PELVIC PAIN AND HERNIAS
JAMES E. CARTER, MD, PhD, FACOG
Introduction: Hernia has been defined as a protrusion of organs or parts thereof from their natural place in a cavity through an abnormal opening. However, it is the hernial defect, the opening through which a protrusion may occur, that characterizes hernias, not the protrusion of a viscus. Consistent with this, the designation of various hernias uses not the protruded viscus but the location or region in which a hernia can take place [1]. Hernias can occur in the following locations: 1) Hernias of the pelvic wall, perineum, and pelvic floor (sciatic hernia, obturator hernia, perineal hernia); 2) Groin hernias (direct inguinal hernia, indirect inguinal hernia, femoral hernia); 3) Hernias of the abdominal wall (epigastric hernia, umbilical hernia, Spigelian hernia, incisional hernia); 4) Internal abdominal hernia (internal supra-vesical hernia and hernia through broad ligaments) 5) Sports hernias; 6) Pelvic floor support defects. Each of these hernias has characteristic symptoms and signs [2]. Of these three will be discussed: incisional hernias, groin hernias, and sciatic hernias.
Incisional Hernias: An incisional hernia is the abnormal protrusion of peritoneum through a separation of the edges of a musculoaponeurotic wound. They are common after open abdominal procedures and occur in 0.5% to 14% of abdominal operative procedures. Seventy percent occur within the first year and 97% within 5 years of surgery [3]. Incisional hernias occur after laparoscopy with risk of herniation through a 12 mm trocar site (3.1%) approximately 13-fold greater than that for a 10 mm trocar site (0.23%) [4]. Laparoscopic incisional hernias can be prevented, however, by mass closure of the fascia and peritoneal layers under direct laparoscopic vision [5].
Etiology: Infection, obesity, postoperative strain, inadequate suture material, and nerve injury are some of the etiological factors of incisional hernias.
Symptoms and History: Patients may complain of intermittent pain or dragging sensation. They may also complain of distention and severe abdominal pain if they have herniated small bowel.
Physical Examination: Palpation of the wound site may identify separation and tenderness in the area of the separation without a small bulge being present. When the patient is asked to cough, a small bulge may be seen or a pulsation felt by the examining finger.
Diagnostic Studies: The diagnosis of herniation into an incision site can be made by CT scan or ultrasonography. If only the separation is present without the protrusion of tissue, the diagnosis may be difficult without exploration. However, the defect can frequently be palpated and is a source of pain.
Treatment: The treatment of the incisional hernia is surgical placement of graft material of an appropriate size for the hernia present.
Groin Hernias: Groin hernias include direct inguinal, indirect inguinal, and external supravesical which emerge through the abdominal wall by way of the external inguinal ring above the inguinal ligament and femoral hernia that emerges beneath the inguinal ligament by way of the femoral canal. The incidence of inguinal hernias is 10% to 15%. Indirect inguinal hernias are congenital, and direct inguinal and femoral hernias are considered acquired [3].
Etiology: The processus vaginalis is a diverticulum of the peritoneal cavity which is patent in 80% of 90% of newborns, but which closes until at adulthood 15% to 30% have a patent processus vaginalis. Many women with patent processus vaginalis remain asymptomatic. However, this is held to be a prime cause of indirect inguinal hernia. Three factors are involved in generating inguinal hernias: the presence of a preformed sac, repeated elevation in the intraabdominal pressure, and weakening of the body muscles and tissues with time. Raised intraabdominal pressure, such as that which occurs during pregnancy, can make a hernia appear for the first time. The cause of hernia is multifactorial. In the case of indirect hernia, a performed sac (patent processus vaginalis), is present, but bowel is prevented from entering by efficient muscular action. A sudden and unusually high increase in intraabdominal pressure may be sufficient to overcome this protective mechanism and a hernia may quite suddenly appear. In direct hernia there is no performed sac; in fact there is no real peritoneal sac at all. The protective mechanisms fail. The weakened transversalis fascia, on its own, cannot withstand the repeatedly raised intraabdominal pressure and stretches or simply tears.
Symptoms or History: The primary symptoms are pain, and in the case of an acute event, ecchymosis of the inguinal region. The patient may feel some discomfort in the groin and notice a small bulge when coughing or straining that immediately subsides.
Physical Examination: Physical examination reveals tenderness along the edges of separation, or a bulge that increases in size with coughing that can usually be reduced. When the patient stands, a cough impulse can be felt at the tip of the finger after introducing it into the inguinal canal through the external ring by invagination.
Diagnostic Studies: Herniography can be performed for the diagnosis of inguinal hernia. Laparoscopically an indirect inguinal hernia is evident as an opening adjacent to the round ligament. A direct or femoral hernia may not be clearly seen until the peritoneum is open [6].
