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Inguinal hernia

Last updated: November 24, 2020

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An inguinal hernia (IH) is an abnormal protrusion of intraabdominal contents through the inguinal canal. IH is one of two different types of groin hernias (in addition to the less common femoral hernia), and can be further subdivided based on anatomic location: an indirect inguinal hernia protrudes lateral to the inferior epigastric vessels through the deep inguinal ring, whereas a direct inguinal hernia protrudes medial to the inferior epigastric vessels through a defect in the posterior wall of the inguinal canal. An uncomplicated inguinal hernia typically manifests as a mass in the groin with or without pain (inguinodynia). Incarceration, obstruction, and strangulation of hernial contents are collectively referred to as complicated inguinal hernia. IH is a clinical diagnosis. Imaging, preferably with ultrasound, is indicated if the clinical diagnosis is uncertain. Surgery is the only definitive management of IH and can be performed as an open surgery or laparoscopically. A strangulated inguinal hernia is a surgical emergency. In patients with an incarcerated hernia with/without bowel obstruction, manual reduction of the hernia may be considered as a temporizing measure before surgery. Conservative management may be considered in a select group of patients with small, uncomplicated inguinal hernia.

Epidemiological data refers to the US, unless otherwise specified.

Inguinal canal

Hesselbach triangle borders

References:[3]

Direct inguinal hernia

Indirect inguinal hernia

"The DIRECT path leads through the MiDdle, the INDIRECT path goes beLow." (DIRECT hernias lie MeDial and INDIRECT hernias lie Lateral to the inferior epigastric vessels)

References:[1][2][3][4]

Uncomplicated inguinal hernia [5][6][7]

  • Typically manifests as an ill-defined mass in the inguinal region with the following features:
    • Increases in size on coughing or straining
    • Decreases in size on lying supine
    • Inguinal pain (inguinodynia) or vague inguinal discomfort that increases with physical activity; can also be painless
  • Inguinodynia with no palpable groin mass is typically the only manifestation of an occult inguinal hernia. [8]
  • Physical examination

Complicated inguinal hernia [6][7][9]

Manual reduction of inguinal hernia should not be attempted if there are any signs of strangulation!

Inguinal hernia is typically a clinical diagnosis. Imaging is useful if the clinical diagnosis is in doubt. All patients should be evaluated for risk factors for an acquired inguinal hernia.

Imaging [5][10]

Emergency surgery should not be delayed for imaging in unstable patients with signs of strangulation or bowel obstruction. [5]

Laboratory studies [15]

The following tests should be obtained in patients with strangulated inguinal hernia or incarcerated inguinal hernia with bowel obstruction for supportive diagnostic evidence and to assess for complications. [18]

Groin or scrotal mass [6][7]

A groin bulge with an expansile cough impulse above the inguinal ligament is diagnostic of an inguinal hernia. A femoral hernia typically manifests as a groin bulge below the inguinal ligament and lateral to the pubic tubercle. [7]

Inguinodynia [6]

The differential diagnoses listed here are not exhaustive.

Surgical repair of the hernial defect is the only definitive treatment of inguinal hernia. The management of direct inguinal hernia and indirect inguinal hernia does not differ.

Approach [5][6]

Complicated inguinal hernia [7][15]

Acute management

Strangulated inguinal hernia and incarcerated inguinal hernia with mechanical bowel obstruction are surgical emergencies.

Manual reduction of inguinal hernia [19][21]

  • Indication: : Consider as a temporizing measure before surgery in patients with incarcerated hernia with/without bowel obstruction.
  • Contraindication: strangulated inguinal hernia
  • Successful hernia reduction: Observe the patient for 12–24 hours.
    • Symptoms improve: Schedule an elective hernia repair as early as possible.
    • Symptoms worsen: Immediate surgical consult to evaluate for reduction en masse. [22]
  • Unsuccessful hernia reduction: urgent surgery (see “Surgical procedures” below)

Manual reduction of hernial contents is contraindicated if there are signs of a strangulated hernia, as necrotic bowel or omentum can be pushed into the abdominal cavity, potentially leading to serious complications including peritonitis. [21]

Incarcerated inguinal hernia causing bowel obstruction (without evidence of strangulation) is not a contraindication for manual reduction of hernial contents. [19]

Uncomplicated inguinal hernia

Elective surgery [5][23][24]

  • Indications
  • Procedures: See “Surgical procedures” below.

Conservative management (watchful waiting) [5][15]

  • Indications [23]
  • Contraindications [5]
  • General recommendations [5]
    • Consider the use of a truss.
    • Advice against lifting heavy weights.
    • Advice to return to hospital if symptoms worsen. [5]
    • Evaluate and treat potential risk factors of hernia.

