Page 58 - International guidelines for groin hernia management

Hernia

when compared with men. In roughly 40% of reoperations A meta-analysis of ultrasound as an initial diagnostic
in women, femoral hernia recurrences are found, suggest- imaging modality for groin hernias showed a high sensi-
ing that these ‘‘recurrences’’ might represent hernias tivity and positive predictive value in cases confounded by
overlooked during primary operations. 5–11 Therefore, the diagnostic uncertainty. The study cited low expense and
European Hernia Society (EHS) guidelines on groin hernia minimal risk as advantages over other radiologic meth-
treatment recommend laparoscopic repair in women cov- ods. 13 However, ultrasound and clinical examination is
ering both the inguinal and femoral orifices. 12 ‘‘operator dependent’’ and may be unable to distinguish an
inguinal from a femoral hernia. Both may also miss
Key Questions femoral hernias entirely. 14–16
The literature confirms that femoral hernias are fre-
KQ16.a In women with a groin lump, what is the best quently found in women undergoing groin hernia repair,
diagnostic modality and is a preoperative diagnosis but that a correct preoperative diagnosis of these hernias is
necessary? uncommon. 14, 15
KQ16.b What is the optimal treatment for women with In a few large epidemiological studies from national
groin hernias? databases, reoperation rates after open anterior groin hernia
KQ16.c What is the risk of incarceration/strangulation in repairs in females are higher when compared with reop-
women with groin hernias? What is the incidence of eration rates in males. In approximately 40% of reopera-
emergent inguinal/femoral hernia repair in women? What tions after anterior mesh or non-mesh repairs, a femoral
are the outcomes? ‘‘recurrence’’ is found, representing a nearly tenfold risk of
this finding in women. 5–9, 17 The explanation for this

Evidence in literature phenomenon may be that femoral hernias are overlooked
When an overt groin hernia is present, the diagnosis can during the initial operations, since an open anterior repair
often be confirmed by physical examination. Textbooks does not always involve opening of the transversalis fascia
state that a femoral hernia produces swelling inferolateral or preperitoneal space exploration. Subgroup analysis from
to the pubic tubercle and an inguinal hernia causes super- the same studies supports this contention by noting that
omedial swelling; however, this subtle distinction is often reoperation rates after laparoscopic approaches (TEP,
difficult to discern, particularly in obese women. TAPP) are lower when compared to Lichtenstein or other
open anterior approaches. 5, 7, 8, 10, 11

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