing optimal patient monitoring and scientific analysis allowing our studies to advance our specialty.
We are particularly interested in the surgery of hernias of groin in the elderly patient, or particularly fragile, it is particularly in them that a hernia should not be neglected. Our studies have shown, after analysis of the database of our learned society (Link: www.club-hernie.com/fr/), that there were no more postoperative complications in our seniors over 90 years old when the hernia was operated “cold” and therefore programmed. This is not the case when the hernia is operated on at the strangulation stage, the vital prognosis can then be engaged.
Our minimally invasive technique is particularly suitable for these very old or very fragile patients, even in this context, we favor outpatient care so as not to "disconnect" the patient from his usual environment, and thus aggravate possible cognitive disorders ( loss of bearings, disorientation, etc.).
TECHNICAL NOTIONS
We are pioneers in the development of a minimally invasive technique. Surgery through a single inguinal orifice, called the Minimal Open Pre Preperitoneal technique.
This is the culmination of a long journey aimed at concretizing older work, and to define a minimally invasive surgical technique effective for most hernias and particularly for the most fragile or elderly patients.
Blog article reference: “Our contribution to the evolution of ideas concerning groin hernia surgery: History of the main currents, our contribution to minimally invasive surgery, called Minimal Open Pre Peritoneal (MOPP).”
For this technique we have created a specific instrumentation: See our blog post “Creation of an Instrumentation used for the cure of groin hernias according to the minimally invasive technique, MOPP, in order in particular to set up the prosthesis”. We also created specially adapted prostheses which helped us a lot at the beginning of our experience. See the Blog post: “Creation of parietal reinforcement protheses"
Large prosthesis through a single orifice
The skin incision located in the lower part of the inguinal region (hidden by underwear) is deliberately reduced. It measures between 25 and 35 millimeters . We place the reinforcement prosthesis throught this hole. It is a mesh, a tulle or a veil (the old term "plate" is really not suitable).
The scar of the single orifice is aesthetic, it does not require post-operative care other than the change of the dressing by the patient himself after the shower for a week..
It is sometimes contraindicated to use this technique for patients who have already undergone hernia surgery, either in childhood (without prosthesis), or in adulthood by Shouldice or Lichtenstein techniques. So I use the Ugahary technique which is also minimally invasive, and which makes it possible to put in place a large prosthesis, The Ugahary is our reference technique in these specific cases and I am a specialist in this technique and its promoter in France. See Ref:005_2004_3_3_28x33.pub (academie-chirurgie.fr), and our Blog post: “La technique de Ugahary. Cure des hernies de l’aine par grande prothèse pré- péritonéale par voie inguinale latérale.”
For patients who recur after an endoscopic technique (coeliosurgery), or for the rare patients who recur after our reference technique (well under 1%), I use the Lichtenstein technique with a good final result. the same is true for most patients who have undergone interventions in the small pelvis (prostatectomy, intervention on the bladder, arterial bypass, radiotherapy, etc.), they are most often operated on according to the Lichtenstein technique, according to the recommendations officially admitted. Ref: cov13178_ehs_groin_hernia_management_a5_fr_10_lr_0.pdf (europeanherniasociety.eu)