Symptoms and Diagnosis
Patients with inguinal hernias typically present with vague groin pain. Inguinal hernias may be asymptomatic, discovered incidentally during physical examination or present as a bulge discovered by the patient. Since most hernias should be repaired, the patient should be referred to a surgeon for evaluation and operative treatment. Sophisticated tests are not required, since the diagnosis can usually be made on physical examination, which is best performed with the patient standing and straining against a held breath (Valsalva maneuver). Ultrasound and diagnostic x-rays are also not usually necessary.
More difficult to diagnose is the occasional patient with groin pain but no history of groin bulge and without physical findings of a hernia by the primary physician or surgeon. Such a patient may not have a hernia, but rather a groin muscle strain. In contrast, if a hernia is not found on physical examination, but the patient describes a groin bulge, a hernia is likely present. Femoral hernias often present as pain below the groin crease, rather than a bulge, and are particularly difficult to diagnose in the elderly or obese female with sudden groin pain but no physical findings of groin hernia of any type.
The majority of groin hernias are readily reducible, have minimal or no tenderness, and can be electively referred to a surgeon within a period of weeks. However, if the hernia is tender and not reducible, the patient should be referred immediately due to the risk of strangulated bowel or other viscera. Aggressive attempts to reduce a groin hernia with sedation, ice packs, or sustained weight or pressure should not be pursued. Symptoms such as nausea and vomiting suggest bowel obstruction, which mandates immediate referral to a surgeon.
Treatment
Because patients with groin hernias are usually offered and receive elective repair, the incidence of emergent incarcerated (non-reducible) hernias is relatively low. Urgent repair is required for a sudden, non-reducible hernia or a chronically incarcerated hernia that becomes acutely painful or tender, as this indicates impending strangulation. While severe morbidity as well as mortality can be avoided by prompt diagnosis, this clinical emergency causes the death of more than 2,000 patients per year in North America.
Most inguinal hernias that should be repaired are symptomatic or are enlarged over time. Hernia belts should be discouraged and should be limited to patients who are not candidates for elective operation. Their use can lead to a more difficult repair and higher risk of complications or recurrence. Femoral hernias should always be repaired because of the high incidence of bowel strangulation. Patients with groin hernias should undergo surgical evaluation within a month after detection. Urgent repair is required for all painful, non-reducible hernias, while asymptomatic hernias can be repaired electively. Elderly patients with minor comorbid conditions will easily tolerate an outpatient elective hernia repair, thus avoiding emergent repair of chronically incarcerated hernias, which occur primarily in the elderly. The timing of repair is determined by the symptoms.
The objective of any inguinal or femoral hernia operation is to repair the defect in the abdominal wall. The three basic approaches are: (1) open repair (the traditional repair, utilizing the patient's own tissue); (2) open tension-free repair (in which mesh is used to bridge or cover the defect); and (3) laparoscopic repair, a tension-free repair also utilizing mesh. Open techniques of hernia repair can be performed under local, regional, or general anesthesia, while laparoscopic hernia repair requires general anesthesia.
Qualifications for Performing Inguinal and Femoral Hernia Repairs
Surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform both elective and emergent inguinal hernia repair. These surgeons have successfully completed at least five years of surgical training after medical school graduation and are qualified to perform open inguinal hernia repair, with and without tension-free techniques. Advanced laparoscopic training is required for laparoscopic groin hernia repair. The qualifications of the surgeon should be based on training (education), experience, and outcomes.
