Page 59 - International guidelines for groin hernia management

Hernia

Two small cohort studies focused on hernia repair in watchful waiting strategy in women with groin hernias.
women also suggest that an open anterior repair is asso- Timely hernia repair is recommended.
ciated with a relatively high postoperative complication
rate and a higher incidence of postoperative pain compared Discussion
with women undergoing TEP hernia repair. 18, 19 There are no systematic reviews or RCTs specifically
The high frequency of femoral hernias in women and the addressing groin hernias in women, but several subgroup
high risk of femoral recurrence mentioned above highlight analyses from large epidemiological studies of national
the need for preperitoneal exploration and repair in all databases provide information about groin hernias and
women with groin hernias. A laparoscopic preperitoneal groin hernia repairs in women. It is abundantly clear that
repair offers a thorough view of the entire myopectineal femoral hernias are more common in women. This argues
orifice and creates easy access to, and coverage of, both for the use of a preperitoneal laparoscopic approach in
inguinal and femoral defects. This also obviates the need women with groin hernias. In addition, since strangulation
for a correct preoperative diagnosis. 7, 15, 16 Anatomically risk is unacceptably high, timely elective repair of groin
and with regard to mesh application, there is a little dif- hernias in women is strongly advised.
ference between the laparoscopic and open preperitoneal
approach, but laparoscopic repair techniques have a long Key question
learning curve (see chapter 22 on learning curve). 20 In
experienced hands though, laparoscopic hernia repair KQ16.d How is a groin lump in a pregnant female diag-
seems to be associated with a slightly lower reoperation nosed and treated?
risk than open preperitoneal repair. 9, 10, 21

Femoral hernias carry a higher risk of strangulation Evidence in literature
when compared with IHs. In the Swedish and Danish IH formation during pregnancy is rare with a prevalence
hernia registries, 36–39% of femoral hernias were emer- estimated as 1; 2000. 23 A watchful waiting strategy is
gently repaired versus 5% of IHs. 10, 22 recommended for those who develop IHs during
About 17% of women with groin hernias require pregnancy. 24
emergent repair versus about 5% of men. 9, 22 Furthermore, Although mainly described in small case series and case
patients with femoral hernias have a greater risk of reports, the onset of a groin lump in pregnancy is often a
undergoing bowel resection (23% of patients undergoing round ligament varicosity rather than a hernia. 25 A round
emergent femoral hernia repair compared with approxi- ligament varicocele arises from the veins draining the
mately 5% of patients undergoing emergent IH repair). round ligament and the inguinal canal. It is a rare entity
Bowel resection occurred in 17% of women undergoing associated with pregnancy, presents with a groin lump
emergent groin hernia repair. There are no specific data typically early in the third trimester, progressively enlarges
about bowel resection after femoral hernia repair. during pregnancy, and regresses soon after delivery. 25 The
A woman’s risk of death in the 30 days after elective diagnosis can be easily confirmed by color Doppler
femoral hernia repair is comparable to the risk of dying in sonography. If, in fact, a groin lump consisting of varicose
an age- and gender-matched population (\ 0.1%). How- veins occurs, symptoms will spontaneously abate after
ever, 3.8% of women die within the 30 days following delivery and expectant management can be used. Varico-
9, 22
emergent femoral hernia repair. cele resection might be necessary only in cases with severe
The higher incidence of femoral hernias in women and pain.
the associated strangulation risk argues strongly against a

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