What is the comprehensive workup and management plan for a patient presenting with an inguinal hernia?

Comprehensive Workup and Management of Inguinal Hernia

Clinical Diagnosis

Physical examination alone is sufficient to diagnose inguinal hernia in the vast majority of patients, making imaging unnecessary in typical presentations. 1, 2

Key Physical Examination Findings

• Examine for a palpable bulge or impulse in the groin while the patient coughs or strains, which confirms the diagnosis in most cases 1
• Check both groins bilaterally to avoid missing contralateral hernias, which occur in 11-50% of cases 3, 4
• In males, palpate the testis to ensure it is present in the scrotum and not involved in the hernia 3
• Look for the "silk sign" (scrotal contents retracting inward on coughing), which is pathognomonic for inguinal hernia with patent processus vaginalis 3
• Assess for femoral hernias, which carry an 8-fold higher risk of requiring bowel resection and have higher strangulation risk 3, 4

Imaging Indications (Rarely Needed)

• Ultrasonography is indicated only when: diagnosis is uncertain, there is a recurrent hernia, suspected hydrocele, surgical complications, or in athletes without palpable bulge 1
• CT scanning with contrast is reserved for emergency settings to assess for complications like bowel obstruction or strangulation (56% sensitivity, 94% specificity for reduced wall enhancement) 3

Assessment for Complications Requiring Emergency Surgery

Immediately assess for signs of incarceration or strangulation, as delayed treatment beyond 24 hours significantly increases mortality. 3, 4

Red Flags Requiring Emergency Intervention

• Irreducibility, tenderness, erythema, or warmth over the hernia 3
• Systemic symptoms: fever, tachycardia, leukocytosis (SIRS criteria) 3, 4
• Abdominal wall rigidity 3
• Laboratory markers: elevated lactate, CPK, and D-dimer levels predict bowel strangulation 3, 4
• Symptomatic periods lasting longer than 8 hours significantly affect morbidity 3

Management Algorithm

For Asymptomatic or Minimally Symptomatic Hernias

• "Watchful waiting" is acceptable for asymptomatic or minimally symptomatic male patients, as their risk of hernia-related emergencies is low 2
• All inguinal hernias in women should be operated on due to higher risk of femoral hernias and complications 5, 2
• All symptomatic groin hernias should be treated surgically 3, 2

For Elective Repair (Non-Complicated Hernias)

Mesh repair is the definitive standard approach for all non-complicated inguinal hernias, with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 4, 2

Surgical Approach Selection

• For bilateral hernias or hernias in women: laparoscopic repair (TAPP or TEP) is preferable 5, 2
• For primary unilateral hernias in men: either open (Lichtenstein) or laparoscopic approach is appropriate 5, 2
• Laparoscopic approaches offer: reduced chronic pain (most important benefit), lower wound infection rates, faster recovery, and ability to identify occult contralateral hernias present in 11.2-50% of cases 4, 2
• Open repair advantages: can be performed under local anesthesia, may be preferred in patients with significant comorbidities 4, 2

Specific Technique Recommendations

• TAPP (transabdominal preperitoneal): requires entering peritoneal cavity, permits identification of occult contralateral hernias; may be easier in recurrent cases 4
• TEP (totally extraperitoneal): mesh fixation is unnecessary in most cases except M3 hernias (large medial) to reduce recurrence 2
• Lichtenstein (open anterior mesh repair): well-evaluated technique, first choice for open repair 2

For Emergency/Complicated Hernias (Incarcerated or Strangulated)

Emergency surgical repair is mandatory when intestinal strangulation is suspected to prevent bowel necrosis and death. 3, 4

Surgical Approach for Complicated Hernias

• For incarcerated hernias WITHOUT strangulation or bowel necrosis: prosthetic mesh repair with synthetic mesh is recommended (Grade 1A), either laparoscopic (TAPP/TEP) or open approach 4
• For strangulated hernias or suspected bowel compromise: open preperitoneal approach is preferable when bowel resection may be needed 4
• Hernioscopy (laparoscopy through hernia sac) can assess bowel viability, avoiding unnecessary laparotomy and decreasing hospital stay 4

Mesh Use in Contaminated Fields

• Clean surgical field (CDC class I): synthetic mesh is strongly recommended 4
• Clean-contaminated field (CDC class II): emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or bowel resection without gross enteric spillage 4
• For small defects (<3 cm) with bowel necrosis or peritonitis: primary repair is recommended 4
• When direct suture is not feasible: biological mesh may be used 4

Anesthesia Selection in Emergency Settings

• Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene (open approach) 4
• General anesthesia is required when bowel gangrene is suspected or peritonitis is present 4

Postoperative Management

Pain Control

• Encourage acetaminophen and NSAIDs as primary pain control 4
• Opioid prescribing should be limited to: 15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg for laparoscopic repair; 15 tablets for open repair 4

Activity Restrictions

• Patients should resume normal activities without restrictions as soon as they feel comfortable 2

Monitoring for Complications

• Monitor for: wound infection, chronic pain (occurs in 10-12% of patients, debilitating pain in 0.5-6%), recurrence, and testicular complications in males 3, 4

Management of Recurrent Hernias

• After anterior repair failure: posterior repair is recommended 3
• After posterior repair failure: anterior repair is recommended 3
• After failed anterior AND posterior approaches: referral to specialist hernia surgeon is recommended 3

Common Pitfalls to Avoid

• Failing to examine both groins bilaterally misses contralateral hernias in up to 50% of cases 3
• Missing femoral hernias, which have 8-fold higher risk of requiring bowel resection 4
• Delaying repair of strangulated hernias leads to bowel necrosis and significantly increased mortality 3, 4
• Not assessing for complications requiring urgent intervention in patients with irreducibility, tenderness, or systemic symptoms 3