Page 11 - International guidelines for groin hernia management

Hernia

abnormal channel and more clearly demonstrate its pres- Chapter 4
ence. Herniography can only diagnose hernias, not other
pathologies. MRI can diagnose adductor tendonitis, pubic
osteitis, hip arthrosis, bursitis iliopectinea, and Groin hernia classification
endometriosis amongst other conditions. If these ailments
are part of the differential diagnosis, then MRI is the most D. Cuccurullo and G. Campanelli
suitable diagnostic tool. 118, 119 CT can diagnose hernias as
well and should be used when US is negative and MRI is Introduction
not possible. In day-to-day surgical practice a classification system for
CE plus US is recommended as most suitable for the groin hernias is seldom used other than to describe hernia
evaluation of patients suspected of having recurrent groin types in general terms (lateral/indirect, medial/direct,
hernias. If diagnostic doubt exists after CE and US, MRI or recurrent, and femoral). However, a consensus classifica-
CT should be considered. One prospective study and one tion system is needed in order to perform research, tailor
retrospective case–control study, both of low quality, have treatments to hernia types, and perform quality audits.
addressed the issue of imaging for groin hernia Presently it is uncertain which hernia classification system
recurrence. 120, 121 is most suited to achieving this purpose.
US, CT or MRI scans are helpful in identifying non-
neuropathic causes of chronic groin pain by identifying Key questions
mesh-related pathologies, recurrent hernias and occasion- KQ04.a Is a groin hernia classification system necessary,
ally neuromas. 122 A tailored, thoughtful approach to and if so, which classification system is most appropriate?
imaging is required since each of these imaging modalities
possesses certain strengths and weaknesses and is not
equally suited to diagnose all the listed conditions.

The use of US-guided nerve blocks is helpful in Evidence in literature
diagnosing the cause of chronic pain after surgery. A The 2009 EHS guidelines recommended that the EHS
3
prospective cohort study described that the US-guided classification system be used. A 2015 literature review
transversus abdominis plane block provided better the failed to reveal new proposed classification systems or new
cause of pain and control than blind ilio-hypogastric nerve evidence on the value of the EHS system. 125 However, it is
block after inguinal hernia repair. 123 Considering the the opinion of the HerniaSurge members that one uniform
much higher number of patients (n = 273) compared to a system be adopted.
randomized controlled trial with 24 included patients the For inguinal hernia repairs, it is increasingly clear that
quality rating of this Pain Catastrophizing Scale (PCS) surgeons tailor techniques to suit various patients and dif-
could be determined as ‘‘moderate’’. 124 In another publi- ferent hernia types. It is also necessary to compare results
cation, the authors renounced the use of imaging as a across different techniques and perform medical audits.
helpful way to diagnose the cause of postoperative More hernia registries are recommended and will require
inguinal pain. 104 In short, it seems that US-guided nerve that a consensus classification system be adopted. How-
blocks are helpful in pinpointing the cause of chronic pain ever, for now there is no consensus amongst general sur-
after groin hernia repair. Due to a lack of new studies and geons or hernia specialists on a preferred system.
conflicting results in the available literature, the evidence The primary purpose of any disease classification sys-
supporting our recommendation on this KQ is considered tem is to allow for severity stratification so that reasonable
‘‘weak’’. comparisons can be made between treatment strategies. 125
Additionally, a classification system must be simple and
easy to use. Given the large number of operative tech-
niques and their variations for groin hernia repair, it

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