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SSAT Patient Care Guidelines

Surgical Repair of Groin Hernias

Introduction
Groin hernias include inguinal and femoral hernias. Repair of groin hernias is one of the most commonly performed outpatient surgical procedures and it is estimated that 750,000 inguinal hernia repairs are performed yearly in the United States. Inguinal hernias occur most commonly in men. While these hernias afflict persons of all ages, this guideline will address only the adult patient.

A groin hernia is not a "rupture" per se, but rather a groin bulge or mass that develops due to weakened layers of the abdominal wall and protrusion of intra-abdominal contents through the defect. Numerous classification systems for groin hernias have been described, but none have gained universal acceptance. The traditional classification system includes direct, indirect, and femoral hernias. Direct inguinal hernias develop when the posterior portion of the inguinal canal attenuates, allowing the underlying contents of the abdominal cavity to protrude. An indirect inguinal hernia occurs along the spermatic cord or round ligament in the inguinal canal. A femoral hernia passes behind the inguinal canal and herniates alongside of the femoral vessels.

Symptoms and Diagnosis
Inguinal hernias may be asymptomatic (discovered incidentally during physical examination) or present as a bulge discovered by the patient. They may be associated with vague groin pain, commonly made worse by straining or physical activity. Patients may also present with complications of groin hernias such as incarceration (not reducible) or strangulation of bowel which causes an obstruction in that segment. Since most hernias should be repaired, the patient should be referred to a surgeon for evaluation and operative treatment. Ultrasound or other radiologic studies are not required because the diagnosis can usually be made by physical examination. This is best performed with the patient standing and straining against a held breath (Valsalva maneuver).

More difficult to diagnose is the occasional patient with groin pain, or inguinodynia, but no history of groin bulge and no physical findings. Such a patient may not have a hernia, but rather a groin muscle strain. In contrast, if a hernia is not found on physical examination, but the patient describes a groin bulge, a hernia is still possible. Femoral hernias can present as pain in the upper thigh rather than a bulge, and are particularly difficult to diagnose in the elderly or obese patient. Ultrasound or axial imaging may be useful in delineating the abnormality. Although these rarer hernias occur mostly in elderly women, the most common type of groin hernia seen in this patient population is still the indirect inguinal hernia.

Most groin hernias are readily reducible, have minimal or no tenderness, and can be electively referred to a surgeon within a period of weeks. However, if the hernia is tender and not reducible, the patient should be referred immediately due to the risk of strangulated bowel or other viscera. Aggressive attempts to reduce a groin hernia with sedation, ice packs, or sustained weight or pressure should not be pursued. Symptoms such as nausea and vomiting suggest bowel obstruction, which also mandate immediate referral to a surgeon.

Treatment
Most groin hernias can be electively repaired. Urgent repair is required for an acutely non-reducible hernia or for a chronically incarcerated hernia that suddenly becomes painful, as this indicates impending strangulation. While significant morbidity and mortality can be avoided by prompt diagnosis, this clinical emergency causes the death of more than 2,000 patients per year in North America.

Inguinal hernias should be repaired surgically. Hernia belts or trusses should be discouraged, and should be limited to patients who are not candidates for an elective operation. Chronic scarring from their use can lead to a more difficult repair and higher risks of complications. Femoral hernias should always be repaired because of the high incidence of associated bowel herniation. Elderly patients with minor co-morbid conditions will easily tolerate an outpatient elective hernia repair, which can be accomplished with intravenous sedation and local anesthesia. All attempts should be made to avoid emergent repairs of chronically incarcerated hernias, which occur primarily in the elderly. The timing of repair is determined by the symptoms.

