Crural Hernia: Symptoms

The crural hernia, as well as the umbilical hernia and diastasis recti is among the most frequent pathologies of female abdominal wall. I frequently diagnose it in patients with a long history of inguinal pain, multiple non-directive specialist visits, and numerous dubious ultrasound scans.
In fact, the diagnosis of a crural hernia is not so immediate, as often the hernial orifice is very small and the hernial sac develops close to the inguinal fold and is adjacent to the femoral vessels; for this reason, the hernia is often masked by the panniculus adiposus also in very thin persons.

What is the first symptom of a crural hernia?

Most of my patients, when describing their first symptoms, report sudden pain and burning, accompanied by a feeling of swelling during physical activity (often during training in the gym).

The feeling of swelling is clearly felt, but often there is no clear asymmetry or prominence during the examination due to the interference of the panniculus adiposeum.

Crural hernia: anatomy and ultrasound scanning

Ultrasound scanning in this type of hernia can be difficult, unlike inguinal hernia, due to the particular anatomical region where the hernial sac develops, the adjacent nature of the femoral vessels, and the presence of inflamed and reactive lymph nodes that often distort the vision of the hernial sac.
The crural hernial sac often contains fat which has the same sonographic appearance as the surrounding panniculus adiposus, constituting an additional factor of diagnostic ultrasound confusion. For this reason it is advisable that the ultrasound is performed by the surgeon himself who, being familiar with the surgical anatomy, can highlight its presence in real time by doing the stress or upright positions ultrasound when in doubt.

Strangulated crural hernia

The evolution towards the strangulated crural hernia, in other words the involvement of an intestinal loop with occlusion and gangrene, remains extremely realistic, unpredictable and very dangerous.
The small size of this type of hernia unfortunately does not correspond to a low risk of throttling, quite the contrary. Often the small size of the hernial collar (hernial crural orifice) determines a mechanism of unidirectional non-return in such a way that the intestine comes out of the hernial defect and can no longer return to its seat.
As with other types of hernia, crural strangulation must also be prevented. The repair intervention is much less complex and risky than the intervention of a strangulated crural hernia.

Crural hernia and pregnancy

The possibility of pregnancy or possible future pregnancy should in no way be underestimated by either the patient or the treating doctor.
All situations that increase the volume contained in the abdominal cavity put stress on and aggravate abdominal wall defects, including hernia.

Pregnancy results in a considerable increase in abdominal volume within a few months. If a patient is already suffering from a crural hernia before pregnancy, there is a real risk of aggravation or complications during pregnancy.

This situation should be avoided in any case by undergoing surgery in good time before pregnancy.
Sadly, I have frequently diagnosed with an advanced pregnancy. This situation is very delicate: on the one hand, there are the increased risks of hernial complication, and on the other, there are the risks associated with the pregnancy itself.
In these cases, the patient is kept under close clinical observation and the hernia is repaired in the first months after the birth.
I have seen patients who tend to underestimate the problem of alleviating the symptoms of a crural hernia, which is usually seen after childbirth, by postponing surgery or considering themselves healed. Unfortunately, the anatomical defect remains and must be treated with surgery, which fortunately becomes less and less invasive thanks to new technologies, materials and instruments.

What is the best intervention to cure the crural hernia?

Traditional surgery: it consists of open incision, hernia reduction and frequently positioning of plugs, i.e. real plastic material devices that have the function of caps and can create various complications to be placed and fixed. Even after years there is the possibility of displacement and migration.

Surgery for laparoscopic crural hernia or, even better, robotics allows:

  • repair of the wall defect from the inside with 3 mm incisions and view of the anatomical structures with optical fibre;
  • Rapid recovery;
  • extensive and unaesthetic inguinal skin incisions must not be practiced.

A further advantage of minimally invasive surgery for the crural hernia is that the nervous branch of the genito-femoral nerve is not moved during surgery and therefore there is no risk of damaging it.

This nerve branch transports the skin sensitivity of the external genital region and part of the thigh.
In the course of the history of surgery, the problem of the intact conservation of these nerves has never really arisen, also because the open-air methods required in almost all cases their resection (neurectomy) with relative deficits of sensitivity and possible alterations in the sexual sphere.
This resection of inguinal nerves parts is necessary in traditional surgery for plugs placement and to avoid conflicts. With laparoscopic and robotic techniques for the repair of the crural hernia, on the other hand, a very soft prosthesis (mesh) is positioned by minimally invasive technique, which has the function of strengthening the tissues. There is also a clear reduction in post-operative pain and the recovery of normal physical activity has accelerated considerably.

Dr. Antonio Darecchio

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