Trip Answers

Question answered:17/01/08 Warning! this question is over two years old.

We searched the NLH Library and TRIP and Medline databases but found no rating or scoring tools to determine which patients with inguinal or femoral hernias should be offered surgery as a priority. However, we did locate information that gives criteria for referral for surgery.

 

A 2007 American guideline notes:

 

• “Urgent repair is required for a sudden, non-reducible hernia or a chronically incarcerated hernia that becomes acutely painful or tender, as this indicates impending strangulation.
• Repair of almost all groin hernias is recommended. Inguinal hernias should ultimately be repaired because they enlarge, leading to a more difficult repair and higher risk of complications or recurrence. However, if symptoms are not severe, watchful waiting may be appropriate for as much as a year or two. Femoral hernias should always be repaired because of the high incidence of bowel strangulation. Patients with groin hernias should undergo surgical evaluation within a month after detection.” [1]

 

A second American guideline, one on surgical repair of groin hernias states:

 

“Patients with inguinal hernias typically present with vague groin pain. Inguinal hernias may be asymptomatic, discovered incidentally during physical examination or present as a bulge discovered by the patient. Since most hernias should be repaired, the patient should be referred to a surgeon for evaluation and operative treatment. Sophisticated tests are not required, since the diagnosis can usually be made on physical examination, which is best performed with the patient standing and straining against a held breath (Valsalva maneuver). Ultrasound and diagnostic x-rays are also not usually necessary.

 

The majority of groin hernias are readily reducible, have minimal or no tenderness, and can be electively referred to a surgeon within a period of weeks. However, if the hernia is tender and not reducible, the patient should be referred immediately due to the risk of strangulated bowel or other viscera. Aggressive attempts to reduce a groin hernia with sedation, ice packs, or sustained weight or pressure should not be pursued. Symptoms such as nausea and vomiting suggest bowel obstruction, which mandates immediate referral to a surgeon.
Because patients with groin hernias are usually offered and receive elective repair, the incidence of emergent incarcerated (non-reducible) hernias is relatively low. Urgent repair is required for a sudden, non-reducible hernia or a chronically incarcerated hernia that becomes acutely painful or tender, as this indicates impending strangulation…” [2]

 

The Patient UK website has articles on femoral and inguinal hernias. In the article on femoral hernia, the authors argue:

 

“In view of the high risk of strangulation, all femoral herniae should be repaired as an elective procedure, but as soon as possible. There is no place for a truss for a femoral hernia.

 

There are 3 surgical approaches, each named eponymously. There is a low approach called Lockwood, a transinguinal called Lotheissen and a high called McEvedy. Each technique has the principle of dissection of the sac with reduction of its contents, followed by ligation of the sac and closure between the inguinal and pectineal ligaments. A laparoscopic technique that uses mesh and keeps outside the peritoneum seems promising. However, with 10 male and 5 female in the series and a mean age of 55 they seem unusually male dominated and unusually young. Laparoscopic hernia repair has advantages but it should be in the province of the specialist. A Cochrane review found that open mesh repair was associated with a reduced risk of recurrence. “ [3]

 

Concerning inguinal hernias, the Patient UK states:

 

“If the hernia is small, the patient may only need reassurance. However, there is always the chance of it becoming a surgical emergency through obstruction and incarceration. Episodes of pain and tenderness suggest need for urgent treatment, but when these become prolonged and severe then emergency surgery is indicated for possible strangulation.
The fundamentals of indirect inguinal hernia repair are the same regardless of the patient's age. Reduction or excision of the sac and closure of the defect with minimal tension are the essential steps in any hernia repair.” [4]

 

References
1. Work Loss Data Institute. Hernia. Corpus Christi (TX): Work Loss Data Institute; 2007 May 2. (http://www.guideline.gov/summary/summary.aspx?doc_id=11021&nbr=5801&ss=6&xl=999)
2. Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of groin hernias. Manchester (MA): Society for Surgery of the Alimentary Tract (SSAT); 2003. (http://www.guideline.gov/summary/summary.aspx?doc_id=5508&nbr=3751&ss=6&xl=999)
3. Patient UK. Femoral hernia. March 2007.
(http://www.patient.co.uk/showdoc/40002779/)
4. Patient Uk. Inguinal hernia. September 2007.
(http://www.patient.co.uk/showdoc/40000295/)

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