Inguinal and Femoral Hernia – Open Repair

Diagnosis

A bulge in the inguinal region is the main diagnostic finding in most groin hernias. There may be associated pain or vague discomfort in the region, but groin hernias are usually not extremely painful unless incarceration or strangulation has occurred. In the absence of physical findings, alternative causes for pain need to be considered. Occasionally, patients may experience paresthesias related to compression or irritation of the inguinal nerves by the hernia. Masses other than hernias can occur in the groin region. Physical examination alone often differentiates between a groin hernia and these masses ( Box 6-1-1 ).

The inguinal region is examined with the patient in the supine and standing positions. The examiner visually inspects and palpates the inguinal region, looking for asymmetry, bulges, or a mass. Having the patient cough or perform a Valsalva maneuver can facilitate identification of a hernia. The examiner places a fingertip over the inguinal canal and repeats the examination. Finally, a fingertip is placed into the external inguinal ring by invaginating the scrotum to detect a small hernia. A bulge moving lateral to medial in the inguinal canal suggests an indirect hernia. If a bulge progresses from deep to superficial through the inguinal floor, a direct hernia is suspected. This distinction is not critical because repair is approached the same way, regardless of the type of hernia. A bulge identified below the inguinal ligament is consistent with a femoral hernia.

A bulge of the groin described by the patient that is not demonstrated on examination presents a dilemma. Having the patient stand or ambulate for a period of time may allow an undiagnosed hernia to become visible or palpable. If a hernia is strongly suspected, but undetectable, a repeat examination at another time may be helpful.

Ultrasonography also can aid in the diagnosis. There is a high degree of sensitivity and specificity for ultrasound in the detection of occult direct, indirect, and femoral hernias. Other imaging modalities are less useful. Computed tomography (CT) of the abdomen and pelvis may be useful for the diagnosis of obscure and unusual hernias as well as atypical groin masses. Occasionally, laparoscopy can be diagnostic and therapeutic for particularly challenging cases.

Classification

There are numerous classification systems for groin hernias. One simple and widely used system is the Nyhus classification ( Box 6-1-2 ). Although their purpose is to promote a common language and understanding for physician communication and to allow appropriate comparisons of therapeutic options, these classifications are incomplete and contentious. Most surgeons continue to describe hernias by their type, location, and volume of the hernia sac.