CHAPTER 4 Inguinal Hernia Repair
INDICATIONS FOR INGUINAL HERNIA REPAIR
I. Reducible Hernias: Traditionally, the presence of an inguinal hernia constituted an indication for its repair. Two major arguments were made in favor of this approach: (1) over time, hernias tend to enlarge and become symptomatic; and (2) the seriousness of complications associated with untreated hernias, namely, incarceration and strangulation, justifies the risks associated with surgical repair. Although many surgeons continue to subscribe to this approach, a role for expectant management of asymptomatic inguinal hernias has emerged, particularly in high-risk patients. Low- to moderate-risk patients are generally offered the option of hernia repair.
II. Incarcerated Hernias: Edema of the contents of a hernia, or formation of adhesions to the peritoneum-lined hernia sac, may result in incarceration. Incarceration of a bowel-containing hernia may result in intestinal obstruction and, if left untreated, strangulation and bowel necrosis. Incarceration of a hernia that contains only one sidewall of the bowel may progress to strangulation without signs of obstruction; such hernias are known as Richter’s hernias. Acutely incarcerated hernias require immediate operative repair. Strangulated, nonviable bowel requires resection at the time of surgery. In contrast, in the absence of pain or obstructive symptoms (e.g., nausea and vomiting), chronically incarcerated hernias may be repaired electively (Fig. 4-1).
PREOPERATIVE EVALUATION
I. History: Important components of the history include the chronicity of a hernia and the presence of associated symptoms. Additionally, an attempt should be made to elicit a history of straining from constipation, urinary obstruction, or chronic cough; these symptoms sometimes reflect underlying comorbidities necessitating additional evaluation (e.g., colonoscopy or urologic evaluation).
II. Physical Examination: Physical examination is performed with the patient supine and standing. The examiner generally places one hand over the inguinal ligament and, if the patient is male, palpates the superficial inguinal ring through the scrotal skin with the other hand. The patient is asked to cough or perform a Valsalva maneuver. Appreciation of a bulge moving from lateral to medial against the examiner’s finger suggests an indirect inguinal hernia; a mass that protrudes directly through the abdominal wall suggests a direct hernia. Bilateral examination should be performed to rule out a contralateral hernia. In appropriate patients, a digital rectal examination should be performed to exclude enlargement of the prostate or a rectal mass.
III. Imaging. In rare cases, the diagnosis of a hernia may be aided by ultrasound or cross-sectional imaging (e.g., computed tomography scan or magnetic resonance imaging).
