Inguinal hernia

Last updated: May 3, 2022

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An inguinal hernia is an abnormal protrusion of intraabdominal contents (most commonly fat) through the inguinal canal. Inguinal hernias are the most common type of groin 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. Inguinal hernia is a clinical diagnosis. Imaging, preferably with ultrasound, is indicated if the clinical diagnosis is uncertain. Surgery is the only definitive management of inguinal hernia 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 or without bowel obstruction, manual reduction of the hernia may be considered as a temporizing measure before surgery. Conservative management may be considered in select patients with a small, uncomplicated inguinal hernia.

Overview of hernias
Inguinal hernia Femoral hernia
Indirect Direct

Epidemiology

  • Less common type of hernia (∼ 5% of all cases)
  • More common in women [1]
  • More common in older men
Etiology
Location
Clinical features
Diagnostics
Treatment
  • Surgical repair

See “Femoral hernia” for further information.

Epidemiological data refers to the US, unless otherwise specified.

Inguinal canal

Hesselbach triangle borders

References:[4]

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:[2][3][4][5]

Uncomplicated inguinal hernia [6][7][8]

Female patients rarely present with visible bulges but often report a sensation of heaviness or dull discomfort in the groin or pelvis that is worsened by lifting, straining, or prolonged standing. [10]

Complicated inguinal hernia [7][8][11]

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

Inguinal hernia is typically a clinical diagnosis; however, imaging may be useful if the clinical diagnosis is unclear or to investigate an underlying cause.

Clinical evaluation

To avoid missing inguinal hernias, routinely examine the inguinal canal in patients with unexplained acute abdominal pain and/or clinical features of bowel obstruction, especially in those with verbal impairment.

Imaging [6][13]

Indications

Modalities [6]

Supportive findings

Do not delay emergency surgery for imaging in unstable patients with signs of strangulated hernia or obstructed hernia. [6]

Laboratory studies [19]

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. [21]

Maintain a high index of suspicion for strangulation in patients with an incarcerated hernia and leukocytosis. [12]

Groin or scrotal mass [7][8]

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. [8]

Groin pain [7]

If these diagnoses are chronic or recurrent, they may cause inguinodynia.

The differential diagnoses listed here are not exhaustive.

Overview [6][7]

Critically ill patients with complicated inguinal hernias need to be stabilized and evaluated concurrently. Well-appearing patients with easily reducible hernias typically do not need further workup in the emergency department.

Strangulated inguinal hernias and obstructed hernias are surgical emergencies.

Initial management and disposition [19][23]

Intestinal infarction can occur within 6 hours of strangulation. [12]

Risk factors associated with poor outcomes in incarcerated and strangulated hernias include older age, obesity (BMI > 30 kg/m2), prolonged duration of symptoms, female sex, and a delayed diagnosis. [6]

Manual reduction of an inguinal hernia [19][23][27]

Manual reduction of hernial contents is contraindicated in patients with signs of a strangulated hernia, as necrotic bowel or omentum may be pushed into the abdominal cavity, which can lead to serious complications including peritonitis. [23]

Manual reduction can be performed in patients with an incarcerated inguinal hernia causing bowel obstruction provided there is no evidence of strangulation. [27]

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

Surgeries for inguinal hernia

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.

Indications

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. [8][25]
  • 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. [8]
    • 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. [29]

Conservative management [6][19]

Most patients who are managed conservatively will eventually require surgical repair.

  • Indications [30]
  • Contraindications [6]
  • General recommendations [6]
    • Consider the use of a truss.
    • Advise against lifting heavy weights.
    • Advise returning to seek care if symptoms worsen. [6]
    • Evaluate and treat potential risk factors of hernia.

All patients with inguinal hernia

Acute management of strangulated inguinal hernia

Preoperative complications [6]

Postoperative complications [6]

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

Inguinal hernia in children

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