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.

Most sliding hernias are recognised during surgery.

CT abdomen and pelvis: particularly useful for large, recurrent or unusual hernias and when bladder involvement is suspected; preoperative recognition substantially reduces risk of visceral injury.

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.