From the Guidelines
For an inguinal hernia, referral to a general surgeon is the most appropriate course of action, as surgery is the definitive treatment and can prevent complications such as incarceration and strangulation 1. The patient should be referred promptly, especially if the hernia is causing pain, is growing in size, or cannot be reduced (pushed back in).
- While awaiting surgical consultation, patients should avoid heavy lifting and strenuous activities that increase intra-abdominal pressure.
- If the patient experiences sudden severe pain, nausea, vomiting, or inability to pass gas or stool, they should seek emergency care immediately as these symptoms suggest hernia incarceration or strangulation, which are surgical emergencies. Some key points to consider in the management of inguinal hernias include:
- The use of mesh in clean surgical fields is associated with a lower recurrence rate, without an increase in the wound infection rate 1.
- For patients with intestinal strangulation and/or concomitant need of bowel resection, emergent prosthetic repair with synthetic mesh can be performed, with a significant lower risk of recurrence 1.
- Diagnostic laparoscopy may be a useful tool for assessing bowel viability after spontaneous reduction of strangulated groin hernias 1.
- The general surgeon will evaluate the hernia and determine whether surgical repair is necessary, which is typically performed as an outpatient procedure using either open or laparoscopic techniques.
- While waiting for surgical consultation, patients with mild to moderate pain may use acetaminophen or NSAIDs as needed, but these medications only address symptoms and do not treat the underlying condition. It is essential to note that early detection of complicated abdominal hernias may be the best means of reducing the rate of mortality, and patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected 1.
- Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are predictive of bowel strangulation 1.
- A recent study demonstrated that the elapsed time from onset to surgery was the most important prognostic factor, highlighting the importance of prompt referral and treatment 1.
From the Research
Proper Referral Service for Inguinal Hernia
- The referral service for inguinal hernia should be based on evidence-based guidelines and recommendations, taking into account the patient's and hernia-related factors, such as unilateral hernia in men and women, bilateral hernia, recurrent hernia, scrotal hernia, previous pelvic and lower abdominal surgery, severe cardiac or pulmonary comorbidities, and incarcerated hernia 2.
- Surgeons should provide both an anterior open (Lichtenstein) and a posterior laparo-endoscopic (TEP or TAPP) approach option, as a generally accepted technique suitable for all inguinal hernias does not exist 2.
- Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias, but it is not recommended in patients with symptomatic hernias or in nonpregnant women 3, 4.
- Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair 4, 5.
- The choice of surgical approach should be based on the specific expertise of the surgeon, as well as the patient's and hernia-related factors 6.
Factors to Consider in Referral Service
- Patient demographics, such as age and sex
- Hernia characteristics, such as unilateral or bilateral, recurrent or primary
- Presence of comorbidities, such as severe cardiac or pulmonary disease
- Previous pelvic or lower abdominal surgery
- Symptom severity, such as asymptomatic or symptomatic hernia
- Surgeon's expertise and experience with different surgical approaches 2, 3, 4, 6, 5