1. Muysoms F, Campanelli G, Champault GG, DeBeaux AC, Dietz

UA, Jeekel J, et al. EuraHS: the development of an international online platform for registration and outcome measurement of ven­tral abdominal wall hernia repair. Hernia. 2012;16(3):239–50.

2. Muysoms FE, Deerenberg EB, Peeters E, Agresta F, Berrevoet F,

Campanelli G, et al. Recommendations for reporting outcome results in abdominal wall repair: results of a Consensus meeting in Palermo, Italy, 28–30 June 2012. Hernia. 2013;17(4):423–33.

6. Fink C, Baumann P, Wente MN, Knebel P, Bruckner T, Ulrich A,

et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg. 2013;101(2):51–4.

7. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J,

Cuccurullo D, et al. European Hernia Society guidelines on the clo­sure of abdominal wall incisions. Hernia. 2015;19(1):1–24.

8. Helgstrand F, Rosenberg J, Bay-Nielsen M, Friis-Andersen H, Wara

As many as 30 % of the patients presenting with an ingui­nal hernia are asymptomatic and up to 50 % of the patients are unaware of their inguinal hernia [2]. Less than 3 % of patients diagnosed with inguinal hernia experience incarcer­ation, if a nonoperative strategy is chosen [3]. Emergency procedures account for 5–10 % of all inguinal hernia repairs, and are almost solely performed due to incarceration [4]. In women, femoral hernias account for 15 % of elective groin hernia repair, whereas 53 % of emergency groin repairs are femoral [5]. In men, the same trend is observed, as elective femoral hernia repair make up less than 1 % of all groin her­nia repairs, compared to 7 % in an emergency setting [5]. Importantly, emergency femoral hernia repair is associated with a sevenfold increased 30-day mortality compared to the background population [5].

24

This is due to the weakness in the inguinal canal through which the testicle descends in early life. As stated, studies suggest that almost one in two men will have an inguinal hernia at some point during their lifetime if they live to become more than 75 years old, and the lifetime risk of inguinal hernia repair for men is 25 % [4, 10, 12]. Contrary, the lifetime risk of inguinal hernia repair in women is <5 % [4]. The incidences of inguinal hernia repair increase almost exponentially for men during their third decade and onward, whereas the corresponding incidence for women exhibits a slow increase with increasing age [9]. The distribution of the types of groin hernia varies by gender. In women, femoral hernia is the second-most common type of groin hernia, fol­lowed by direct and pantaloon inguinal hernia [13]. In men, direct hernia is the second-most common, followed by pan­taloon hernia, while femoral hernias are rare (Fig. 4.2) [13].

Several studies have reported a positive family history of inguinal hernia to be associated with an increased incidence of inguinal hernia, as reflected by adjusted odds ratios as high as 4–8 compared with families without a history of inguinal hernia [14, 15]. Whether this is partly due to increased patient awareness remains unknown. Furthermore, there seems to be an increased risk of inguinal hernia regard­less of which family member has a positive history (parents or siblings). Of note, twin studies on inguinal hernias of mono- and dizygotic twins have led to conflicting results

Several studies on the association between inguinal hernia and a physically demanding occupation have been con­ducted. Most of these studies include only men, due to the low incidence of inguinal hernia in women. A Spanish case­control study reported increased risk of inguinal hernia in men holding occupation of medium to high physical effort [18], a finding confirmed by a large-scale American cross­sectional study in which sanitation workers were compared to non-sanitation workers [19]. Contrary, a prospective cohort study did not find any association between self­reported non-recreational physical activity and inguinal her­nia [12]. One reason for these conflicting results may be the pooling of direct and indirect hernias, as a recent register study differentiating between the types of hernia found that indirect hernias are more frequent after exposure to lifting activities and prolonged standing/walking at work [20]. However, until further literature on this potential association emerges, no association between occupation and the risk of inguinal hernia development can be confirmed.

Several comorbidities, some of which are associated with altered collagen metabolism, have been proposed to be asso­ciated with inguinal hernia formation. It has been suggested

that patients diagnosed with aortic abdominal aneurism or thoracic aortic disease are predisposed to inguinal hernia for­mation, but the evidence on this is inadequate [23, 24]. Ehlers–Danlos syndrome, characterized by altered collagen metabolism, increases the risk of inguinal hernia by a factor 4–5 depending on gender [25].

Smoking does not alter the risk of a primary inguinal her­nia [12, 15, 21]. Conditions resulting in increased intraab­dominal pressure have been reported to increase the risk of developing an inguinal hernia. In one study it was found that

26

In summary, several risk factors for development of pri­mary and recurrent inguinal hernia exist, although there is dis­crepancy between factors associated with primary and recurrent hernias. Future research in inguinal hernia epidemiology might focus on identifying the patients best suited for a tailored surgi­cal approach according to recognized risk factors.

41. Rosemar A, Angeras U, Rosengren A, Nordin P. Effect of body mass index on groin hernia surgery. Ann Surg. 2010;252:397–401.

42. Junge K, Rosch R, Klinge U, Schwab R, Peiper C, Binnebosel M, Schenten F, Schumpelick V. Risk factors related to recurrence in inguinal hernia repair: a retrospective analysis. Hernia. 2006;10: 309–15.

43. Sorensen LT, Friis E, Jorgensen T, Vennits B, Andersen BR, Rasmussen GI, Kjaergaard J. Smoking is a risk factor for recur­rence of groin hernia. World J Surg. 2002;26:397–400.

The inguinal, or “groin” area of the human abdominal wall, is bound by the thigh inferiorly, the pubic tubercle medially, and the anterior superior iliac spine (ASIS) supero­laterally. The “watershed” area of weakness of the inguinal region is the acquired inguinal canal. The inguinal canal is an oblique passage connecting the peritoneal surface of the abdomen to the scrotum or, in females, the labia majoris. It is bound by a pair of openings called the deep (or posterior) inguinal ring and the superficial inguinal ring anterior and external to the abdominal cavity. The inguinal rings are thought to overlie each other at birth and separate in a super­olateral to inferomedial orientation by adulthood. In the average adult, the inguinal canal is 4–5 cm long. The bound­aries of the inguinal canal, discussed later in this text, become important in understanding surgical approaches to hernias formed in this region. The structure central to the anatomy and repair of this region is the inguinal ligament, otherwise known as the Poupart ligament, which is formed from the external oblique aponeurosis as it folds over and inserts from the ASIS to the pubic tubercle.

grows into the mesenchyme of the gubernaculum and forms the

processus vaginalis. The processus vaginalis extends through

the inguinal canal into the scrotum, forming, with the layers of

the spermatic cord, what is called the inguinal bursa…

Presumably guided by the gubernaculum, the testis slides down

from the posterior abdominal wall, through the inguinal canal,

to pass retroperitoneally outside and behind the processus vagi-

nalis, but within the sleeve of the internal spermatic fascia [2].

At this point, the gubernaculum will shorten and eventu­ally become indistinguishable and will persist only as the tunica vaginalis.

3. Innominate fascia (of Gallaudet). This is the superficial

4. External oblique aponeurosis, including the inguinal

Inguinal region anatomy is illustrated in Fig. 5.1.

• Floor—Inguinal (Poupart’s) ligament and medially by the lacunar (Gimbernat’s) ligament.

The male inguinal canal contains several structures of

importance:

internal oblique muscle and fascia

transversalis fascia

• The round ligament (ligamentum teres) of the uterus

• The genital branch of the genital femoral nerve

• Cremasteric vessels

• Ilioinguinal nerve