Groin hernia

Definition/Description

A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall. The resulting ‘lump’ can often be pushed back in (reducible) or disappears (reduces) when patients lie down. Any increase in intra-abdominal pressure such as bending, coughing or straining may make the lump appear.

Groin Hernia include femoral hernia and inguinal (direct and indirect) Indirect (75%) - these originate lateral to the inferior epigastric artery and follow the path of the spermatic cord or round ligament through the internal inguinal ring and along the inguinal canal direct (25%) - these originate medial to the inferior epigastric artery and push through a weakness in the posterior wall of the inguinal canal rather than down the canal itself

In all the sac usually contains omentum or small bowel and less often, large bowel or appendix. Occasionally it contains diseased tissue - carcinoma, appendicitis, or peritoneal secondaries.

Femoral hernias occur far more frequently in women, particularly older women. This is because of the wider shape of the female pelvis.

Red Flag Symptoms

Exclude solid lumps that may be lymphadenopathy, lipomas or sarcomas, or secondaries

Guidelines on Management

General Points

Suspect a hernia from the history and examine the patient

Management

Where examination confirms PALPABLE hernia.

If non reducible and acutely painful (i.e. incarcerated) then refer to surgeons that day
If non reducible without pain refer to surgeons – urgently or routinely at GP’s discretion
If reducible….in MEN…Apply the principles of the Montgomery vs Lanarkshire ruling and discuss the three options of do nothing and wait and see, with or without a truss or have surgery - depending on age and fitness of patient.
Generally younger and fit patients with discomfort refer for consideration of surgery as likely to get worse with time and it’s better to fix a small hernia under local or a spinal anaesthesia than a large one under general, both of which carry a higher risk of morbidity.
Older and more unfit patients consider a watch and wait approach +/- a trial of a surgical truss if not terribly symptomatic. GPs and surgeons can discuss with patients their options. The European Hernia Society Guidelines Update in 2014 concluded “watchful waiting is safe and an acceptable option for men with minimally symptomatic or asymptomatic inguinal hernias. It is very likely (>70 % chance) that, in time, the symptoms will increase leading to surgical intervention and it is recommended in minimally symptomatic or asymptomatic inguinal hernia in men to consider a watchful waiting strategy, especially when older or in the presence of major comorbidity”.
If FEMALE where it is more likely to be a femoral hernia, which are more likely to obstruct, refer to surgeons for further assessment.
- This can usually by routine referral if been present for a while and no pain, but urgently if new and there is discomfort and that day if non-reducible
Warn all patients of the risk of strangulation and early presentation (to A&E if GP surgery closed) if increasing pain and / or not reducible. Operating on strangulated, gangrenous herniae carries the highest risk of morbidity.
You should also warn patients with an unrepaired hernia NOT to travel anywhere far from good surgical care as this puts them risk. They may they may find themselves uninsured and seeking damages and costs from you.

Investigations prior to referral

The CCG, and radiologists and surgeons at YHFT, ask that GPs do not order USS or any other imaging for suspected hernias and instead refer patients, to surgical outpatient clinics.

Clinically obvious hernias – there is no benefit from an ultrasound in general practice Ultrasonography is good at detecting and already confirming clinically apparent hernias (and so are GPs). Don’t scan just to confirm your clinical findings.

Clinically uncertain hernias
The diagnostic accuracy of ultrasonography is reduced in the absence of any clinically palpable hernia so only experienced ultrasonographers who work with the surgeons should scan these.

Please don’t order ultrasound or any imaging in primary care for clinically uncertain hernias.
Please refer them to local surgeons to examine them.

The European Hernia Society guidelines 2009 state ‘In everyday practice, the sensitivity and specificity of ultrasonography for diagnosing inguinal hernia is low’. They recommend that groin diagnostic investigations are performed only in patients with obscure pain and/or swelling and they recommended in these cases

Ultrasound (if expertise is available)
If ultrasound negative → MRI (with Valsalva)
If MRI negative → consider herniography

Referral Criteria/Information

Information to include in referral letter

Hernias that are at a high risk of obstruction are an exclusion from the Optimising Outcomes from all Elective Surgery Criteria. An outpatient surgical opinion is permitted where there is diagnostic uncertainty.

Basic history of symptoms

Amount of discomfort and impact on daily activities
General fitness of patient and pre-existing morbidity
Presence of exacerbating factors / factors that might impact on recovery eg obesity, chronic cough
Smoking status

Examination findings

State side and size
Whether reducible or not

Investigations prior to referral

None are routinely recommended in otherwise fit and healthy patients.

Inguinal hernia repair is regarded as Intermediate surgery and where patients have mild systemic disease just knowing recent U&Es (< 3mths before operation date) or FBC and U&Es if severe systemic disease, helps speed up pre-assessment.

All diabetic patients should have a recent HbA1c. Surgery is likely to be delayed if > 69mmol/l

Additional Resources & Reference

Patient information

Give all patients (where appropriate) information about PROMs and Shared Decision Making tools so they can consider their options and give them NHS information on hernias

https://www.nhs.uk/conditions/hernia/

https://www.nhs.uk/conditions/inguinal-hernia-repair/

https://www.nhs.uk/conditions/femoral-hernia-repair/

https://www.nhs.uk/video/Pages/Herniaanimation.aspx