What is the recommended approach for a hernia work-up?

From the Guidelines

The recommended approach for a hernia work-up begins with a thorough clinical examination, which is often sufficient for diagnosis in many cases, and patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected 1.

Key Components of Hernia Work-up

• A detailed history focusing on symptoms like pain, bulging, and any exacerbating factors
• Physical examination with the patient both standing and lying down, including the Valsalva maneuver to increase intra-abdominal pressure
• Imaging studies, with ultrasound being the first-line option due to its cost-effectiveness, lack of radiation, and good sensitivity for ventral and inguinal hernias
• CT scans are recommended when ultrasound results are inconclusive or for complex cases, particularly for detecting small hernias or evaluating complications like strangulation
• Laboratory tests, including complete blood count to check for leukocytosis and basic metabolic panel to assess for electrolyte imbalances, may be ordered if complications like bowel obstruction or strangulation are suspected

Predictive Factors for Bowel Strangulation

• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are predictive of bowel strangulation 1
• Elevated D-dimer levels measured upon admission were found to correlate strongly with intestinal ischaemia 1
• Lactate level was the only laboratory parameter significantly associated with a lack of viability (P < 0.01, Mann–Whitney U test) 1

Timing of Intervention

• Early detection of complicated abdominal hernias may be the best means of reducing the rate of mortality 1
• The elapsed time from onset to surgery was the most important prognostic factor (P < 0.005) 1
• Delayed diagnosis can lead to septic complications, and the benefits of immediate surgical intervention outweigh the risks in cases of suspected bowel strangulation 1

From the Research

Hernia Work-up Approach

The recommended approach for a hernia work-up involves several steps:

• Physical examination is the primary method for diagnosing inguinal hernias, especially in men 2, 3.
• Ultrasonography is useful for diagnosing hernias in women, recurrent hernias, and when physical examination is inconclusive 2, 3, 4.
• Magnetic resonance imaging (MRI) or computed tomography (CT) scans may be necessary in some cases, such as diagnosing occult hernias or evaluating the extent of the hernia 2, 3, 4.
• The EHS classification system can be used to stratify patients for tailored treatment, research, and audit 2.

Diagnostic Tools

The following diagnostic tools can be used in a hernia work-up:

• Ultrasonography: sensitive and specific for diagnosing hernias, especially in women and recurrent cases 3, 4, 5.
• MRI or CT scans: useful for diagnosing occult hernias, evaluating the extent of the hernia, and ruling out other causes of groin pain 2, 3, 4.
• Herniography: may be used in selected patients to diagnose hernias, especially when other imaging modalities are inconclusive 2, 4.

Management

The management of hernias depends on the type, size, and symptoms:

• Symptomatic groin hernias should be treated surgically 2, 3.
• Asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with "watchful waiting" 2, 3.
• Mesh repair is recommended as the first choice for hernia repair, either by an open procedure or a laparo-endoscopic repair technique 2.
• Laparo-endoscopic techniques have faster recovery times, lower chronic pain risk, and are cost-effective, especially for bilateral hernias 2, 3.