Page 120 - International guidelines for groin hernia management

Hernia

a Lichtenstein/TEP. Follow-up should entail 5 years primary IHs in adults. Risk factors associated with IH
with primary outcomes recurrence and pain. formation are inheritance, a previous contralateral hernia,
• A randomized controlled trial in a specialized environ- male gender, elderly age, impaired collagen metabolism,
ment comparing Shouldice with Lichtenstein and TEP/ low body mass index, obesity and a history of
TAPP. prostatectomy.
• Propensity score matching analysis comparing Shoul- Symptoms
dice versus Lichtenstein versus TEP versus TAPP in Groin hernias can be either asymptomatic or symptomatic.
large patient population from registries with an equal Approximately one-third of patients with IHs are asymp-
distribution of patient characteristics, risk factors and tomatic. Roughly 70% of asymptomatic individuals with
hernia findings. IHs will develop symptoms within 5 years, generally pain
• An RCT in which unilateral one sided symptomatic IH or discomfort.
is compared to bilateral repair (laparo-endoscopically) Diagnostics
stratified for medial and lateral hernias. Prospective History, physical examination and diagnostic work-up
analysis of the prognosis of an occult hernia should be History and physical examination are usually all that are
performed. required to confirm the diagnosis of a clinically evident
• Large registry randomized controlled trials with long- groin hernia. Approximately 95% of IHs can be diagnosed
term follow-up ([ 5 years) comparing all surgical by physical examination. IHs produce swelling supero-
techniques (open non-mesh, open anterior mesh, open medial to the pubic tubercle and femoral hernias cause
posterior mesh and laparo-endoscopic) in primary and infero-lateral swelling. However, in practice this subtle
recurrent hernia, unilateral and bilateral inguinal hernia distinction is often difficult to discern.
repair in male and female patients. Patients should be Imaging may be required if there is vague groin swelling
operated by expert surgeons in the respective technique. and diagnostic uncertainty, poor localization of swelling,
intermittent swelling not present at time of physical
examination and other groin complaints without swelling.
Physical examination and ultrasound combined are suit-
able for diagnosing patients with vague groin swelling or
Chapter 30
possible occult groin hernias. When groin ultrasound is
negative or non-diagnostic, a dynamic MRI, dynamic CT
or even herniography can be considered. Dynamic in this
Summary for general practitioners
context refers to Valsalva maneuver during testing in an
attempt to force a possibly occult or small hernia into its
N. van Veenendaal and M. P. Simons
abnormal channel and more clearly demonstrate its
presence.
Background
In female patients, the existence of a femoral hernia
should be excluded in all cases of a hernia in the groin. No
Definition
clinical or diagnostic test can reliably distinguish inguinal
A groin hernia is defined as a protrusion of viscera or
from femoral hernias in women.
adipose tissue through the inguinal or femoral canal. This
For the evaluation of patients suspected of having a
protrusion results in either an inguinal or femoral hernia.
recurrent groin hernia clinical examination and ultrasound
In day-to-day practice a classification system for groin
are the most suitable. In case of diagnostic doubt after the
hernias is seldom used other than to describe hernia types
ultrasound, MRI or CT can be considered.
in general terms such as: lateral/indirect, medial/direct,
recurrent and femoral.
Management of groin hernia
An occult hernia is an asymptomatic hernia not
Treatment indications
detectable by physical examination.
Not all IHs require surgical treatment. There is a low risk
Epidemiology
of complications like incarceration or strangulation in
The lifetime incidence of a groin hernia is 27–43% in men
asymptomatic or minimally symptomatic men with IHs.
and 3–6% in women. Inguinal hernias (IHs) occur 9–12
Therefore, in men, a watchful waiting management strat-
times more commonly in men. Femoral hernias occur
egy is safe for minimally symptomatic or asymptomatic
approximately 4 times more commonly in women.
IHs. However, the crossover rate to surgery in men with
Etiology/pathology
minimally symptomatic or asymptomatic IHs is high due to
Numerous risk factors—mostly a combination of genetic
the development of symptoms, mostly pain. Approximately
and acquired features—exist for the development of
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