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TThe article reports the incidence of multiple inguinal protrusions in the same groin in a patient collect

who underwent open hernia repair. Multiple ipsilateral inguinal hernias compose an almost neglected

topic that, if not identified during hernia repair, could lead to unclear discomfort, pain, and reoperation.

A collect of 100 consecutive open anterior inguinal hernia procedures was analyzed. The patients were

divided into two subsets—A: patients with a single protrusion and B: patients with more than one protrusion

simultaneously arising from the inguinal floor. The single hernias from cohort A and the multiple hernias

from cohort B were further categorized using the Nyhus classification system.

Eighty-eight single unilateral hernias were detected and 12 multiple inguinal hernias were ipsilaterally

arising from the same groin. Nine percent of the multiple protrusions were double (three double indirect

Multiple Ipsilateral Inguinal Hernias:More Frequent Than Imagined,

If Undetected Source of Discomfort,Pain, and Re-interventions

ABSTRACT

AMATO GIUSEPPE, MDCONSULTANT PROFESSOR

DEPARTMENT OF GENERAL SURGERY AND EMERGENCYUNIVERSITY OF PALERMO

PALERMO, ITALY

ROMANO GIORGIO, MDASSOCIATE PROFESSOR

DEPARTMENT OF GENERAL SURGERY AND EMERGENCYUNIVERSITY OF PALERMO

PALERMO, ITALY

AGRUSA ANTONINO, MDDEPARTMENT OF GENERAL SURGERY

AND EMERGENCYUNIVERSITY OF PALERMO

PALERMO, ITALY

DI BUONO GIUSEPPE, MDDEPARTMENT OF GENERAL SURGERY

AND EMERGENCYUNIVERSITY OF PALERMO

PALERMO, ITALY

COCORULLO GIANFRANCO, MDASSOCIATE PROFESSOR

DEPARTMENT OF GENERAL SURGERY AND EMERGENCYUNIVERSITY OF PALERMO

PALERMO, ITALY

GULOTTA GASPARE, MDPROFESSOR - HEAD OF DEPARTMENT

DEPARTMENT OF GENERAL SURGERY AND EMERGENCYUNIVERSITY OF PALERMO

PALERMO, ITALY

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In recent years, thanks to the develop-ment of prosthetic repair techniques, inthe surgical treatment of inguinal herniathe recurrence rate decreased significant-ly, especially when compared with thepre-prosthetic era. Nevertheless, despitethis indubitable progress, the attention ofthe surgical community is growinglyfocused upon unsatisfying side effectsrelated to prosthetic hernia repair. Longlasting postoperative discomfort and painas well as a relatively high incidence ofre-intervention, are a source of increas-ing debate among the herniologists.1-3

Probably, despite the great frequency ofinguinal hernia, there are aspects of thisdisease that have not been sufficiently

investigated. The present report isintended to highlight a peculiarity of thesurgical anatomy of the inguinal regionthat can help clarifying the above-men-tioned matters. It concerns multiple her-nias ipsilaterally protruding from thesame groin. Although multiple ipsilateralhernias appear to occur more frequentlythan conceived, in previous and recentliterature, few scientific articles haveevaluated multiple protrusions simulta-neously arising within the same groin.4-6

Therefore, insufficient knowledge on thissurgical-anatomical variant of hernia dis-ease is an additional threat to safety ininguinal hernia repair procedures. Aim-ing to assess the incidence of multipleprotrusions during open unilateral herniarepair, the anatomical aspects of 100 con-secutive groin hernia repair procedures

performed by a single operator wereanalyzed. The data collected in thepatient cohorts indicates that the rate ofmultiple ipsilateral hernias is not insignif-icant as previously believed. If undetect-ed, this occurrence can lead topostoperative complications. The resultsof this study should yield enhancedknowledge on surgical anatomy and fur-ther reflection, which may improve sur-gical technique and the results of inguinalhernia repair procedures.

Material and Methods

The report was conceived as a retro-spective study describing the intraoper-ative features of the protrusions

INTRODUCTION

MATERIAL AND METHODS

and six in combination direct + indirect). Three patients (3%) presented with triple protrusions; of those two

individuals, one had a combination of double indirect, one had a direct hernia, and the third patient showed

a tricomponent protrusion (hernia of the fossa supravescicalis + hernia of the fossa inguinalis media +

indirect hernia).

