What is the appropriate workup and management for a patient presenting with an inguinal (near groin) hernia?

Workup and Management of Inguinal Hernia

For a patient presenting with a groin hernia, diagnosis is primarily clinical through history and physical examination, with imaging reserved for uncertain cases, and surgical mesh repair is the definitive treatment for symptomatic hernias. 1, 2

Initial Clinical Assessment

The diagnosis of inguinal hernia is made by physical examination in the vast majority of cases. 2, 3

Key History Elements

• Ask about groin pain, which may be burning, gurgling, or aching in character, often worsening toward the end of the day and after prolonged activity 2
• Inquire about a visible bulge that may disappear when lying down 2
• Assess for symptoms of incarceration: sudden onset of severe pain, nausea, vomiting, inability to reduce the hernia 4
• Identify risk factors including family history, previous contralateral hernia, male gender, advanced age, and history of prostatectomy 3

Physical Examination Technique

• Palpate for a bulge or impulse while the patient coughs or performs Valsalva maneuver 2
• Examine both standing and supine positions 2
• Assess for signs of incarceration/strangulation: firm, tender, irreducible mass; skin changes (erythema, warmth, discoloration); peritoneal signs on examination 5
• In women, carefully evaluate to distinguish inguinal from femoral hernias, as femoral hernias carry an 8-fold higher risk of requiring bowel resection 1

Diagnostic Imaging

Imaging is rarely necessary when physical examination findings are clear. 2, 3

Indications for Imaging

• Ultrasonography is indicated when: 2

  • The diagnosis is uncertain despite physical examination
  • An athlete presents without palpable impulse or bulge
  • Recurrent hernia is suspected
  • Suspected hydrocele needs differentiation
  • Surgical complications are being evaluated

• CT scan with contrast is indicated when strangulation is suspected, as reduced bowel wall enhancement is the most significant independent predictor of bowel strangulation (56% sensitivity, 94% specificity) 4

Laboratory Workup for Suspected Complicated Hernias

When incarceration or strangulation is suspected, obtain the following laboratory studies: 1, 6

• Complete blood count (CBC): Elevated WBC count is independently predictive of bowel strangulation and is significantly associated with morbidity in incarcerated hernias 4
• Arterial lactate level: A level ≥2.0 mmol/L is a useful predictor of non-viable bowel strangulation 4
• Serum creatinine phosphokinase (CPK): Elevated levels correlate with bowel strangulation 6
• D-dimer: Elevated levels correlate strongly with intestinal ischemia 4
• Fibrinogen: High levels are significantly predictive of morbidity in incarcerated hernias 4
• Assess for SIRS criteria (temperature, heart rate, respiratory rate, WBC), which are predictive of bowel strangulation 6, 5

Treatment Algorithm Based on Clinical Presentation

Uncomplicated, Reducible Hernia

Mesh repair is the standard of care for symptomatic inguinal hernias, with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 1, 3

Surgical Approach Selection

• For bilateral hernias or hernias in women: Laparoscopic approach (TAPP or TEP) is preferable 1, 7, 3

  • Advantages include: reduced chronic postoperative pain, lower wound infection rates, faster return to normal activities, and ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 3

• For primary unilateral hernias in men: Either open (Lichtenstein) or laparoscopic approach is appropriate 7, 3

  • Laparoscopic patients develop chronic pain less often than open surgery patients 7
  • Open repair can be performed under local anesthesia, which has fewer cardiac and respiratory complications, shorter hospital stays, and lower costs 1, 3

Watchful Waiting Option

• Asymptomatic or minimally symptomatic male patients may be managed with watchful waiting, as the risk of hernia-related emergencies is low 3
• All inguinal hernias in women should be operated on to avoid missing femoral hernias and due to higher complication risk 7, 3
• Watchful waiting is NOT appropriate for femoral hernias due to high strangulation risk 1

Incarcerated Hernia (Without Strangulation)

Immediate assessment for signs of strangulation is mandatory, followed by either manual reduction or urgent surgical repair. 6, 5

