Inguinal Hernia: Diagnosis and Surgical Management
This elderly female has a symptomatic inguinal hernia that requires surgical repair, as the painful bulge on the left side of the pubic bone that reduces when lying down is pathognomonic for this condition.
Clinical Diagnosis
The presentation described is classic for inguinal hernia and diagnosis can be made clinically without imaging in most cases 1:
- Groin pain is a cardinal symptom, often described as burning, gurgling, or aching, and may be severe 1, 2
- Visible/palpable bulge that appears with standing or straining and disappears when lying down (reducible hernia) 1
- Pain typically worsens toward the end of the day and after prolonged activity 1
- A heavy or dragging sensation in the groin is common 1
Physical examination is usually sufficient for diagnosis - palpate for a bulge or impulse while the patient coughs or strains 1. In elderly females, inguinal hernias may present atypically, and the diagnosis is often delayed because hernias are less common in women 3.
When Imaging Is Indicated
Imaging is rarely necessary but should be considered in specific situations 1:
- Ultrasonography is the first-line imaging modality when physical examination is equivocal or to rule out other pathology 1
- MRI can help diagnose occult hernias when there is groin pain without a palpable bulge 1, 3
- Imaging may also be indicated for suspected recurrent hernia or surgical complications 1
Treatment Recommendation
Surgical repair is strongly recommended for this patient because she has a symptomatic hernia with pain 1, 4. The key considerations are:
Indications for Surgery
- Symptomatic hernias with pain should be repaired to prevent prolonged suffering and avoid progression to complications 3
- Delaying repair in symptomatic patients is associated with increased opioid use and prolonged pain, with 83% symptom resolution achievable after repair 3
- Small, minimally symptomatic hernias may be observed, but this patient has pain, making surgery appropriate 1
Surgical Approach Options
Open mesh repair is the preferred technique for most inguinal hernias based on superior outcomes 4:
- Open mesh repair demonstrates advantages over laparoscopic procedures in terms of lower cost, less operative time, and potentially lower recurrence rates 4
- Laparoscopic procedures (TAPP or TEP) may offer faster recovery but require more time, cost more, and carry specific complications like trocar injuries and bowel obstruction 4
- In elderly patients, open repair under local anesthesia may be safer given comorbidities 4
Critical Management Points
The patient should be counseled about both open and laparoscopic options, with the decision based on surgeon expertise, patient factors, and preferences 1:
- Mesh repair is standard of care for inguinal hernias in elderly patients 4, 5
- Surgical complications and recurrences are uncommon with modern techniques 1
- If recurrence occurs, referral back to the original surgeon is recommended 1
Common Pitfalls to Avoid
- Do not delay surgery in symptomatic patients - prolonged conservative management leads to increased pain medication use including opioids, especially in females 3
- Do not dismiss groin pain without a prominent bulge - occult hernias account for 44% of inguinal hernias and cause significant suffering if untreated 3
- Do not assume all groin pain is hernia-related - consider other diagnoses like hip pathology, but in this case the reducible bulge confirms the diagnosis 1, 2
- Elderly patients may have atypical presentations - maintain high clinical suspicion even with subtle findings 3