Indirect inguinal hernias are the most common groin hernias in men and women.

The
hernia develops at the internal ring, which is the site where the spermatic cord in
males exits the abdomen. The origin is lateral to the inferior epigastric artery, in
contrast to direct hernias which arise medially to the inferior epigastric vessels
through Hesselbachs triangle. Hesselbachs triangle is an anatomic landmark, bounded
by the rectus abdominis muscle medially, the inguinal ligament (Pouparts) inferiorly
and the inferior epigastric vessels laterally.

Most indirect inguinal hernias are most commonly thought to arise due to defective
obliteration of the fetal processus vaginalis, which follows the path of the
gubernaculums though the inferior anterior abdominal wall, preceding the testicle
which then passes through the inguinal canal and into the scrotum at birth.
Increased abdominal pressure in association with reduced muscular tone in the groin
area may ultimately lead to protrusion of intraabdominal contents into the sac,
resulting in a clinically detectable hernia.

Clinical Presentation:

The most common symptom is a heaviness or dull sense of discomfort that is most
pronounced when straining, lifting, or otherwise increasing intraabdominal pressure.
This pain is caused by the contents of the hernia pressing into the tight ring at
the neck of the sac. As the intraabdominal pressure increases, the contents of the
hernia are forced into the ring constricting them. Pain may also arise from
stretching of the ilioinguinal nerve. Little pressure is required to create
discomfort, which then resolves as the pressure is released when the patient stops
straining or lies down. Discomfort is more prominent at the end of the day or after
prolonged standing.

Physical Exam: Patients should be examined in a standing position while coughing,

straining, or performing a Valsalva maneuver. In most cases it is easier and more reliable
to demonstrate a hernia while the patient is standing. The most common physical finding in
adults is a bulge in the groin. Using the second or third finger, the examiner should
invaginate the scrotal skin adjacent to the external ring and direct the finger toward the
pubic tubercle.

Hernia Repair:

The main principles of hernia repair are to reinforce the floor of the inguinal
canal and tighten the external inguinal ring. All herniologists agree that repairs
must be tension free to mitigate recurrences. Mesh has been incorporated in hernia
repairs to reduce tension, leading to a fall in recurrence rates.
 Many techniques have been proposed for hernia repair. These can be divided into
tissue approximation repairs (such as the Bassini or McVay repair) and tension free
repairs using mesh. The most commonly used open approaches include the Lichtenstein open tension-
free hernioplasty, a plug and patch, or an open preperitoneal approach. All of these options have
their advocates and result in recurrence rates of 1 to 2 percent when performed by surgeons
skilled in the technique.

The Lichtenstein open tension-free hernioplasty is considered the "gold standard"

for open hernia repair Long-term results favor the Lichtenstein technique because of
its low recurrence rate and ease of technical mastery, and because it can be
performed in the outpatient setting with local anesthetic.