How do you diagnose and manage an inguinal (in the groin area) hernia?

From the Guidelines

Inguinal hernias should be diagnosed through a combination of physical examination and imaging, and managed with either watchful waiting or surgical repair, prioritizing surgical intervention for symptomatic hernias or those at risk for complications, as this approach is associated with reduced morbidity, mortality, and improved quality of life 1.

Diagnosis

• Physical examination is the primary method for diagnosing inguinal hernias, where a healthcare provider examines the groin area while the patient stands and coughs, looking for a bulge or protrusion.
• Imaging studies such as ultrasound or CT scans may be used to confirm the diagnosis in unclear cases.

Management

• Asymptomatic or minimally symptomatic hernias, especially in older adults or those with medical comorbidities, can be managed with watchful waiting and regular monitoring.
• Surgical repair is recommended for symptomatic hernias or those at risk for complications, as it reduces the risk of incarceration, strangulation, and other serious complications 1.
• Surgical options include open repair using mesh (Lichtenstein technique) or laparoscopic approaches (TAPP or TEP), with the choice depending on patient factors and surgeon expertise.
• Open repair typically uses polypropylene mesh and is performed under local or regional anesthesia, while laparoscopic repairs require general anesthesia but offer faster recovery.

Post-Surgery Care

• Patients should avoid heavy lifting (>10 pounds) for 4-6 weeks after surgery.
• Pain management with acetaminophen or NSAIDs is recommended.
• Patients should watch for complications like infection, chronic pain, or recurrence.

Evidence-Based Recommendations

• The use of mesh in clean surgical fields is associated with a lower recurrence rate and is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 1.
• For patients with complicated hernia and intestinal strangulation, emergent prosthetic repair with synthetic mesh can be performed without increasing 30-day wound-related morbidity 1.
• The choice of surgical approach and mesh type should be individualized based on patient factors, defect size, and degree of contamination, with the goal of minimizing morbidity, mortality, and improving quality of life 1.

From the Research

Diagnosis of Inguinal Hernia

• The diagnosis of inguinal hernia can be made through physical examination alone in the vast majority of patients with appropriate signs and symptoms 2.
• The history and physical examination are usually sufficient to make the diagnosis, with symptomatic patients often experiencing groin pain, a burning, gurgling, or aching sensation in the groin, and a heavy or dragging sensation that worsens toward the end of the day and after prolonged activity 3.
• Examination involves feeling for a bulge or impulse while the patient coughs or strains 3.
• Imaging such as ultrasonography or magnetic resonance imaging can help diagnose a hernia in an athlete without a palpable impulse or bulge on physical examination, or in cases of recurrent hernia or suspected hydrocele 3, 4.

Management of Inguinal Hernia

• Symptomatic groin hernias should be treated surgically 2.
• Asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low 4, 2.
• Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics, and local/national resources 2.
• Mesh repair is recommended as the first choice, either by an open procedure or a laparo-endoscopic repair technique 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 4, 5.

Treatment Options

• Laparoscopic repair offers significant advantages over open techniques for patients with recurrent inguinal hernia, bilateral inguinal hernia, or for women 5.
• The Lichtenstein and laparo-endoscopic repair techniques are well-established and effective options for inguinal hernia repair 2, 5.
• Day surgery is recommended for the majority of groin hernia repair, provided aftercare is organized 2.
• The use of low-weight mesh may have slight short-term benefits, but it is not associated with better longer-term outcomes like recurrence and chronic pain 2.