Surgical Treatment: A sheet of prosthetic mesh is used to reconstruct the inguinal floor. These procedures can be performed laparoscopically and the prosthesis used to cover and overlap all potential defects in the myopectineal orifice [6].
Femoral Hernia: Femoral hernia is a protrusion of preperitoneal fat or intraperitoneal viscus through a weak transversalis fascia into the femoral ring and the femoral canal. It is not unusual for individuals to develop a femoral hernia who have had a previous repair of an inguinal hernia.
Etiology: Natural weakness of the tissues and loss of elasticity is the basic cause. They are more common in multiparous women.
Symptoms or History: The patient may notice a small reducible lump in the medial aspect of the groin.
Physical Examination: The diagnosis can usually be made on finding a soft tumor at the femoral fossa.
Diagnostic Studies: If suspected by symptoms, a gentle push with a blunt instrument at the time of laparoscopy will reveal weakness in the peritoneum.
Surgical Treatment: Non-absorbable mesh is placed appropriately to occlude the orifice.
Sciatic Hernia: A sciatic hernia is a protrusion of a peritoneal sac and its contents through the greater or lesser sciatic foramen. In one study of women with CPP diagnosed and treated during laparoscopy, sciatic hernia was diagnosed in 20 of 1100. This gives an incidence of 1.8% in women with Chronic Pelvic Pain (CPP) requiring laparoscopic intervention [7].
Symptoms or History: Sciatic hernias present with pain originating in the pelvis. Patients may report ipsilateral posterior thigh or buttocks pain or both. Compression of the sciatic nerve may occur, causing pain to radiate down the posterior thigh that is aggravated by dorsiflexion.
Physical Examination: Sciatic hernias pass downward and may present under the lower border of the gluteus maximus muscle in the posterior medial aspect of the thigh. Sciatic hernias, however, are only rarely evident on physical examination. If the ureter herniates into the sciatic foramen it may give rise to a urographic appearance of a redundant, horizontally oriented ureter within a hernia sac that has been called a “curlicue” ureter. Laparoscopically a sciatic hernia may be found to be filled with the ipsilateral ovary or fallopian tube. A prior history of laparoscopic evaluation may not preclude the need for reevaluation.
Surgical Therapy: When the sciatic hernia is approached laparoscopically, its contents are reduced and the peritoneum overlying the sciatic hernia is elevated and transected transversely with scissors. Mesh is then placed in the space created by the atrophic piriformis muscle. A second piece of mesh is trimmed to the size of the peritoneal defect and placed over the folding mesh. This overlying mesh is secured to the obturator internus fascia laterally and the coccygeus medially. The peritoneum is then closed over the mesh [2].
Address reprint requests to: James E. Carter, MD, PhD, FACOG, Mission
Hospital Reg. Med. Ctr., 26732 Crown Valley Pkwy #541, Mission Viejo,
CA 92691,
Telephone: 949 364 5802, Fax: 949 364 2871, E-mail: drjamescarter@cox.net
Dr Carter, a clinical associate professor in the Department of
Obstetrics and Gynecology at the University of California, Irvine
College of Medicine, has researched and applies techniques that assist
in diagnosis and treatment of chronic pelvic pain, osteoporosis,
polycystic ovary disease and insulin resistance, stress urinary
incontinence and pelvic floor support defects, and avoidance of
complications in advanced laparoscopic procedures. Dr Carter’s
published works include two chapters in Prevention and Management of
Laparoendoscopic Surgical Complications, and he co-authored Pelvic
Pain: Diagnosis and Management. He has served as President of the
Society of Laparoendoscopic Surgeons and the International Pelvic Pain
Society.
References
1. Netter FH, Iason AH, Pansky B. Hernias. In: Oppenheimer E, ed. The CIBA Collection of Medical Illustrations. Summit, NJ: CIBA; 1962:204-230.
2. Carter JE. Hernias. In: Howard FM, Perry CP, Carter JE, El-Minawi AM. Pelvic Pain: Diagnosis and Management. New York, NY: Lippincott Williams and Wilkins; 2000:385-413.
3. Abrahamson J. Hernias. In: Zinner MJ, Schwartz SI, Ellis H, eds. Maingot’s abdominal operation. Stanford, CT: Appleton & Lange; 1997:479-580.
4. Kadar N, Reich H, Liu CY, et al. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol. 1993; 168:1493-1495.
5. Carter JE. A new technique of fascial closure for laparoscopic incisions. J Laparoscop Endoscop Surg. 1994;4:143-148.
6. Kavic MS. Laparoscopic Hernia Repair. The Netherlands: Harwood Academic Publishers; 1997.
7. Miklos JR, O’Riley MJ, Saye WB. Sciatic hernias as a cause of chronic pelvic pain in women. Obstet Gynecol. 1998; 91: 998-1001.
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