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inguinal hernia

A hernia in the inguinal region. Etiology: - risk factors - advanced age is a risk factor [9] - higher body mass index may be protective [9] Epidemiology: - more common in men than women, ratio 9:1 Pathology: 1) direct inguinal hernia: - involves the abdominal wall between the deep epigastric artery & the edge of the rectus muscle 2) indirect inguinal hernia: - involves the internal inguinal ring & the inguinal canal Clinical manifestations: 1) pain suggests incarceration or strangulation of bowel 2) hernias generally easier to demonstrate with patient standing Special laboratory: - avoid routine ultrasound for clinically apparent inguinal hernia [12] Complications: 1) incarceration, strangulation, bowel obstruction (rare) [1] 2) long-term pain may be associated with surgery (6-30%) [5] Differential diagnosis: - males: 1) testicular torsion 2) epididymitis 3) hydrocele, varicocele, spermatocele 4) epididymal cyst 5) testicular tumor - femoral hernia Management: 1) asymptomatic hernias may be observed [1,11] a) watchful waiting for minimally symptomatic hernias [1,4] b) use of truss c) majority of men will ultimately be referred for surgery, primarily because of pain, within 10 years [8] d) emergency surgery required in 2% [11] 2) symptomatic hernias require surgical inguinal hernia repair [2] a) laparoscopic mesh repair [2,3,6] under general anesthesia 1] less postoperative pain than with open mesh repair [3,6] 2] severe complications (0.05% vs 0.55%) & recurrent hernia within 2 years (0.25% vs 0.5%) more likely than with open mesh repair b) open mesh repair under local anesthesia - lower initial costs [8] c) suture repair is associated with a higher risk of recurrence within 5 years compared with laparoscopic mesh repair & open mesh repair - with long-term follow-up, benefits of mesh repair are partially offset in part by mesh-related complications [10]

Related

inguinal canal

General

groin hernia

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18. American College of Physicians, Philadelphia 2009, 2012, 2018.
  2. Journal Watch 23(13):104, 2003 Douek M, Smith G, Oshowo A, Stoker DL, Wellwood JM. Prospective randomised controlled trial of laparoscopic versus open inguinal hernia mesh repair: five year follow up. BMJ 326:1012, 2003 PMID: 12742923 http://bmj.com/cgi/content/full/326/7397/1012
  3. Journal Watch 24(11):85, 2004 Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, Reda D, Henderson W; Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004 Apr 29;350(18):1819-27. Epub 2004 Apr 25. PMID: 15107485
  4. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, Neumayer LA, Barkun JS, Hoehn JL, Murphy JT, Sarosi GA Jr, Syme WC, Thompson JS, Wang J, Jonasson O. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006 Jan 18;295(3):285-92. PMID: 16418463
  5. O'Dwyer PJ et al, Observation or operation for patients with an asymptomatic inguinal herna: a randomized trial. Ann Surg 2006, 244:167 PMID: 16858177 - Franneby U et al, Risk factors for long-term pain after hernia surgery. Ann Surg 2006, 244:212 PMID: 16858183
  6. O'Reilly EA et al. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg 2012 May; 255:846. PMID: 22470068
  7. Shah NR, Mikami DJ, Cook C, Manilchuk A et al A comparison of outcomes between open and laparoscopic surgical repair of recurrent inguinal hernias. Surg Endosc. 2011 Jul;25(7):2330-7 PMID: 21298523
  8. Fitzgibbons RJ, Forse RA Groin Hernias in Adults. N Engl J Med 2015; 372:756-763. February 19, 2015 PMID: 25693015 http://www.nejm.org/doi/full/10.1056/NEJMcp1404068
  9. de Goede B et al. Risk factors for inguinal hernia in middle-aged and elderly men: Results from the Rotterdam Study. Surgery 2015 Mar; 157:540 PMID: 25596770
  10. Kokotovic D, Bisgaard T, Helgstrand F. Long-term Recurrence and Complications Associated With Elective Incisional Hernia Repair. JAMA. Published online October 17, 2016 PMID: 27750295 http://jamanetwork.com/journals/jama/article-abstract/2565771 - Itani KM New Findings in Ventral Incisional Hernia Repair. JAMA. Published online October 17, 2016 PMID: 27750293 http://jamanetwork.com/journals/jama/fullarticle/2569750
  11. de Goede B, Wijsmuller AR, van Ramshorst GH et al. Watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: A randomized controlled trial. Ann Surg 2018 Jan; 267:42. https://insights.ovid.com/crossref?an=00000658-201801000-00010
  12. Society of American Gastrointestinal and Endoscopic Surgeons Five Things Physicians and Patients Should Question. Choosing Wisely, January 9, 2019 http://www.choosingwisely.org/societies/society-of-american-gastrointestinal-and-endoscopic-surgeons/
  13. Inguinal Hernia https://www.niddk.nih.gov/health-information/digestive-diseases/inguinal-hernia

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