Sliding Inguinal Hernia

A sliding inguinal hernia is an inguinal hernia in which a retroperitoneal or pelvic organ forms part of the wall of the hernia sac rather than simply lying freely inside it.

Common sliding structures include:

Sigmoid colon on the left
Caecum or ascending colon on the right
Urinary bladder

The operative hazard is inadvertent injury caused by attempting to dissect what appears to be a thickened hernia sac when that tissue is actually bowel or bladder.

Presentation resembles a conventional inguinal hernia, often with a large longstanding groin or inguinoscrotal swelling.

A bladder component may produce:

Lower urinary tract symptoms
Reduction in groin swelling after voiding
Two stage voiding, where the patient manually compresses the groin or scrotum to empty the bladder completely

Large bladder hernias can rarely produce ureteric obstruction, hydronephrosis or renal impairment.

Repair symptomatic sliding hernias using standard principles of inguinal hernia reconstruction, but modify the dissection according to the sliding organ.

The central operative rule is:

Do not attempt to circumferentially strip or excise the entire sac when an organ forms part of its wall.

Identify the true peritoneal sac carefully, free only enough tissue to permit safe reduction and return the sliding organ to its anatomical position.

For bladder involvement, decompress the bladder with a urinary catheter when helpful. Cystoscopic assistance can be useful when anatomy is uncertain or previous surgery has distorted the bladder.

Bladder resection is rarely necessary and should be reserved for nonviable bladder, true diverticular pathology, tumour or a neck that cannot otherwise be managed safely.

After reduction, perform durable mesh reinforcement.

Open Lichtenstein, TEP, TAPP and robotic posterior approaches are all possible. Posterior minimally invasive repair provides excellent visualisation of bladder and pelvic anatomy in experienced hands.

Repair becomes urgent when sliding bowel becomes incarcerated, obstructed or strangulated.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Richter Hernia

A Richter hernia occurs when only part of the circumference of the bowel wall, usually the antimesenteric border, becomes trapped within a small fascial defect.

Because the intestinal lumen is not completely occluded, the patient may continue passing stool and flatus despite progressive strangulation of the trapped bowel wall.

This makes Richter hernia particularly dangerous. Bowel necrosis or perforation can occur without classical complete bowel obstruction.

Common sites include femoral and inguinal defects and small laparoscopic port sites.

Presentation may be deceptively mild.

There is often focal pain and tenderness over a small irreducible hernia, while vomiting and abdominal distension may be absent.

Patients can continue passing stool.

As strangulation progresses, local erythema, increasing pain, fever, tachycardia and systemic toxicity develop.

If the trapped segment necroses and perforates, the patient may present with local abscess, enterocutaneous fistula or generalised peritonitis rather than obstruction.

A reducible Richter hernia without acute symptoms should undergo planned repair because future strangulation risk remains.

An acutely tender irreducible Richter hernia requires urgent operative assessment.

Do not use continued passage of stool or absence of bowel dilatation as evidence that urgent surgery is unnecessary.

At operation, release the trapped bowel and assess the entire circumference carefully. A small antimesenteric segment can appear severely compromised while the remaining bowel appears normal.

If viability returns completely after reduction, bowel resection is unnecessary.

Full thickness necrosis requires excision. Segmental small bowel resection with primary anastomosis is preferred when the necrotic area is substantial, margins are uncertain or limited repair would compromise lumen calibre.

Repair the underlying femoral, inguinal, port site or ventral defect.

Synthetic mesh is appropriate if the field remains clean. Gross perforation or heavy enteric contamination should generally preclude permanent synthetic prosthetic placement during the contaminated phase.

If the hernia contents reduce spontaneously during anaesthetic induction before bowel viability has been seen, inspect the bowel laparoscopically or through an appropriate abdominal approach rather than assuming that the reduced segment is viable.

Sliding Inguinal Hernia

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management