These numbers demonstrate that multiple ipsilateral inguinal hernias are more frequent than imagined. If

undiscovered during a herniorrhaphy, the “forgotten” protrusion may generate unclear groin pain requiring

reoperation. Consequently, is to envisage that many re-interventions will likely involve false “recurrences.”

Therefore, during hernia repair, more attention and adhesiolysis is essential during inspection of the inguinal

floor. In fact, a careful exposure of the anatomical structures of the groin could be very advantageous in

properly managing such conditions. This kind of surgical approach can help to prevent patient’s discomfort

and re-interventions.

Figure 1. Right inguinal hernias. Triple protrusion from the internal inguinalring: two peritoneal sacculations and one preperitoneal lipoma (already excisedat its base).

Figure 2. Right inguinal hernias: double sac protrusion from the internalinguinal ring.

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observed in 100 consecutive malepatients with primary unilateral groinhernias. All patients underwent openinguinal hernia repair at the affectedgroin. Hernia type was classified usingthe Nyhus classification. The procedureswere performed under local, spinal, orgeneral anesthesia. According to theintraoperative diagnosis, the patientswere classified into two subsets—A:patients with a single unilateral hernia,and B: patients with multiple ipsilateralhernias. Multiple hernias included thepresence of more than one protrusionarising from the abdominal cavitythrough the inguinal floor. The occur-rence of a single hernia protrusionaccompanied by one or more preperi-toneal lipomas arising from the herniadefect was not considered as an inclu-sion criterion for group B.

Surgical procedureThe operation started with a 4–5 cm

oblique skin incision over the affectedgroin. After opening the external fasciaand isolating the spermatic cord, theinguinal area was inspected in allpatients to ascertain the presence of ahernia protrusion. If an indirect herniasac was present, the sac was isolatedfrom the cord structures. Further dis-section of the spermatic cord and inter-nal r ing was carried out aiming toidentify additional hernias arising fromthe abdominal cavity through the inter-nal ring. All recognized protrusionswere isolated along the spermatic ves-sels. These were always followed andskeletonized until the intra-abdominalaspect of the internal ring was reached.Following adhesiolysis, the protrusionswere ligated as deep as possible beyondthe ring, then the distal stumps wereexcised and the proximal stump wasreturned to the abdominal cavity. After-ward, the medial inguinal fossa wasinspected to detect direct hernia pro-trusions that would eventually exist.This maneuver was achieved by meticu-lous dissection and removal of fat. If adirect hernia was found, adhesiolysiswas performed until the confluence ofthe hernia sac to the fascia transversaliswas reached. Then, the protrusion wasreturned back as usual to the abdominalcavity and the prosthetic repair accom-plished as planned.

In case of direct hernia, after identi-fying and dissecting the protrusion fromfat and adhesion as explained above, amandatory step was the exploration of

the spermatic cord. The spermatic ves-sels were always skeletonized beyondthe internal ring in order to evidenceeventual peritoneal sacculations pro-truding through the internal ring. Aftercompleting the prosthetic repair of thehernia defect(s), the external obliquefascia, subcutaneous fat and skin weresutured as usual.

Results

Among the 100 male patients whoconsecutively underwent primary openinguinal hernia repair, the median agewas 50.3 (range 18–85) years. Local

anesthesia was administered to 78patients, spinal anesthesia to 13, andgeneral to nine. The mean operativetime was 33.2 min (range 25–57 min).

Single unilateral hernias were identi-fied in 88 subjects who were conse-quently enrolled in patient subset A.Amid the individuals with a single her-nia, eight hernias could be classified asNyhus type 1, 48 as Nyhus type 2, 21 asNyhus type 3a and 11 as Nyhus type 3b.In 10 of these patients, an additionalprotrusion of a preperitoneal lipomawas found.

Group B included 12 patients (12%)who presented multiple ipsilateralinguinal hernias. The inguinal protru-sions were classified as follows:

RESULTS

Figure 3. Double inguinal protrusion left groin, both indirect. Of note, the skeletonized spermatic ductcrossing amid both hernia protrusions.

Figure 4 a. Triple inguinal protrusion in the left groin: one direct hernia and two indirect. The larger indi-rect hernial sac is manifestly thicker and altered by inflammation. b. After opening the larger indirect her-nia sac, an incarcerated ischemic altered epiploon was observed. There was no evident damage to theconcomitant herniated sigma loop.

a b

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�One patient had a double indirecthernia (both Nyhus 2) and one largepreperitoneal lipoma arising fromthe internal ring (Fig. 1).

