What is the proper referral service for an initial diagnosis of hernia?

From the Guidelines

For an initial hernia evaluation, patients should be referred to a general surgeon as soon as possible, especially if there are signs of intestinal strangulation, as immediate surgical intervention is crucial in such cases 1. When a hernia is suspected, the primary care provider should first perform a basic physical examination to confirm the presence of a hernia and then make a prompt referral to general surgery for definitive evaluation and treatment planning. The general surgeon will assess the type of hernia (inguinal, femoral, umbilical, incisional, etc.), its size, reducibility, and risk of complications, using diagnostic tools such as contrast-enhanced CT findings, lactate, serum creatinine phosphokinase (CPK), and D-dimer levels to predict bowel strangulation 1. They will then determine whether watchful waiting or surgical intervention is appropriate, considering the high morbidity and mortality rates associated with delayed treatment of complicated abdominal hernias 1. Surgery remains the definitive treatment for most hernias, with options including open repair or laparoscopic approaches, often using mesh reinforcement. Timely referral is particularly important for hernias with concerning features such as pain, rapid growth, or irreducibility, as these may indicate incarceration or strangulation requiring urgent surgical intervention 1. Patients should be advised to seek immediate medical attention if they experience severe pain, nausea, vomiting, or inability to reduce a previously reducible hernia while awaiting their surgical consultation. Key factors that may affect morbidity and mortality rates include symptomatic periods lasting longer than 8 h, the presence of comorbid disease, high American Society of Anesthesiologists (ASA) scores, the use of general anesthesia, the presence of strangulation, and the presence of necrosis 1. Early detection of complicated abdominal hernias is crucial in reducing mortality rates, and patients with acute complications as their first hernia-related symptom should undergo immediate surgical intervention 1. In cases where bowel resection is required, risk factors such as lack of health insurance, obvious peritonitis, and femoral hernia should be considered 1. Overall, prompt referral to a general surgeon and timely surgical intervention are essential in managing initial hernias and preventing complications.

From the Research

Proper Referral Service for Initial Hernia

• The proper referral service for initial hernia involves a thorough diagnosis and management plan, as outlined in the study 2.
• According to the study 3, symptomatic groin hernias should be treated surgically, while asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with "watchful waiting".
• The study 4 recommends that surgeons master both open and endoscopic/laparoscopic techniques for hernia repair, and that the choice of procedure should be based on international guidelines.
• In terms of pain management, the study 5 found that a combination of IV acetaminophen and either intramuscular pethidine or IV parecoxib was superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair.
• The study 6 found that ibuprofen offers equivalent pain control at a lower cost and reduced potential for adverse drug events compared with intravenous ketorolac in patients having laparoscopic hernia repair.

Diagnosis and Treatment

• Diagnosis of inguinal hernia can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms, as stated in the study 3.
• Ultrasonography may be necessary in some cases, particularly in women, as mentioned in the study 2.
• The study 3 recommends that surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics, and local/national resources.
• Mesh repair is recommended as the first choice, either by an open procedure or a laparo-endoscopic repair technique, as stated in the study 3.

Postoperative Care

• The study 5 found that patients treated with a combination of analgesics had lower postoperative pain scores compared to those treated with monotherapy.
• The study 6 found that ibuprofen provided adequate pain control for patients having laparoscopic hernia repair, and that it was equivalent to ketorolac in terms of pain relief.
• The study 3 recommends that patients resume normal activities without restrictions as soon as they feel comfortable, and that perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair.