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CLINICAL REVIEW
Inguinal hernias
John T Jenkins, Patrick J O’Dwyer
University Department of Surgery, Abdominal wall hernias are common, with a preva- hernia is usually a longstanding condition, and
Western Infirmary, Glasgow lence of 1.7% for all ages and 4% for those aged over diagnosis is made clinically, on the basis of typical
G11 6NT 45 years. Inguinal hernias account for 75% of symptoms and signs. The condition may be unilateral
Correspondence to: J T Jenkins
mrianjenkins@hotmail.com
abdominal wall hernias, with a lifetime risk of 27% in or bilateral and may recur after treatment (recurrent
men and 3% in women.1 Repair of inguinal hernia is hernia).
BMJ 2008;336:269-72 one of the most common operations in general surgery,
doi:10.1136/bmj.39450.428275.AD
Inguinal hernias are often classified as direct or
with rates ranging from 10 per 100 000 of the indirect, depending on whether the hernia sac bulges
population in the United Kingdom to 28 per 100 000 directly through the posterior wall of the inguinal canal
in the United States.2 In 2001-2 about 70 000 inguinal (direct hernia) or passes through the internal inguinal
hernia repairs (62 969 primary, 4939 recurrent) were ring alongside the spermatic cord, following the
done in England, requiring more than 100 000 hospital coursing of the inguinal canal (indirect hernia) (fig 1).
bed days. Ninety five per cent of patients presenting to However, there is no clinical merit in trying to
primary care are male, and in men the incidence rises differentiate between direct or indirect hernias. The
from 11 per 10 000 person years aged 16-24 years to box outlines important elements in examining patients
200 per 10 000 person years aged 75 years or above.3 who have a suspected inguinal hernia.
Iliohypogastric nerve
general anaesthesia in the Swedish study.17 Many
countries, however, still use general or regional
anaesthesia for hernia repair, with a minority using
local anaesthesia. A recent study in Denmark of 57 505
elective open groin (mainly inguinal) hernia operations
found that 64% were via general anaesthetic, 18%
Ilio-inguinal nerve
regional anaesthetic, and 18% local anaesthetic.18
Inferior epigastric Regional anaesthesia gives the poorest results and
vessels probably has little role in modern inguinal hernia
Cremasteric vessels surgery. Poor uptake of local anaesthesia may relate to
Spermatic cord surgical tradition, surgeon preference, inadequate
Genital nerve technical proficiency, and little incentive for cost
Inguinal ligament effective techniques.
Fig 1 Anatomy of the inguinal canal What to do with a hernia with minimal or no symptoms
A third of patients have minimal or no symptoms, and,
as strangulation is uncommon, whether such hernias
population based study examining risk of recurrence should be repaired is unclear. To try to clarify this, two
five years or more after primary mesh (Lichtenstein
recent randomised trials (from the US and the UK)
repair) and sutured inguinal hernia repair in 13 674
have compared surgery with observation.19 20 The
patients found that recurrence after mesh repair was a
primary outcome in both studies was pain, as allowing
quarter of that after sutured repair (hazard ratio 0.25
chronic pain in previously asymptomatic patients
(0.16 to 0.40)).8 Open mesh repair is reproducible by
would be unacceptable. At one and two years (US
non-specialist surgeons, and hence open repair is the
and UK respectively), no difference between groups
preferred repair technique for primary inguinal hernia
existed in either trial. However, in the UK study,
(by 96% of UK surgeons, 99% of Japanese surgeons,
patients in the observation group were more likely to
95% of Danish surgeons, and 86% of US surgeons.9
cross over to surgery because of pain or discomfort.
The likely explanation is that many patients (40%) in
Open or laparoscopic repair?
the US study had a small inguinal hernia palpable on
Systematic review and meta-analysis of randomised
impulse only. Continued follow-up in both studies
clinical trials have found that, compared with open
should determine whether observation delays rather
repair, laparoscopic surgery for hernia is associated
than prevents surgery. In the meantime we recom-
with longer operation times but less severe post-
mend that all medically fit patients with an inguinal
operative pain, fewer complications, and a more
hernia should have it repaired.
rapid return to normal activities.10 11 Laparoscopic
surgery is associated with higher recurrence rates
Is there a role for a hernia truss?
during the learning curve12 but causes less chronic pain
and numbness when assessed by questionnaire up to The use of a truss to manage an inguinal hernia has
five years after operation.13 The National Institute for been present from ancient times. The truss has been
Health and Clinical Excellence (NICE) recently popular in the UK in the era of long waiting times for
recommended laparoscopic surgery as a treatment surgery; however, it is difficult for the patients to
option for inguinal hernia and said that patients should manage and cannot be recommended as a definitive
be fully informed of the risks and benefits of open and form of treatment.1
laparoscopic surgery to enable them to choose between
procedures.14 What is the recovery period after inguinal hernia
surgery?
Local, general, or regional anaesthesia? Convalescence is of socioeconomic importance. Single
A recent, Swedish, multicentre trial randomised centre studies suggest that for most repairs five to eight
patients to receive local infiltration anaesthesia, days should be adequate, although studies are difficult
regional anaesthesia, or general anaesthesia for repair to integrate owing to different definitions of convales-
of inguinal hernia in non-specialist centres. The trial cence. Recently Bay-Nielsen and colleagues examined
found a significant advantage with local infiltration convalescence after Lichtenstein repair in a case-
anaesthesia, which was associated with a shorter control study using data from the Danish hernia
hospital stay, less severe postoperative pain, and database.21 The median length of absence from work
fewer micturition difficulties.15 Significantly reduced was seven days (sedentary work 4.5 days, strenuous
overall costs were found with local anaesthesia owing work 14 days). The study found that a single day of
to shorter total time in theatre, earlier discharge, and convalescence was feasible without increasing recur-
equipment requirements.16 Other studies report rences. Pain was the most common cause of a delay in
similar results but with less pronounced differences. returning to work (60%), followed by wound problems
This may be the result of a lack of standardisation of (20%).
Chronic pain
Chronic pain is pain that persists or occurs after normal
SOURCES AND SELECTION CRITERIA tissue healing has taken place and can reasonably be
We used several databases to identify studies for this defined as pain persisting three months after inguinal
review (Medline (1966 to September 2006); Embase hernia repair. About 30% of patients when asked, or on
(1980 to September 2006); the Cochrane Library), and we completion of a confidential questionnaire, report long
searched the websites of the NHS Centre for Reviews and term pain or discomfort at the hernia repair site. When
Dissemination; Database of Abstracts of Reviews of asked at the clinic, 10% report pain that is usually mild
Effects; Health Technology Assessment; the National but may be moderate to severe in 3% of patients,
Institute for Health and Clinical Excellence (for clinical interfering with work and leisure activities.28 Chronic
guidelines); and of national hernia databases. We
pain is the most serious long term complication of
searched for information on the symptoms,
hernia repair and may persist for several years. The
complications, and treatment of inguinal hernia. In
addition, we used PJOD’s extensive understanding and cause of the pain is poorly understood and is more
experience of hernia surgery and research. likely in younger patients who have been in severe pain
from their hernia in the first instance. Regression