What is the diagnosis and treatment for inguinal (groin) issues?

From the Guidelines

Patients with inguinal hernias should undergo emergency hernia repair immediately when intestinal strangulation is suspected, as this approach is associated with improved outcomes in terms of morbidity, mortality, and quality of life. The management of inguinal hernias involves surgical repair, which can be performed through open surgery or laparoscopic techniques, with mesh reinforcement being the standard approach for most adult cases 1.

Key Considerations

• The use of mesh in clean surgical fields is associated with a lower recurrence rate without an increase in wound infection rate, and is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 1.
• For patients with complicated hernias and intestinal strangulation, emergent prosthetic repair with synthetic mesh can be performed without an increase in 30-day wound-related morbidity, and is associated with a significant lower risk of recurrence 1.
• Diagnostic laparoscopy may be a useful tool for assessing bowel viability after spontaneous reduction of strangulated groin hernias, and laparoscopic repair of incarcerated hernias can be performed in the absence of strangulation and suspicion of the need for bowel resection 1.

Treatment Approaches

• Surgical repair is the primary treatment approach for inguinal hernias, with mesh reinforcement being the standard for most adult cases.
• Conservative management with watchful waiting may be appropriate for small, asymptomatic hernias.
• The choice of surgical approach (open or laparoscopic) depends on various factors, including the presence of strangulation, suspicion of bowel resection, and the patient's overall health status.

Predictive Factors

• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, lactate, CPK, and D-dimer levels are predictive of bowel strangulation 1.
• Elevated D-dimer levels and lactate levels are associated with intestinal ischemia and non-viable bowel strangulation, respectively 1.

Complications

• Bowel resection is required in approximately 15% of cases, and is associated with increased morbidity and mortality rates 1.
• Wound infection and mesh infection are potential complications of hernia repair, but the use of mesh is not contraindicated in cases of bowel resection or non-viable intestine 1.

From the Research

Inguinal Hernia Diagnosis and Management

• Inguinal hernias are one of the most common reasons a primary care patient may need referral for surgical intervention 2
• The history and physical examination are usually sufficient to make the diagnosis, with symptomatic patients often experiencing groin pain, burning, gurgling, or aching sensations in the groin 2
• An abdominal bulge may disappear when the patient is in the prone position, and examination involves feeling for a bulge or impulse while the patient coughs or strains 2

Treatment Options

• Surgical intervention is not always necessary, such as with a small, minimally symptomatic hernia 2
• Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair 3
• Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias, but not recommended in patients with symptomatic hernias or in nonpregnant women 3
• The Lichtenstein technique is the standard in open inguinal hernia repair, while transabdominal preperitoneal and totally extraperitoneal approach have comparable outcomes 4

Surgical Techniques and Recommendations

• The use of the EHS classification system is suggested, and mesh repair is recommended in elective operations 4
• Mesh repair is also recommended in the case of strangulation, but only in clean and clean-contaminated operations 4
• A laparoscopic approach should be considered, as it allows an assessment of bowel viability during the whole procedure and has a lower need for bowel resection compared to open surgery 4
• The International Guidelines of the Hernia-Surge Group only recommend the totally extraperitoneal patch plasty (TEP), transabdominal preperitoneal patch plasty (TAPP), and Lichtenstein techniques 5

Non-Surgical Treatment and Readmission Rates

• Watchful-waiting strategy is the most common treatment approach in patients admitted non-electively for symptomatic inguinal hernia 6
• Readmission after non-elective hospitalization for inguinal hernia is rare, but surgical intervention decreased the likelihood of readmission compared to non-operative management, while also increasing length of stay and cost of care 6
• Non-surgical treatment is a viable temporary option even in symptomatic inguinal hernias, while surgical treatment may reduce the likelihood of future readmission 6