Surgical procedures

Once the hernial contents are reduced (i.e., returned to the abdominal cavity), the goal of hernia surgery is to reinforce the posterior wall of the inguinal canal with a synthetic mesh or through primary tissue approximation. Emergency surgery is associated with an increased risk of complications; elective surgery is preferred when it is an option.

Hernioplasty (mesh repair)

Herniorrhaphy (non-mesh repair)

  • Definition: open surgical repair of a hernial defect using autologous tissue
  • Indication: Consider in patients at high risk of surgical site infection. [7][20]
  • Options: Shouldice repair
    • A pure tissue repair that involves a multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique. [7]
    • Preferred procedure when hernioplasty is not feasible
    • Has a lower recurrence rate than other non-mesh repairs
  • Important consideration: Herniorrhaphy is associated with a greater risk of recurrence than hernioplasty. [25]

Complicated inguinal hernia

Uncomplicated inguinal hernia

Preoperative complications [5]

Postoperative complications [5]

We list the most important complications. The selection is not exhaustive.

Inguinal hernia in infants

References:[27][28]

  1. Le T, Bhushan V, Sochat M, Petersen M, Micevic G, Kallianos K. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical ; 2014
  2. Brooks DC, Hawn M. Classification, clinical features and diagnosis of inguinal and femoral hernias in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/classification-clinical-features-and-diagnosis-of-inguinal-and-femoral-hernias-in-adults.Last updated: February 4, 2016. Accessed: December 12, 2016.
  3. Rather AA. Abdominal Hernias. In: Geibel J, Abdominal Hernias. New York, NY: WebMD. http://emedicine.medscape.com/article/189563. Updated: December 1, 2015. Accessed: December 12, 2016.
  4. Jiang ZP, Yang B, Wen LQ, et al. The etiology of indirect inguinal hernia in adults: congenital or acquired?. Hernia. 2015; 19 (5): p.:697-701.
  5. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018; 22 (1): p.1-165. doi: 10.1007/s10029-017-1668-x . | Open in Read by QxMD
  6. LeBlanc KE, LeBlanc LL, LeBlanc KA. Inguinal hernias: diagnosis and management.. Am Fam Physician. 2013; 87 (12): p.844-8.
  7. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier ; 2016
  8. Miller J, Cho J, Michael MJ, Saouaf R, Towfigh S. Role of imaging in the diagnosis of occult hernias.. JAMA surgery. 2014; 149 (10): p.1077-80. doi: 10.1001/jamasurg.2014.484 . | Open in Read by QxMD
  9. Towfigh S, Shafik Y. Diagnostic Considerations in Inguinal Hernia Repair. In: Hope WW, Cobb WS, Adrales GL, eds. Textbook of Hernia. Springer ; 2017.
  10. Piga E, Zetner D, Andresen K, Rosenberg J. Imaging modalities for inguinal hernia diagnosis: a systematic review. Hernia. 2020 . doi: 10.1007/s10029-020-02189-4 . | Open in Read by QxMD
  11. Jacobson JA, Khoury V, Brandon CJ. Ultrasound of the Groin: Techniques, Pathology, and Pitfalls. American Journal of Roentgenology. 2015; 205 (3): p.513-523. doi: 10.2214/ajr.15.14523 . | Open in Read by QxMD
  12. Murphy KP, O’Connor OJ, Maher MM. Adult Abdominal Hernias. American Journal of Roentgenology. 2014; 202 (6): p.W506-W511. doi: 10.2214/ajr.13.12071 . | Open in Read by QxMD
  13. Ng TT, Hamlin JA, Kahn AM. Herniography: analysis of its role and limitations.. Hernia. 2009; 13 (1): p.7-11. doi: 10.1007/s10029-008-0423-8 . | Open in Read by QxMD
  14. Heise CP, Sproat IA, Starling JR. Peritoneography (herniography) for detecting occult inguinal hernia in patients with inguinodynia.. Ann Surg. 2002; 235 (1): p.140-4. doi: 10.1097/00000658-200201000-00018 . | Open in Read by QxMD
  15. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy D, Meckler GD, Cline DM. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th edition. McGraw Hill Professional ; 2019
  16. Stavros AT, Rapp C. Dynamic ultrasound of hernias of the groin and anterior abdominal wall.. Ultrasound Q. 2010; 26 (3): p.135-69. doi: 10.1097/RUQ.0b013e3181f0b23f . | Open in Read by QxMD
  17. Rettenbacher T, Hollerweger A, Macheiner P, et al. Abdominal wall hernias: cross-sectional imaging signs of incarceration determined with sonography.. AJR Am J Roentgenol. 2001; 177 (5): p.1061-6. doi: 10.2214/ajr.177.5.1771061 . | Open in Read by QxMD
