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Hernias

Occult or hidden Inguinal hernia as a cause of pelvic pain in women

Currently in the U.S., there are fewer than 5 programs considering or offering treatment for inguinal hernias as a cause of pelvic pain in women. These hernias are called hidden because they are not appreciated on exam, x-ray or even visible initially on laparoscopy. This is a clinical syndrome that is diagnosed solely based on history, with some findings on exam that relate to the location of pain. The diagnosis is confirmed with a special search or dissection into the inguinal region at laparoscopy and the treatment is administered at that time in the same way a traditional hernia is repaired. To further define this, while typical hernias are visible immediately at laparoscopy because of the prolapse of the peritoneum through the inguinal ring, with occult hernias, there is no prolapse of peritoneum in most cases and therefore would be “missed” in a standard laparoscopy. This is a large part of the confusion with this diagnosis.

Little research has been done or exists on this topic but the buzz words for the syndrome are “sports hernia” or “runner’s hernia.” Even so, less than 15 articles exist on this topic. Dr. Debra Metzger, a reproductive endocrinologist, was instrumental in developing this diagnosis and treatment approach back in the 1980’s and 90’s. She treated hundreds of patients with great success and promoted the procedure. Diagnosis and treatment of hernias, however, is done by general surgeons as an integral part of their specialty. The vast majority of General surgeons on a philosophical basis do not operate solely for pain without diagnostic findings. This certainly would be a prudent approach for traditional hernias where a bulge is usually appreciated. This approach though would exclude 90+ percent of the occult hernias that we see and treat. Gynecologists on the other hand have been operating for pain for over 100 years to diagnose and treat endometriosis. The idea of operating on pain without specific findings is therefore not at all foreign to us.
At JCRM, we have established a working relationship with some general surgeons in Jacksonville who were open minded enough initially to work with us and now see the dramatic results in their patients. Other surgeons have been critical of the approach and universally would tell our patients that they do not have a hernia if the patient was evaluated by these physicians. This is not a criticism of them as surgeons, this is simply a very obscure description and we wouldn’t expect any physician to understand this without specific education. This syndrome is very common in association with endometriosis and about 30-40% of our pain surgeries include attention to this problem.

The History: Patients may report the following*:
Lateral lower quadrant pain (often, “my ovaries”) that is sharp and intermittent or constant
Radiates:Down the front of the leg / inner thigh / groin
Through or around to the back
Less commonly to the hip or up towards ribs
Pain is worse with intercourse, periods and with exercise or standing for a long time
The pain can be relieved by recumbent position
Often relieved some by pressing on the area
Generally worsens over time but may come and go.
A prior laparoscopy seems to be able to relieve this pain for 3-12months.
A common history is a patient who has had several laparoscopies for endometriosis followed by losing one ovary (the bad pain side) followed by hysterectomy only to continue with the same pain localized to the groin.
The Physical Exam:
Pain just above the crease of the leg to palpation.
Valsalva or straining can make the pain increase in some.
Pain on vaginal exam when directed toward the inguinal ring.
The exam findings are not subtle in the vast majority of cases.
*Few patients exhibit all of these symptoms. Most patients have several of these key elements.
X-rays: CT would almost never find this. MRI might see it in a minority of cases.

Surgery for this condition is the same as for a traditional hernia where the channels or dilated openings are cleaned out and the inguinal region is covered by a very light mesh to prevent recurrence. Primarily fat intrusion into the dilated natural inguinal openings is found to be present. We believe the fat is pushed down a narrowing channel that causes pressure and inflammation that triggers the pain nerve impulses associated with this process. There can be some pain recurrence in a small minority of patients that responds to physical therapy in nearly all cases which has led us to recommend this combined with pelvic floor therapy in all our post op patients. This has dramatically improved our patients’ post procedure experience and long term success.
Our approach is to decipher the causes of pain which in most patients are multiple. The 3 most common sources of pain are endometriosis, adenomyosis, and inguinal region pain (occult hernia). By addressing all the pain sources that each patient is determined to have, we have been successful in dramatically or completely relieve pain in well over 90% of our patients.

