Which specialist should I refer a patient with an inguinal hernia to?

Referral Specialist for Inguinal Hernia

Refer all patients with inguinal hernias to a general surgeon for definitive surgical repair. 1

Primary Referral Pathway

General surgeons are the appropriate specialists for inguinal hernia repair in adults and adolescents, as they perform the vast majority of these procedures using open mesh techniques with excellent outcomes. 1, 2 The choice between a general surgeon and a pediatric surgeon depends primarily on patient age:

Adult and Adolescent Patients (≥16 years)

• Refer to a general surgeon who performs inguinal hernia repairs regularly 2, 3
• General surgeons typically use mesh-based repairs (open or laparoscopic), which are the standard of care for this age group 1, 3
• For routine adolescent hernias, 65% of general surgeons appropriately choose adult-type mesh repairs 3

Pediatric Patients (<16 years, especially infants)

• Refer to a pediatric surgeon for high ligation repair 4, 5
• Pediatric surgeons use different techniques (high ligation without mesh) that are age-appropriate 4, 3
• In a 2005 survey, 86% of pediatric surgeons chose pediatric-type repairs for adolescents, reflecting their specialized approach 3

Urgency of Referral

Emergency/Urgent Surgical Referral (Same-Day)

Immediate surgical consultation is mandatory for: 1

• Incarcerated hernia (irreducible bulge with pain, nausea, or vomiting)
• Strangulated hernia (signs include severe pain, fever ≥38°C, tachycardia ≥110 bpm, systemic inflammatory response) 1
• Bowel obstruction symptoms (persistent vomiting, inability to pass gas/stool)
• Delayed diagnosis beyond 24 hours dramatically increases mortality 1

Routine Elective Referral (Within Weeks)

For uncomplicated, reducible hernias: 2

• Symptomatic hernias causing groin pain, burning, or dragging sensation 2
• Visible bulge that may disappear when lying down 2
• Even minimally symptomatic hernias warrant surgical evaluation, though not all require immediate repair 2

Special Populations Requiring Specific Expertise

Recurrent Hernias

• Refer back to the original surgeon if possible 2
• If unavailable, refer to a general surgeon with specific expertise in recurrent hernia repair 1
• Laparoscopic approach may be preferred for recurrent cases 1

Bilateral Hernias

• Laparoscopic repair (TAPP or TEP) is particularly beneficial, allowing simultaneous repair of both sides 1
• Refer to a general surgeon experienced in laparoscopic techniques 1

Preterm Infants

• Refer to a pediatric surgeon with NICU experience 4
• Timing of repair varies: 63% of pediatric surgeons repair before NICU discharge, while others wait until specific corrected gestational ages 4
• Postoperative respiratory monitoring is critical for infants <60 weeks corrected gestational age 4

Common Pitfalls to Avoid

Do not delay referral for strangulated hernias – every hour of delay increases mortality by approximately 2.4%, and diagnosis beyond 24 hours is associated with significantly higher death rates. 1

Do not assume all general surgeons have equal expertise – while most general surgeons perform excellent hernia repairs, outcomes approach those of specialists when surgeons use tension-free mesh techniques regularly. 6

Do not overlook contralateral hernias – occult contralateral hernias are present in 11.2-50% of cases, particularly in children under 4 years and those with left-sided initial hernias. 1, 5 Laparoscopic evaluation during initial repair can identify these. 5

Avoid referring adolescents (age 16) based solely on surgeon availability – the type of practitioner (pediatric vs. general surgeon) currently dictates treatment more than the disease itself, with pediatric surgeons favoring high ligation and general surgeons favoring mesh repair. 3 For routine adolescent hernias with normal BMI and small defects, either approach is acceptable, but general surgeons' mesh-based approach aligns with adult guidelines. 1, 3