Hernies inguinales

Qu'est-ce qu'une hernie inguinale ?

An abdominal hernia comprises a protrusion of abdominal contents through the fascia of the abdominal wall; an inguinal hernia is where this protrudes through the internal inguinal ring. Hernias contain a portion of peritoneal sac and may contain viscera, usually small bowel and omentum.

Hernie inguinale

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Épidémiologie de la hernie inguinale

Inguinal hernias are common, making up 75% of all abdominal hernias.

Inguinal hernias are more common in men (the lifetime risk of an inguinal hernia is 27-43% in men and 3-6% in women).¹ Although they are much more common in men, women with a groin hernia are still more likely to have an inguinal than a femoral hernia.²

As well as male sex, risk factors include increasing age (although there is also a significant spike in cases below the age of 5 years) and a genetic predisposition.²

Other risk factors are thought to include: smoking, chronic obstructive pulmonary disease, lower body mass index, high intrabdominal pressure, thoracic or abdominal aortic aneurysm, patent processes vaginalis, history of open appendectomy, peritoneal dialysis, and collagen vascular disease.²

Présentation de la hernie inguinale

• An inguinal hernia will usually present as a swelling in the groin that may appear with lifting and be accompanied by sudden pain.

• There may be a cough impulse. The hernia may not be visible when lying flat but may appear on standing.

• The hernia may be reducible.

• Indirect hernias can cause pain in the scrotum and cause a 'dragging sensation'.

Les hernies inguinales congénitales sont généralement détectées à la naissance et nécessitent toutes une référence urgente en consultation externe pour une réparation chirurgicale.

Inguinal hernias in older children and adults usually develop gradually but can occur suddenly with an episode of heavy lifting:

• À première vue, une hernie est généralement facilement réductible lorsque le patient s'allonge. Cependant, elle peut nécessiter un remplacement manuel si elle est grande.

• Avec le temps, la hernie s'agrandit et devient plus difficile à replacer, en raison de la formation d'adhérences fibreuses.

• Lorsqu'elle ne peut plus être réduite, elle est irréductible ou incarcérée. Cela peut se produire à tout moment, tout comme l'étranglement. Cela se produit lorsque le contenu viscéral de la hernie se tord ou se retrouve piégé par l'ouverture étroite. Cela compromet l'apport sanguin, provoquant un gonflement et éventuellement une infarctus. L'étranglement conduit généralement à une obstruction intestinale.

Il existe deux types de hernie inguinale :

• Indirect: a protrusion through the internal inguinal ring passes along the inguinal canal through the abdominal wall, running laterally to the inferior epigastric vessels. This is the more common form accounting for 80% of inguinal hernias, especially in children. It is associated with failure of the inguinal canal to close properly after passage of the testis in utero or during the neonatal period.

• Direct: la hernie fait saillie directement à travers une faiblesse de la paroi postérieure du canal inguinal, se dirigeant médialement vers les vaisseaux épigastriques inférieurs. Elle est plus fréquente chez les personnes âgées et rare chez les enfants.

Évaluation³

• Examinez le patient à la fois debout et allongé et demandez-lui de tousser ou de se contracter.

• Insérez un doigt à travers le haut du scrotum dans l'anneau inguinal externe et palpez pour détecter une masse lors de la toux - impulsion de toux.

• Les hernies glissantes sont probables avec de grandes hernies scrotales.

Diagnostic différentiel

Voir également le document séparé Masse dans l'aine et le scrotum article.

• Hernie fémorale.

• Hydrocèle (lors de la différenciation d'une hernie inguinoscrotale, notez qu'il est possible de passer au-dessus d'un hydrocèle lors de l'examen).

• Hydrocèle du cordon spermatique.

• Gonflement des ganglions lymphatiques.

• Abcès.

• Saphena varix.

• Varicocèle.

• Saignement.

• Testicule non descendu.

Enquêtes

Whilst most specialists agree that imaging is not necessary to make the diagnosis, in the UK there are often local constraints on referrals for hernia repair which mean that the diagnosis needs to be confirmed by imaging. Ultrasound scan is the imaging option of choice.³⁴

Traitement et gestion de la hernie inguinale

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If the inguinal hernia is small, the patient may only need reassurance. There is good recent evidence that "watchful waiting" is a safe option for many adults with inguinal hernias. Long-term follow-up of these patients suggests that around 68% proceed to surgical management eventually, usually due to worsening pain or lifestyle limitations from progression.²

Patients with pain, reduced mobility or other symptoms should be offered surgical management. Many patients with chronically incarcerated hernias may be asymptomatic but patients with obstruction or strangulation are a surgical emergency.

However, there is always the chance of it becoming a surgical emergency through obstruction and incarceration. Episodes of pain and tenderness suggest the need for urgent treatment but when these become prolonged and severe then emergency surgery is indicated for possible strangulation. The fundamentals of indirect inguinal hernia treatment are the same regardless of the patient's age. Reduction or excision of the sac and closure of the defect with minimal tension are the essential steps in any hernia repair.

Surgical guidelines recommend tailoring the choice of surgery to individual patient factors. Surgical options include either an open (tissue- or mesh-based) procedure or a minimally invasive (laparoscopic or robotic) procedure.

An open repair with mesh is associated with a 50%-75% lower risk of hernia recurrence, lower risk of chronic pain post-operatively, and an earlier return to work compared with a sutured repair. A tissue (sutured) repair is usually used where mesh is contraindicated, for example where there may be potential for infection from a contaminated field. Laparoscopic repair is recommended for bilateral inguinal hernias as the same port sites can be used.

Studies have shown no significant difference between mesh, laparoscopic and robotic procedures in terms of post-operative haematoma, surgical site infection, urinary retention, or hospital length of stay. However post-operative chronic pain appears to be lower in patients who have undergone laparoscopic procedures, though studies have been of questionable quality.

Hernies inguinales chez les enfants

The incidence of incarcerated or strangulated hernias in paediatric patients is higher than in adults, at around 7-11%.⁶ It is higher in infants than in older children. The risk increases with waiting time from diagnosis to procedure.⁶⁷

Surgical repair is usually recommended as early as possible in paediatric patients because of these risks.

Laparoscopic repair has been shown to have better outcomes than open repair though both have low risks of complications.⁸⁹¹⁰

Complications

Ceux-ci incluent :

• Post-operative chronic pain is reported to occur in between 8 and 16% of patients, though laparoscopic repair appears to reduce the risk.²

• Récurrence : 1,0 % - la plupart se produisent dans les cinq ans d'exploitation. Le taux de récidive augmente :

  • Chez les enfants âgés de moins de 1 an.

  • Chez les patients âgés.

  • Après les incarcérations.

  • Chez ceux ayant une pression intra-abdominale augmentée persistante.

  • Où il y a un échec de croissance.

  • Avec prématurité.

  • Où il y a des problèmes respiratoires chroniques.

  • Chez les filles avec des hernies glissantes.

• Testicule ou ovaire infarci avec atrophie.

• Infection de la plaie.

• Lésion de la vessie.

• Lésion intestinale.

• Un hydrocèle dû à une accumulation de liquide dans le sac distal se résout généralement spontanément, mais nécessite parfois une aspiration.

Pronostic

C'est généralement très bon, selon la comorbidité.