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Inguinal hernia

Key sources
The following summarized guidelines for the evaluation and management of inguinal hernia are prepared by our editorial team based on guidelines from the HerniaSurge Group (HSG 2023; 2018), the American College of Radiology (ACR 2022), the Surgical Infection Society Europe (SIS-E/WSES 2018), the World Society of Emergency Surgery (WSES 2017), and the International Endohernia Society (IEHS 2015).


1.Classification and risk stratification

Use the following terminology for groin hernias:
Acutely irreducible hernia
A hernia in which the contents cannot be reduced on physical examination but were previously reducible before the acute onset of symptoms
Chronically irreducible hernia
A long-standing hernia in which the contents cannot be reduced on physical examination and is not associated with sudden onset of new symptoms
Strangulated hernia
A hernia with strangulated content which can only be described as such after the diagnosis is confirmed by preoperative imaging or intraoperative findings
Do not use the term incarcerated hernia and substitute it with the aforementioned definitions, as it does not correctly describe the issue of acute hernias.
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2.Diagnostic investigations

Initial evaluation: as per ACR 2022 guidelines, obtain pelvic ultrasound, MRI, or abdominopelvic CT (with or without IV contrast) as the initial imaging in patients with suspected inguinal hernia.

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  • Evaluation for bowel strangulation

  • Evaluation of the contralateral groin

3.Diagnostic procedures

Diagnostic laparoscopy: as per HSG 2023 guidelines, consider performing diagnostic laparoscopy in patients with acutely irreducible groin hernia, provided the expertise and resources are available and the patient's condition allows.

4.Medical management

Management of modifiable risk factors: take into consideration acquired, surgical, and perioperative risk factors since they are potentially modifiable and can influence the type of repair performed.

5.Therapeutic procedures

Manual reduction: consider performing manual reduction in all patients with acutely irreducible hernias without suspicion of bowel ischemia. Obtain observation for a period after successful reduction until the analgesic/sedative drugs have worn off and the patient feels well enough to go home. Perform emergency surgery if the manual reduction is unsuccessful.

6.Perioperative care

Antibiotic prophylaxis: as per HSG 2023 guidelines, do not administer antibiotic prophylaxis in elective open inguinal mesh hernia repair in average-risk patients in low infection-risk environments.
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  • Choice of anesthesia

  • Prevention of postoperative pain

7.Surgical interventions

Indications for emergency repair, wound class I, HSG: perform emergency surgery immediately when a suspicion of strangulation is made or manual reduction is unsuccessful.

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  • Indications for emergency repair (wound class II)

  • Indications for emergency repair (wound class III-IV)

  • Choice of surgical approach

  • Technical considerations for surgery (transabdominal preperitoneal approach)

  • Technical considerations for surgery (totally extraperitoneal endoscopic approach)

  • Technical considerations for surgery (mesh repair)

  • Technical considerations for surgery (non-mesh repair)

8.Specific circumstances

Female patients: as per HSG 2018 guidelines, include femoral hernia in the differential diagnosis of groin swelling in female patients.
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  • Patients with sportsman's hernia

  • Resource-limited settings

9.Patient education

General counseling: as per HSG 2023 guidelines, discuss the decision on whether to perform the repair of an occult contralateral hernia identified during a laparoendoscopic repair of a unilateral hernia with the patient at the time of informed consent.

10.Follow-up and surveillance

Management of postoperative pain: as per HSG 2023 guidelines, centralize chronic postoperative inguinal pain evaluation and treatment in specialist centers with an experienced multidisciplinary team, depending on local settings.
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  • Management of mesh infection

  • Return to normal activities

  • Management of recurrent hernia

11.Quality improvement

Hernia registries
Consider developing and implementing national or regional groin hernia registries with high coverage and long-term follow-up for quality control.
Develop hernia registries including patient follow-up data and accounting for local healthcare structures for research and audit purposes.