Bibliography:
Herrington JK. Occult inguinal hernia in the female. Ann Surg 1975; 181:481-3.
Spangen L, Andersson R, Ohlsson L. Nonpalpable inguinal hernia in the female. Am Surg 1988;54:574-7
Spangen L. Nonpalpable inguinal hernia in women. In: Fitzgibbons RJ IV, ed. Hernia. Philadelphia (PA): Lippincott Williams & Wilkins; 1995. p. 87-90.
Fodor PB, Webb WA. Indirect inguinal hernia in the female with no palpable sac. South Med J 1971;64:15-17.
Hunt RB, Camer SJ. Laparoscopy in the diagnosis of occult inguinal hernia. Am J Obstet Gynecol 1982;142:924-5.
Roos H, Smedberg S. Symptomatic nonpalpable inguinal hernias. Post grad Gen Surg. 1992;4:131-134
Aakela JT, Kiviniemi H, Palm J, et al. The value of herniography in the diagnosis of unexplained groin pain. Ann Chir Gynaecol. 1996;85: 300-304
Loftus IM, Ubhi SS, Rodgers PM, et al. A negative herniogram does not exclude the presence of a hernia. Ann R Coll Surg Engl. 1997;79:372-375.
Renzulli P, Frei E, Schafer M, Werlen S, Wegmuller H, Krahenbuhl L. Preoperative Nyhus classification of inguinal hernias and type-related individual hernia repair. Surg Laparosc Endosc Percutan Tech 1997;7:373-7.
Ponka JL. The hernia problem in the female. In Ponka JL 9ed): Hernias of the abdominal wall. Philadelphia: W.B. Aaunders; 1980:82-90.
Gullmo A. Herniography. Act Chir Scand Suppl. 1980;361
HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/…” Miller J, HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Cho%20J[Author]…” Cho J2, HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/…” Michael MJ3, HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/…” Saouaf R., HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/…” Towfigh S, Role of imaging in the diagnosis of occult hernias. JAMA Surg, 2014 Oct;149(10):1077-80. doi: 10.1001/jamasurg.2014.484.
Groin Pain Etiology: The Inguinal Hernia, the Occult Inguinal Hernia, and the Lipoma HYPERLINK “https://link.springer.com/cha…/10.1007/978-3-319-21587-7_6https://link.springer.com/cha…/10.1007/978-3-319-21587-7_6
Fatih Ciftci (2015) Single Surgeon Experience With Repair of Occult Inguinal Hernias Using the TAPP Approach: A Prospective Study. Int Surg: Nov.-Dec. 2015, Vol. 100, No. 11-12, pp. 1403-1407. HYPERLINK “http://www.internationalsurgery.org/…/INTSURG-D-15…http://www.internationalsurgery.org/…/INTSURG-D-15…
HYPERLINK “https://www.sages.org/…/laparoscopic-inguinal-hernia…/https://www.sages.org/…/laparoscopic-inguinal-hernia…/
HYPERLINK “https://link.springer.com/book/10.1007/978-3-319-21587-7” The SAGES Manual of Groin Pain, pp 49-58 HYPERLINK “https://www.researchgate.net/…/301264737_Groin_Pain…https://www.researchgate.net/…/301264737_Groin_Pain…
Patient descriptions and other articles from the press:
HYPERLINK “http://www.nytimes.com/2011/05/17/health/17brody.htmlhttp://www.nytimes.com/2011/05/17/health/17brody.html NY Times article
HYPERLINK “http://www.pelvicpainrehab.com/…/hernia-may-cause…/http://www.pelvicpainrehab.com/…/hernia-may-cause…/
Real life patient descriptions: HYPERLINK “https://patient.info/…/femoral-hernia-near-my-inguinal…https://patient.info/…/femoral-hernia-near-my-inguinal…
HYPERLINK “http://inguinalhernia.org/…/challenge-diagnosing-female…http://inguinalhernia.org/…/challenge-diagnosing-female…
HYPERLINK “https://onelofajourney.com/…/excision-surgery-occult…/https://onelofajourney.com/…/excision-surgery-occult…/
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