�Two patients presented double indi-rect hernias (both Nyhus 2) (Figs. 2and 3).

�Three patients had a triple hernia:double indirect (both Nyhus 2) +one direct (Nyhus 3a). (Fig. 4 a/b,Fig. 5 a/b) and one a multiple tri-component protrusion (hernia of thefossa supravescicalis + hernia of thefossa inguinalis media + indirecthernia).

�Six patients presented one indirect(respectively 1 Nyhus 1 and 5 Nyhus2) and one direct hernia (all Nyhus3a) (Figs. 6 a/b).

Overall, the mean length of stay was0.98 days. Concerning early postopera-tive complications, two hematomaswere recorded, four seromas, and fourswelling of the scrotal skin. There wereno infections or other adverse events. Inthe long term, no discomfort, chronicpain or recurrences were recognized.At the time of writing the manuscript,the follow up of the 100 patient groupranged from 14 to 36 months.

Discussion

The aim of this retrospective study isto provide the surgical community withepidemiological records, photographic

documentation, and procedural consid-erations relating to the almost neglectednosological entity of multiple ipsilateralhernias. Furthermore, in case of unclearpostoperative discomfor t, pain oringuinal bulging, the analysis of thereported data could be helpful in inter-preting the symptoms, giving to thesesigns the right significance in order toachieve a correct diagnosis. The fre-quency of the anatomical variety ofmultiple ipsilateral inguinal protrusionshas been scarcely considered in the sci-entific literature. Studies performedbefore the laparoscopic era were mainlyfocused upon the incidence of inguinalhernia on the contralateral side follow-ing unilateral open repair. Such occur-rence was considered to range up to30%.7 This approximate frequency wasconfirmed after the advent oflaparoscopy. In fact, video-laparoscopicdata for bilateral inguinal defects inpatients with a preoperative diagnosis ofa pure unilateral hernia became almostcommon.5,9-11 Contrariwise, a review ofthe past literature revealed few articlesdealing with multiple ipsilateral inguinalprotrusions, some of which are veryold.12,13 Thanks to the increase inlaparoscopic hernia procedures, onlyrecently has this subject been more con-sistently reported, but scientific data arestill limited. However, these articlesonly discuss the laparoscopic repair ofthe herniated posterior abdominalwall.14-17 To date, no photographic doc-umentation exists regarding multiplehernias identified during anterior openinguinal hernia repair. The presentreport is also intended to fill this void.

The results of this study show thatthe presence of multiple protrusions inthe inguinal canal is much more fre-quent than previously imagined. Thisfinding corresponds to the results of aninteresting study published by Ekbergand colleagues nearly two decadesago.13 The article addressed herniogra-phy, a radiological examination carriedout using radiopaque contrast in acohort of 1010 patients, of whom 310had hernial protrusions. Among theherniated patients, 71 (23%) presentedmultiple protrusions (ipsilateral orbilateral) of various types (femoral,obturator, inguinal direct, and indirect).There were 288 groin protrusions, andamong these, 26 (9%) were multipleipsilateral inguinal hernias.

Our experience shows almost identi-cal results to the study by Ekberg. In

Figure 5 a. Triple inguinal hernia right. Double indirect hernia protrusion through the internal ring, beingthe smaller almost disguised within the proximal aspect of the spermatic cord. The third protrusion is rep-resented by a small direct hernia (yellow circle) and arises from the fossa inguinalis media. This additionalhernia could be detected after meticulous dissection of fat and adhesions. b. The small direct herniapushed back to the abdominal cavity (yellow circle).

Figure 6 a/b. Double inguinal protrusion left groin. Large direct hernia sac (Nyhus 3a) and small indirectsac (yellow circle) hidden among the spermatic cord structures. This additional indirect hernia protrusionwas detected after meticulous skeletonization of the spermatic cord.

