A diagnosis of a hernia is not enough, on its own, to warrant surgical management. Only symptomatic hernias and those at risk of incarceration need surgical management.
Inguinal hernias affect predominantly men: approximately 95% of the patients are male. The lifetime risk of developing an inguinal hernia is approximately 27% in men, whereas in women the risk is only 3-6%.
Types
An indirect (lateral) inguinal hernia descends along the spermatic cord or the round ligament of the uterus towards the scrotum or labia. In men, this type of hernia may become very large.
A direct (medial) hernia bulges through the base of the inguinal canal. It becomes more common in men with age, may be symptomless and rarely leads to complications.
A femoral hernia penetrates through the femoral canal underneath the inguinal ligament. Femoral hernias affect mainly elderly women. As the canal is narrow, the risk of incarceration is high.
The different types of inguinal hernia cannot be distinguished with certainty by clinical examination. Nevertheless, a hernia extending all the way into the scrotum is always lateral, and an irreducible hernia in a female patient is usually femoral.
An incarcerated hernia is painful on palpation, and the patient is no longer able to reduce the hernia. There may be more extensive abdominal pain. Less than 4% of inguinal hernias are incarcerated; the risk is highest with femoral hernias in women and painful hernias in elderly men.
Clinical examination
Examine the patient (inspection and palpation) in standing and supine positions.
A hernia is visible as bulging or asymmetry of inguinal folds in the standing position.
If applying pressure with the patient supine reduces the hernia, the diagnosis is confirmed.
In the abundant tissue in the inguinal fold of an obese male patient, the hernia may not be easy to feel or to see. It may be felt by passing the examining finger through the scrotum to the orifice of the inguinal canal and asking the patient to cough.
Bulging of a femoral hernia can be felt at the base of the thigh, next to the pubic bone. A femoral hernia is most often irreducible and can be felt as a plum-sized, oval, mobile mass, for instance.
As severe, constant inguinal pain in the absence of visible bulging is not typical for an inguinal hernia, other causes of pain should be sought.
Ultrasonography should only be used for examining irreducible lumps in the groin. It is unsuitable for examining inguinal pain, alone (false positive findings, such as small fat deposits or tissue protrusion that are part of normal anatomy are common and do not explain inguinal pain).
the hernia is painful and adversely affects the activities of daily living (an inguinal hernia may be painful for a few weeks immediately after its development, but often becomes asymptomatic or causes only a few symptoms thereafter)
the hernia is troublesome because of its large size
a femoral hernia is suspected (in practice, all inguinal hernias in women are treated surgically)..
In the case of an incarcerated hernia an attempt should be made to reduce the hernia by gripping it with the fingertips and squeezing it gently and for sufficiently long, so as to diminish the amount of fluid in the hernial sac and to make reduction possible. The patient should preferably be lying in a relaxed position. The head of the bed can be lowered. If reduction is unsuccessful, the patient should be referred immediately for surgical assessment. If reduction only succeeded with difficulty, the patient should be referred for surgical assessment urgently but not as an emergency case.
Most inguinal hernias can be treated by open surgery under local anaesthesia; in elderly patients, in particular, this is the most riskless and simplest form of treatment.
Laparoscopic repair often has the benefit of slightly more rapid recovery, and chronic postoperative pain occurs slightly less frequently. Severe intestinal complications mainly occur after laparoscopic surgery. Regardless of the type of surgery, recovery will take 1-2 weeks and no limitation of movement or exertion is required afterwards.
A laparoscopic procedure is recommended particularly to repair a bilateral hernia in patients of working age and for hernias recurring after open surgery.
A hernia recurring after laparoscopic surgery should preferably be treated by open surgery.
Abdominal hernias
Types
An incisional (ventral) hernia develops in surgical scars. They may be large and vary in form. Hernias may form in small laparoscopy scars, too.
Primary hernias occur in sinewy areas between abdominal muscles, most often in the midline (linea alba), and are round in shape.
Epigastric hernias form at the linea alba between the umbilicus and the xiphoid process. These may be difficult to palpate through a thick subcutis. There is local pain.
Umbilical hernias are situated in the umbilicus or its immediate vicinity.
Spigel hernias are situated at the semilunar line at the outer rim of the rectus abdominis muscle. They are most common in frail elderly women and otherwise rare.
It may be difficult to palpate a small Spigel hernia, since it remains under the aponeurosis of the external oblique abdominal muscle and does not bulge into the subcutis like other hernias. There is local pain.
Clinical examination
Abdominal hernias are best visible and palpable with the patient standing. Successful reduction in the supine position confirms the diagnosis. Other examinations are usually not necessary.
The size of the hernial orifice can best be palpated with the patient in the supine position, with the hernia reduced. In addition to the size of the hernial orifice, the size of the bulge should also be stated in the referral.
Unlike in inguinal hernias, ultrasonography is a useful imaging method in unclear cases. The examination can be performed with the patient standing and/or supine, as necessary. It is advisable to use ultrasonography particularly if an epigastric or Spigel hernia is suspected to be the cause of the abdominal pain.
Indications for surgery
In adults, only symptomatic umbilical or epigastric hernias need surgical repair.
Epigastric hernias are usually small, contain only fat and are rarely incarcerated but they may be painful.
There is an about 10% risk of incarceration of an umbilical hernia, and this occurs particularly in obese patients and those with liver cirrhosis.
Patients with liver cirrhosis and ascites often develop umbilical or inguinal hernias, or both. Surgical repair of an inguinal hernia should be avoided because in most cases the hernial sac only contains fluid and the risk of incarceration is low. However, surgical repair of umbilical hernias should be considered because incarceration may occur and the risks of emergency surgery are higher than those of well-prepared elective surgery. However, surgery can only be performed if the cirrhosis is compensated.
Incisional hernias tend to become very large. Patients in good health should therefore be referred early for surgical assessment, even though the decision may be made not to treat an asymptomatic incisional hernia by surgery. Painful hernias are associated with a risk of incarceration and rapidly growing hernias with a risk of skin traction and ulceration. In patients of advanced age or poor general health, surgical repair of large incisional hernias is, if possible, avoided because of the high risk of complications.
Hernias are repaired based on individual assessment either by laparoscopy or by open surgery. A supportive mesh is nearly always used. Recovery will take 2-4 weeks.
Other hernias
Obturator and sciatic hernias at the bottom of the pelvis and lumbar hernias in the lumbar region are rarities.
Diastasis rectus abdominis
Stretching of the linea alba and resulting diastasis of the rectus abdominis muscles is associated with aging, obesity or stretching of the abdominal wall due to pregnancies.
Such diastasis appears as vertical bulging when contracting the abdominal muscles whilst lying down (the skin and subcutis are raised to form a crest). In the standing position, the abdomen will protrude evenly.
This is not a hernia because the linea alba is intact, and this does not cause upper abdominal pain.
Significant stretching of the linea alba (> 5 cm) after pregnancies, particularly twin pregnancies, may contribute to poor trunk muscle control and painful lumbar lordosis.
Surgical treatment may be useful to alleviate severe symptoms but more than one year must have elapsed since the latest pregnancy, no further pregnancies must be planned, and the patient must be of normal weight and have the best possible muscle condition before surgery can be considered.
References
HerniaSurge Group.. International guidelines for groin hernia management. Hernia 2018;22(1):1-165. [PubMed]