What is the recommended approach for examining and managing a suspected hernia?

Recommended Approach for Examining and Managing Suspected Hernias

For suspected hernias, a focused physical examination followed by appropriate imaging is strongly recommended, with management decisions based on hernia type, symptoms, and patient factors.

Diagnostic Approach

Clinical Examination

• Perform a complete physical examination focusing on the suspected hernia site, including inspection and palpation 1
• For groin hernias, examine the patient both standing and supine, asking them to perform Valsalva maneuver to potentially reveal reducible hernias 1
• Digital rectal examination may be necessary for suspected anorectal hernias, but should be performed after abdominal X-ray if a foreign body is suspected 1

Laboratory Testing

• Routine laboratory tests are not recommended for uncomplicated hernias 1
• In cases of suspected strangulation or incarceration, obtain:
  • Complete blood count (elevated WBC may indicate strangulation) 1
  • Serum lactate (levels ≥2.0 mmol/L suggest non-viable bowel) 1
  • D-dimer (elevated levels correlate with intestinal ischemia) 1
  • CPK and inflammatory markers (C-reactive protein, procalcitonin) 1

Imaging Studies

• For diaphragmatic hernias:

  • Chest X-ray (anteroposterior and lateral views) as first-line imaging, though sensitivity is only 2-60% 1, 2
  • Contrast-enhanced CT scan of chest and abdomen is the gold standard for suspected diaphragmatic hernias 1, 2
  • In pregnant patients, ultrasonography followed by MRI if necessary 1, 2

• For abdominal wall and inguinal hernias:

  • Ultrasonography is recommended as first-line imaging, especially for women and when diagnosis is unclear 2, 3, 4
  • MRI has higher sensitivity and specificity than ultrasound and is useful for occult hernias with negative ultrasound findings 3
  • CT scan is preferred when complications (strangulation, incarceration) are suspected 5, 6
  • Herniography (contrast injection into hernial sac) may be used in selected patients with groin pain but no palpable hernia 3, 7

Management Approach

Non-surgical Management

• Watchful waiting is reasonable for men with asymptomatic or minimally symptomatic inguinal hernias 3
• Watchful waiting is not recommended for symptomatic hernias or in non-pregnant women 3

Surgical Management

• For uncomplicated hernias:

  • Laparoscopic repair is associated with shorter recovery time, less pain, and lower recurrence rates than open repair 3
  • Decision between open or laparoscopic approach should be based on patient characteristics and surgeon expertise 1

• For complicated hernias (incarcerated/strangulated):

  • Repair of incarcerated hernias may be performed laparoscopically in the absence of strangulation or need for bowel resection 1
  • Open pre-peritoneal approach is preferable when strangulation is suspected 1
  • In patients with signs of peritonitis or hemodynamic instability, an open abdominal approach is strongly recommended 1
  • Diagnostic laparoscopy may be useful to assess bowel viability after spontaneous reduction of strangulated hernias 1

Common Pitfalls and Caveats

• Normal chest X-rays do not exclude diaphragmatic hernias (false negatives in 11-62% of cases) 2
• A negative CT scan should not rule out internal hernias in post-bariatric surgery patients 2
• Older patients and those with a history of a groin lump are more likely to have a positive diagnosis confirmed at surgery 7
• Ultrasonography can prevent unnecessary surgery by distinguishing hernias from other masses such as hematomas, abscesses, or tumors 4, 5