DISCUSSION

a b

a b

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fact, of 100 patients, there were 12cases of multiple ipsilateral hernias. Thisoccurrence, if not detected duringsurgery, is likely to be a source of post-operative problems. We should alsoconsider that while it is relatively easyto highlight multiple indirect hernias, asall of these protrude from the internalinguinal orifice, the recognition of anoccult indirect hernia during direct her-nia repair, or vice versa, may be moredifficult. Several factors lead to missinga concomitant “occult” hernia. Amongthese are the rush to finish the proce-dure once the primary hernia defect isrepaired, insufficient or inaccurateadhesiolysis of the inguinal floor in thecase of an indirect hernia, and not ade-quately inspecting the spermatic cord orthe internal inguinal orifice in the caseof a direct hernia. Therefore, duringopen inguinal hernia repair, more care-ful attention should be paid to theinspection of both the internal inguinalring and the inguinal floor. Consequent-ly, in the case of a direct hernia, a stepsuch as a skeletonization of the proximalcord in the area close to the confluenceinto the internal inguinal ring is recom-mended. If an indirect hernia is present,meticulous adhesiolysis with inspectionof the medial inguinal fossa should bemandatory. It should also be stressedthat the search for occult multiple her-nias is not always easy, in effect some-times the additional protrusion isextremely small and very difficult toidentify (Fig. 5 a/b and 6 a/b). This is arisky occurrence because a failure in itsdetection will almost certainly lead topostoperative complications.

In light of the described findings, it isclear that the long-established practicederiving from years of surgical routineshould be fur ther modified andimproved. Actually, being aware of thefrequency of this anatomical condition,a surgeon would always schedule ameticulous search for occult herniasduring repair procedures. If an addition-al ipsilateral hernia is present, thisbehavior makes possible the simultane-ous repair of the protrusions. Neverthe-less, if such a search is incompletely orinaccurately executed, the risk to over-look an additional hidden hernia is high.If this happens, we would hypothesizethat during movement or strain, theprogression of the overlooked herniacan lead to postoperative discomfortand pain caused by the impact of theprotrusion against the implant, thus

putting under tension the mesh and itsboundary (Fig. 7). We also envisage thatthis occurrence, after time, can provokea partial or even complete detachmentof the mesh from its insertion pointsand, therefore, the appraisal of a “recur-rence.” However, this is not a truerecurrence, but simply the progressionof a hidden hernia that went undetectedduring the previous intervention. Inthese cases, addressing the effectivediagnosis is the most challenging eventhough that ultrasonography and sur-geon skill could help clarify the issue. Inour experience, if after a short timefrom herniorrhaphy a protrusionbetween inguinal floor and the mesh isdetectable, not a recurrence but a “for-

gotten” hernia should be taken intoaccount. Concerning long-term postop-erative pain and discomfort, whichactually is the most discussed topic inthis field, the above-mentioned hypoth-esis could help in clarifying the issue.

Conclusion

In summary, during anterior herniarepair, an accurate preparation withadhesiolysis of the groin structuresshould be mandatory. This strategyappears to be the only method for detect-ing additional pathological modificationsof the groin anatomy. A meticulous and

Figure 7. Schematic representation of the impact against the prosthesis of an overlooked additional herniaafter Lichtenstein hernia repair. The forgotten hernia protrudes and under load pushes forward the meshputting under tension the anchoring points. To this may follow discomfort and pain. Mesh dislodgementcan also occur. In this case, the hernia protrusion can be erroneously categorized as recurrent.

Table IIntraoperative findings in patients with multiple ipsilater-

al inguinal hernias.

Multiple ipsilateral ingunial hernias/100 patients Nr %

Double indirect hernia (2 x Nyhus 2) 2 2%

Double indirect hernia (2 x Nyhus 2) + one preperitoneal Iipo-ma from the internal ring

1 1%

Double hernia: one indirect (respectively 1 xNyhus 1 and 5 x Nyhus 2) + one direct hernia (Nyhus 3a type)

6 6%

Triple hernias:�Two double indirect (2 x Nyhus 2) + 1 direct (Nyhus 3a) �One tricomponent hernia: protrusions in the fossa

supravescicalis + fossa inguinalismedia + indirect hernia

3 3%

Total 12 12%

CONCLUSION

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atraumatic dissection of the inguinalstructures helps to prevent the onsetof “forgotten” hernias, thus diminish-ing the incidence of false “recurrences”and unclear postoperative pain/dis-comfort.

Authors’ Disclosures

The authors have no actual or poten-tial conflicts of interest in relation tothis paper.

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AUTHORS’ DISCLOSURES