Page 91 - International guidelines for groin hernia management

Hernia

Evidence in literature Discussion
No RCTs, systematic reviews, or meta-analyses were found Although the statement is only weakly supported by evi-
that address the KQ21.c. Two NRSs exist on ultrasound as dence, the recommendation was upgraded to strong,
a means to detect incarcerated/strangulated groin hernias. because potential benefits greatly outweigh risks. RCTs are
In the first of these, ultrasound was found to be helpful in needed on the value of imaging studies in the setting of
diagnosing those with atypical presentations (e.g., obese suspected incarcerated/strangulated groin hernias.
patients). 313 Hernia complications such as incarceration
and strangulation are usually diagnosed or strongly sus- Key question
pected based on a constellation of signs and symptoms
occasionally supported, or augmented, by laboratory data. KQ21.d Should adults with acutely incarcerated/strangu-
However, sonography is required when the clinical picture lated IHs undergo repair emergently?
is inconclusive or when the surgeon believes that he must

assess the contents of an incarcerated/strangulated groin Evidence in literature
hernia sac preoperatively. Sonographic findings associated Although most would immediately and intuitively answer
with incarcerated hernias include: free fluid in the hernia ‘‘yes!’’ to the question, there is no RCT supporting this
sac (accuracy 96%), bowel wall thickening within the opinion. However, results from NRSs consistently support
hernia (accuracy 97%), fluid within a herniated bowel loop the approach. A low-quality, comparative cohort study
(accuracy 94%), or dilated intraabdominal bowel loops with small numbers of adult patients with incarcerated/
(accuracy 92%). 313 This ultrasound study did not comment strangulated groin hernias analyzed time from symptom
313
on strangulated hernias due to a paucity of cases. In a onset to surgery in two ways. 315 The first comparison was
second study, sonography was used as a guide to show the between patients requiring bowel resection and those not
location and direction of the fascial defect when the requiring it. The second was between patients treated
inguinal mass was compressed with two hands. 314 This within 12 h of symptom onset with those treated outside
ultrasound-guided maneuver may achieve incarcerated that window. Both analyses found a significant increase in
hernia reduction—reducing the number of emergent oper- morbidity and mortality in those with delayed surgeries.
ation—and was found to be easier than blind manual Another similar study comparing patients operated upon
reduction. Another advantage of sonography in this setting within 24 h of symptom onset versus those operated on
is its ability to diagnose other inguinal conditions pre- after that period found a statistically significant increase in
senting this groin pain or mass (e.g., varicocele, hydrocele, bowel resection rates (29 vs 49%, p = 0.047).
abscess, and lymphadenopathy). Notably, both studies In addition, data related to the question which risk fac-
included small patient numbers and their results must be tors increase morbidity and mortality impact this issue. In
interpreted cautiously. particular, presentation and treatment delays, incarceration
No studies have been found regarding other imaging duration, and prolonged symptom duration are related to
modalities in adults with incarcerated/strangulated groin increased morbidity and mortality in adults with incarcer-
hernias. ated/strangulated groin hernias.
Regarding the importance of clinical examination, in a
retrospective cohort study from the Swedish Hernia Discussion
Register, 135 the authors concluded that ‘‘In patients with Although all studies in this subject area are of low quality,
bowel obstruction, physical examination of the groin may the statement is graded as strong, since benefits to patients
decrease the time-to-surgery and reduce imaging investi- seem to clearly outweigh risks. RCTs would be difficult, if
gations in patients needing emergency surgery for groin not frankly impossible, to perform; however, large-scale
hernia.’’ epidemiological studies based on national or international

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