Inguinal Hernia: Diagnosis and Management
Immediate Clinical Assessment
All inguinal hernias in infants and children require surgical repair to prevent life-threatening complications including bowel incarceration and gonadal infarction. 1, 2
Key Presentation Features
In pediatric patients:
- Inguinal bulge that increases with crying or straining, may extend into scrotum (males) or labia (females) 2
- Incidence of 3-5% in term infants, 13% in preterm infants (<33 weeks gestation) 1, 2
- Over 90% occur in boys, 60% on the right side 2
- Results from incomplete involution of processus vaginalis 1, 2
In adults:
- Groin pain (burning, gurgling, or aching sensation) 3
- Heavy or dragging sensation worsening throughout the day 3
- Abdominal bulge that may disappear when prone 3
- Palpable impulse with coughing or straining 3
Emergency Red Flags Requiring Immediate Surgery
Assess for strangulation/incarceration immediately: 2, 4
- Irreducibility with tenderness and erythema 2
- Overlying skin redness, warmth, or swelling 2
- Fever, tachycardia, leukocytosis (SIRS criteria) 2
- Abdominal wall rigidity 2
- Symptoms >8 hours duration significantly increase morbidity 2
- Delayed treatment >24 hours dramatically increases mortality 2, 4
Diagnostic Laboratory Markers for Suspected Strangulation
When strangulation is suspected, obtain: 2
- Arterial lactate ≥2.0 mmol/L (predicts non-viable bowel)
- Elevated CPK and D-dimer levels
- White blood cell count
- CT with contrast (56% sensitivity, 94% specificity for bowel strangulation) 2
Indications for Repair
Pediatric Population
Urgent surgical referral within 1-2 weeks of diagnosis for all infant inguinal hernias 2
- All diagnosed inguinal hernias require repair - no observation period 1, 2
- Preterm infants should undergo repair soon after diagnosis despite higher surgical complication rates, as incarceration risk is even higher 2
- Contralateral patent processus vaginalis occurs in 64% of infants <2 months old 2
- 25-50% of children with patent processus vaginalis develop contralateral hernias 2
Adult Population
Symptomatic groin hernias should be treated surgically 2
- Concerning symptoms: groin pain, heavy/dragging sensation, tenderness over inguinal canal 2
- Small, minimally symptomatic hernias may be observed in select cases 3
- History of previous inguinal hernia surgery carries 23% risk of contralateral or recurrent hernias 2
Preferred Treatment Options
Pediatric Surgical Approach
High ligation of the hernia sac with anatomic closure is the standard repair 5
Timing considerations: 2
Bilateral exploration commonly performed given 64% contralateral patent processus vaginalis rate in infants <2 months 2
Laparoscopic exploration identifies contralateral patent processus vaginalis with 96% accuracy 2
Laparoscopic approaches (TEP or TAPP) are viable options 2, 6
Adult Surgical Approach
Prosthetic (mesh) repair is the primary treatment for most uncomplicated inguinal hernias in older male patients 2
- Choice between open vs laparoscopic depends on: 2
- Patient age and comorbidities
- Hernia characteristics
- Surgeon expertise
- Both open and laparoscopic approaches are acceptable 2
- Examine both groins bilaterally (11-50% have occult contralateral hernias) 2
Critical Pitfalls to Avoid
- Never delay evaluation when signs of strangulation present - time from onset to surgery is the most important prognostic factor 2
- Do not miss femoral hernias - they have higher strangulation risk 2
- Always examine both groins bilaterally 2
- Physical hernia features (size, ease of reduction) do not reliably predict incarceration risk 2
- In obese or post-surgical patients, physical exam may be unreliable - use CT scanning 2
- Patients with previous abdominal/groin surgery have increased hernia risk 2
Postoperative Complications
Potential complications include: 2
- Infection
- Testicular complications in males
- Recurrence (uncommon with proper technique)
- Apnea in preterm infants