What are the next steps for managing a tender lump near a hernia on the right hip?

Immediate Evaluation and Management of Tender Lump Near Hip Hernia

A tender lump adjacent to a known hernia on the right hip requires urgent clinical assessment for incarceration or strangulation, with immediate surgical referral if any signs of bowel compromise are present, as delayed diagnosis beyond 24 hours significantly increases mortality risk.

Initial Clinical Assessment

The tenderness is a red flag that demands immediate evaluation for hernia complications:

• Assess for strangulation indicators: Look for signs of bowel compromise including peritonitis (guarding, rebound tenderness), hemodynamic instability (tachycardia, hypotension), or systemic inflammatory response 1
• Check for incarceration: Determine if the lump is reducible—inability to reduce the hernia with gentle pressure suggests incarceration 2
• Laboratory markers: Obtain lactate, CPK, and D-dimer levels, as these are predictive of bowel strangulation 3
• Evaluate for SIRS criteria: Temperature, heart rate, respiratory rate, and white blood cell count help stratify risk 3

Imaging Strategy

Do not delay surgery for imaging if clinical signs of strangulation are present 1. However, if the patient is stable:

• CT abdomen/pelvis with IV contrast is the gold standard for evaluating hernia complications, with sensitivity of 14-82% and specificity of 87% 3, 1
• Critical CT findings of ischemia include: absence of bowel wall contrast enhancement, intestinal wall thickening with target enhancement, lack of enhancement after contrast injection, and the "collar sign" (constriction of herniating organ at the defect) 4, 3
• Include both abdomen and pelvis in the scan to capture the full extent of the hernia 3
• Multiplanar reconstructions increase accuracy in locating transition zones and hernia defects 3

Common Imaging Pitfall

Point-of-care ultrasound can be useful for initial evaluation but should not replace CT when complications are suspected 3. Normal imaging does not exclude hernia complications if clinical suspicion remains high 3.

Surgical Decision-Making Algorithm

Immediate Surgery Required (Within Hours):

• Any signs of bowel strangulation: peritonitis, hemodynamic instability, or gastrointestinal obstruction 1
• CT findings of ischemia: absent bowel wall enhancement, pneumatosis, or portal venous gas 4
• SIRS criteria met with elevated lactate/CPK/D-dimer 3

Rationale: Delayed treatment beyond 24 hours after symptom onset dramatically increases risk of bowel perforation, severe peritonitis, sepsis, and multi-organ failure 1.

Urgent Surgery (Within 24-48 Hours):

• Incarcerated hernia that is tender but without signs of strangulation 2
• Inability to reduce the hernia 2
• Progressive symptoms despite conservative measures 2

Surgical Approach Selection:

For groin/hip hernias requiring emergency repair:

• Mesh repair is recommended as first choice even in emergency settings, provided there is no gross contamination 2, 5
• If bowel resection is required or gross contamination is present, use suture repair (non-mesh) 5
• Open approach is preferred in emergency/unstable patients over laparoscopic techniques 2
• Laparoscopic approach may be considered in stable patients with appropriate expertise available, particularly for femoral hernias 2

Special Considerations for Hip Region Hernias

Femoral Hernia Specific:

• Femoral hernias have higher risk of incarceration/strangulation compared to inguinal hernias, particularly in women 2
• Timely mesh repair by laparoscopic approach is suggested when expertise is available 2
• Women with groin hernias should undergo laparoscopic repair to avoid missing a femoral hernia 2

If Diagnostic Uncertainty Exists:

• Diagnostic laparoscopy may be useful for assessing bowel viability, particularly after spontaneous reduction of a previously strangulated hernia 3
• Low threshold for surgical exploration is warranted given the high morbidity of missed strangulation 3

Critical Time-Sensitive Actions

1. Do not adopt "watchful waiting" for a tender hernia—this strategy only applies to asymptomatic or minimally symptomatic hernias 2
2. Ensure surgical consultation within hours, not days 1
3. NPO status and IV access immediately if any concern for strangulation
4. Avoid attempting repeated manual reduction if initial gentle attempt fails, as this may cause bowel perforation

The combination of a known hernia with new tenderness represents a surgical emergency until proven otherwise, as the consequences of delayed intervention far outweigh the risks of early surgical evaluation 1, 5.