Manual Reduction Attempt

• Contraindications to manual reduction include: 5

  • Skin changes (erythema, warmth, discoloration)
  • Firm, tender, irreducible mass
  • Peritoneal signs on examination
  • Prolonged incarceration (>24 hours increases mortality risk) 5

• If manual reduction is successful, diagnostic laparoscopy should still be considered to evaluate bowel viability and rule out occult ischemia 5

Surgical Management

• Prosthetic repair with synthetic mesh is recommended for clean surgical fields (CDC wound class I - no signs of strangulation or bowel resection) 1, 6
• Laparoscopic approach (TEP or TAPP) is appropriate when: 4, 1
  • No clinical signs of strangulation or peritonitis are present
  • Expertise is available
  • Patient can tolerate general anesthesia
• Open preperitoneal approach is preferable when: 4, 1
  • Strangulation is suspected
  • Bowel resection may be needed
  • Laparoscopic expertise is unavailable
• Local anesthesia can be used for open repair in the absence of bowel gangrene 4, 6

Strangulated Hernia

Emergency surgical repair is mandatory when intestinal strangulation is suspected to prevent bowel necrosis and increased morbidity/mortality. 1, 6, 5

Preoperative Management

• Immediate surgical consultation and preparation for emergency surgery 6, 5
• Administer antimicrobial prophylaxis: 48-hour coverage for intestinal strangulation and/or concurrent bowel resection (CDC classes II and III); full antimicrobial therapy for peritonitis (CDC class IV) 1, 6
• Resuscitate with IV fluids and correct electrolyte abnormalities 4
• General anesthesia is required when bowel gangrene is suspected or peritonitis is present 4, 6

Surgical Approach

• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed 4, 1
• Hernioscopy (laparoscopy through hernia sac) can be used to assess bowel viability after spontaneous reduction, decreasing hospital stay and preventing unnecessary laparotomies 1, 6

Mesh Selection Based on Contamination

• 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, with significantly lower recurrence risk 1, 6
• Contaminated/dirty field (CDC class III-IV): 1, 6
  • Primary tissue repair for small defects (<3 cm)
  • Biological mesh or polyglactin mesh for larger defects when direct suture is not feasible
  • Open wound management with delayed repair if biological mesh unavailable

Special Populations

Femoral Hernias

• Timely mesh repair by laparoscopic approach is recommended provided expertise is available 5, 3
• Femoral hernias carry 8-fold higher risk of requiring bowel resection and should not be managed with watchful waiting 1

Women

• Laparoscopic repair is suggested for all groin hernias in women to decrease chronic pain risk and avoid missing femoral hernias 1, 3

Pregnant Women

• Watchful waiting is suggested, as groin swelling most often consists of self-limited round ligament varicosities 3

Patients with Cirrhosis and Ascites

• Control ascites before elective herniorrhaphy, as uncontrolled ascites increases recurrence and complication rates 5
• Laparoscopic approaches are recommended when surgery is necessary 5

Postoperative Management

Pain Control

• Encourage acetaminophen and NSAIDs as primary pain control 1
• Limit opioid prescribing: 15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg for laparoscopic repair; 15 tablets for open repair 1

Activity Restrictions

• Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable 3

Monitoring for Complications

• Monitor for: 1, 3
  • Wound infection (significantly lower with laparoscopic approach)
  • Chronic postoperative inguinal pain (CPIP) - defined as bothersome moderate pain impacting daily activities lasting ≥3 months
  • Recurrence (0% with mesh vs 19% with tissue repair)
  • Testicular complications in males

Common Pitfalls to Avoid

• Delaying repair of strangulated hernias leads to bowel necrosis and increased morbidity/mortality - delayed diagnosis >24 hours is associated with significantly higher mortality rates 1, 5
• Overlooking contralateral hernias - consider laparoscopic approach to identify occult hernias present in 11.2-50% of cases 1, 3
• Attempting manual reduction when contraindicated - skin changes, peritoneal signs, or prolonged incarceration are absolute contraindications 5
• Missing femoral hernias in women - always consider laparoscopic approach to properly evaluate 1, 3
• Using watchful waiting for femoral hernias or hernias in women - these should be repaired due to high complication risk 1, 3