  18. Montagnana M, Danese E, Lippi G. Biochemical markers of acute intestinal ischemia: possibilities and limitations.. Annals of translational medicine. 2018; 6 (17): p.341. doi: 10.21037/atm.2018.07.22 . | Open in Read by QxMD
  19. East B, Pawlak M, de Beaux AC. A manual reduction of hernia under analgesia/sedation (Taxis) in the acute inguinal hernia: a useful technique in COVID-19 times to reduce the need for emergency surgery-a literature review. Hernia. 2020; 24 (5): p.937-941. doi: 10.1007/s10029-020-02227-1 . | Open in Read by QxMD
  20. Birindelli A, Sartelli M, Di Saverio S, et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World Journal of Emergency Surgery. 2017; 12 (1). doi: 10.1186/s13017-017-0149-y . | Open in Read by QxMD
  21. Yeh DD, Alam HB. Hernia emergencies. Surg Clin North Am. 2014; 94 (1): p.97-130. doi: 10.1016/j.suc.2013.10.009 . | Open in Read by QxMD
  22. Yatawatta A. Reduction en masse of inguinal hernia: a review of a rare and potential fatal complication following reduction of inguinal hernia. BMJ case reports. 2017; 2017 . doi: 10.1136/bcr-2017-220475 . | Open in Read by QxMD
  23. Montgomery J, Dimick JB, Telem DA. Management of Groin Hernias in Adults-2018.. JAMA. 2018; 320 (10): p.1029-1030. doi: 10.1001/jama.2018.10680 . | Open in Read by QxMD
  24. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009; 13 (4): p.343-403. doi: 10.1007/s10029-009-0529-7 . | Open in Read by QxMD
  25. Niebuhr H, Köckerling F. Surgical risk factors for recurrence in inguinal hernia repair - a review of the literature. Innovative surgical sciences. 2017; 2 (2): p.53-59. doi: 10.1515/iss-2017-0013 . | Open in Read by QxMD
  26. Hakeem A, Shanmugam V. Current trends in the diagnosis and management of post-herniorraphy chronic groin pain. World journal of gastrointestinal surgery. 2011; 3 (6): p.73-81. doi: 10.4240/wjgs.v3.i6.73 . | Open in Read by QxMD
  27. Ramsook C, Endom EE. Overview of inguinal hernia in children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-inguinal-hernia-in-children.Last updated: October 6, 2016. Accessed: December 12, 2016.
  28. Inguinal Hernia, Pediatric. http://5minuteconsult.com/collectioncontent/1-153411/diseases-and-conditions/inguinal-hernia-pediatric. . Accessed: December 12, 2016.
  29. Kim B, Robinson P, Modi H, Gupta H, Horgan K, Achuthan R. Evaluation of the usage and influence of groin ultrasound in primary and secondary healthcare settings.. Hernia. 2015; 19 (3): p.367-71. doi: 10.1007/s10029-014-1212-1 . | Open in Read by QxMD
  30. Köckerling F, Schug-Pass C. Diagnostic Laparoscopy as Decision Tool for Re-recurrent Inguinal Hernia Treatment Following Open Anterior and Laparo-Endoscopic Posterior Repair.. Frontiers in surgery. 2017; 4 : p.22. doi: 10.3389/fsurg.2017.00022 . | Open in Read by QxMD
  31. Miller J, Tregarthen A, Saouaf R, Towfigh S. Radiologic Reporting and Interpretation of Occult Inguinal Hernia.. J Am Coll Surg. 2018; 227 (5): p.489-495. doi: 10.1016/j.jamcollsurg.2018.08.003 . | Open in Read by QxMD
  32. Miserez M, Alexandre JH, Campanelli G, et al. The European hernia society groin hernia classification: simple and easy to remember.. Hernia. 2007; 11 (2): p.113-6. doi: 10.1007/s10029-007-0198-3 . | Open in Read by QxMD
  33. Ekberg O. Inguinal herniography in adults: technique, normal anatomy, and diagnostic criteria for hernias.. Radiology. 1981; 138 (1): p.31-6. doi: 10.1148/radiology.138.1.7455093 . | Open in Read by QxMD
  34. Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ. Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings.. Radiographics. undefined; 31 (2): p.E1-12. doi: 10.1148/rg.312105129 . | Open in Read by QxMD
  35. Revzin MV, Ersahin D, Israel GM, et al. US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation.. Radiographics. 2016; 36 (7): p.2028-2048. doi: 10.1148/rg.2016150181 . | Open in Read by QxMD
  36. Ijpma FFA, Boddeus KM, de Haan HH, van Geldere D. Bilateral round ligament varicosities mimicking inguinal hernia during pregnancy. Hernia. 2008; 13 (1): p.85-88. doi: 10.1007/s10029-008-0395-8 . | Open in Read by QxMD