The objective of any inguinal or femoral hernia operation is to repair the defect in the abdominal wall. The three basic approaches are: (1) open repair (the traditional repair, utilizing the patient's own tissue); (2) open tension-free repair (in which mesh is used to bridge or cover the defect); and (3) laparoscopic repair, a tension-free repair also utilizing mesh. In general, the traditional, tissue-based repairs have been replaced by tension-free or mesh-based repairs. These include the Lichtenstein, Plug and Patch, laparoscopic, and “hybrid” techniques. No particular technique has been found to be superior, and all of them can be expected to result in excellent outcomes when performed by adequately trained surgeons with sufficient experience in their performance. Open techniques of hernia repair may be safely performed under local, regional, or general anesthesia with equivalent outcomes, while laparoscopic hernia repair requires general anesthesia.

Some selected hernias can be treated nonoperatively with careful observation. Suitable hernias for nonoperative management are direct hernias with a wide neck that easily reduce particularly in elderly asymptomatic patients or patients at a heightened risk for operative intervention.

Risks
The risk of infection or significant hematoma is approximately 1%. With contemporary tension free techniques hernia recurrence occurs in 2%-5% of patients and requires another repair. Chronic groin pain (inguinodynia) may be seen after groin hernia repair (approximately 5%) and is a difficult problem to treat and may require multimodality pain management or further surgery.

Expected Outcomes
Short-term outcome studies suggest that a quick return to normal activities can be achieved following both open and laparoscopic hernia repair. Usual daily activities can be resumed within a few days after surgery, depending on the patient's comfort level. Oral pain medications are needed for only a few days. Heavy lifting and exercise are commonly discouraged for four to six weeks following inguinal hernia repair, although patients can typically resume any physical activity that is comfortable to them and progress at their own pace.

Qualifications for performing inguinal and femoral hernia repairs
Surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform both elective and emergent inguinal hernia repair. These surgeons have successfully completed at least five years of surgical training after medical school graduation and are qualified to perform open inguinal hernia repair, with and without tension-free techniques. Advanced laparoscopic training is required for laparoscopic groin hernia repair. The qualifications of the surgeon should be based on training (education), experience, and outcomes.

Suggested Readings
Chung R S, Rowland D Y. Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs. Surg Endoscopy 1999; 13:689-694.

Grunwaldt LJ, Schwaitzberg SD, Rattner DW, Jones DB. Is laparoscopic inguinal hernia repair an operation of the past? J Am Coll Surg. 2005; 200(4):616-20.

Koninger J, Redecke J, Butters M. Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP. Langenbecks Arch Surg. 2004; 389(5):361-5.

O'Dwyer PJ, Serpell MG, Millar K, Paterson C, Young D, Hair A, Courtney CA, Horgan P, Kumar S, Walker A, Ford I. Local or general anesthesia for open hernia repair: a randomized trial. Ann Surg. 2003; 237(4):574-9.

Nordin P, Haapaniemi S, van der Linden W, Nilsson E. Choice of anesthesia and risk of reoperation for recurrence in groin hernia repair. Ann Surg. 2004; 240(1):187-92.

Nordin P, Zetterstrom H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet. 2003; 362(9387):853-8.

Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004; 350(18):1819-27.

Rutkow IM. The PerFix plug repair for groin hernias. Surg Clin North Am. 2003 Oct;83(5):1079-98

Sanchez-Manuel FJ, Seco-Gil JL Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003769.

Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, Neumayer LA, Barkun JS, Hoehn JL, Murphy JT, Sarosi GA Jr, Syme WC, Thompson JS, Wang J, Jonasson O. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006; 295 (3):285-92

Keywords - patient, guideline, groin hernia, inguinal hernia, femoral hernia, open repair, tension-free repair, laparoscopic repair, recurrence, groin pain, complications, mesh, incarcerated

Written 1/20/96
Revised 5/5/96
Revised 9/27/96
Revised 10/10/96
Revised 2/5/97
Revised 5/11/97
Revised 9/26/99
Revised 11/1/99
Proofed 1/8/00
Revised 12/16/02
Board Approved 2/1/03
Revised 4/4/06
Board Approved 5/20/06
Reviewed 11/22/13

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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