The patient’s unmet needs (PUNs)
A 42-year-old builder attends the surgery complaining of a lump in his groin. He’s otherwise fit and well. Although the swelling aches slightly when he’s been on his feet for a while, it’s not causing him any significant discomfort. ‘I reckon I’ve got a hernia’ he says – and examination proves him right. The hernia is on the left side, is moderately sized and reduces easily. You also note that he is significantly overweight and smokes 30 per day. ‘So I guess that’s going to mean an operation?’ he says. ‘How will they do that, then? And how long will I need off work?’
The doctor’s educational needs (DENs)
Some local health authorities currently place restrictions on hernia repairs, for example recommending a non-interventionist approach in hernias that are causing no problems – how reasonable is this? What are the clear indications for referral?
Many hernias cause few symptoms, and while hernias never disappear without treatment, growth may be very slow indeed - they often remain fairly static in size over many years. If the hernia is not causing the patient any trouble or interfering with their lifestyle, there are probably few merits to intervention 1. The advantages of early intervention are that hernias are technically easier to repair when they are small, and intervention removes any concerns about irreducibility or strangulation 2.
The important questions to ask if you’re considering referral are:
· Does the patient report episodes of painful irreducibility? This might herald trouble and should be taken as a significant warning sign.
· Is there anything that the patient would like to do, but is prevented from doing by the hernia? If so, there is something definite to gain from surgery, which can be offset against the risk of the operation.
· Does the patient’s occupation or lifestyle mean that the hernia will almost inevitably increase in size and become troublesome?
How important are lifestyle measures - such as stopping smoking and losing weight – in patients with hernias? Could these measures ‘cure’ a hernia or do they just make surgery safer and reduce the risk of recurrence?
Lifestyle measures such as losing weight and stopping smoking are to be applauded, but there is really no evidence that they can cure a hernia. One the hernia has appeared it will essentially always be there until it is fixed. But if patients are going to have surgery this will be easier, less risky and has a higher likelihood of success if they can lose weight and generally improve their health status beforehand.
What is the likelihood of strangulation? Are some hernias more of a risk than others, and how can this be assessed? And what are the implications of a hernia that is incarcerated but not strangulated?
There are some useful pointers to consider when working out the likelihood that a hernia is at risk of becoming strangulated:
Can the hernia be easily reduced?
Remember that the patients are often better at doing this than we are! If it pushes back when the patient is standing without much difficulty and without a pronounced ‘click’, that would be a very reassuring sign. The ‘click’ implies that it is getting a little caught, and may be a sign that referral is needed.
Direct hernias - so called because they don’t come through the same hole as the spermatic cord, but directly push forward into the back of the inguinal canal - almost always have a very wide neck, and so rarely strangulate. From a face-on view, with the patient standing, direct hernias look as though they are just bulging forwards from the more medial part of the inguinal canal, and with a single finger, can often be pushed easily back in. They will then almost certainly pop straight back out again as the finger is removed. Hernias like this are usually quite safe to leave, especially if they are completely painless (as they invariably are).
Is the hernia really incarcerated?
Many hernias appear incarcerated, but it may be that neither the patient nor doctor has tried properly to reduce it. Incarceration on its own may not mean very much, unless it has been accompanied by significant discomfort or pain – this would be a significant warning. That said, an incarcerated hernia is probably more likely to eventually strangulate that a non-incarcerated one.
Is the hernia in fact a femoral hernia?
Femoral hernias are more common in women than men, and are far less common than inguinal hernias. Femoral hernias are much more likely to be incarcerated and much more likely to strangulate – this is because they herniate through the femoral canal, which is a small and tight gap beneath the inguinal ligament, medial to the femoral vessels.
Distinguishing clinically between an inguinal and femoral hernia is not an exact science, but the clue is that the neck of the hernia will be below and lateral to the pubic tubercle, whereas the neck of an inguinal hernia will be above and lateral to the pubic tubercle.
If the hernia is about the size of a grape or walnut, is irreducible, and you think it arises below the pubic tubercle, it is a femoral hernia until proved otherwise. These cases warrant relatively urgent referral unless the lump is hot, red, tender or accompanied by abdominal pain and vomiting, in which case emergency referral is needed. Do not forget to expose the groin properly – the classic mistake is to not examine low enough, perhaps in an unwise attempt to preserve the patient’s modesty.
What are the surgical options available and their various pros and cons?
There are two basic options for surgical treatment of an inguinal hernia.
1. Open repair using mesh. The hernia is reduced through a 10cm incision and then held with a piece of mesh, sandwiched between the outer one and inner two layers of muscle. Many open repairs can be done under local anaesthetic.
2. Laparoscopic repair. Here the mesh is placed inside all three layers of muscle, but outside the peritoneal lining of the abdominal cavity. Some surgeons operate from within the peritoneal cavity, and then close the incision they have made it in before exiting, while others create a space between the peritoneum and the back of the abdominal wall and don’t enter the peritoneum at all. There is little significant difference between these approaches. All laparoscopic repairs have to be done under general anaesthesia.
Femoral hernias are repaired in various ways, usually with open surgery.
How long is the patient likley to need off work? Should he limit what he lifts after surgery?
If a hernia repair is properly done, it should only be necessary to restrict the patient’s immediate activity in two areas - driving and contact sport. There is no absolute rule about driving, but general consensus suggests that a week off would be reasonable for insurance purposes –patients should of course only start driving again when they feel capable and safe to do so. Contact sports are best avoided for at least a few weeks.
Aside from these two areas, it is not necessary to restrict the patient’s activity, and indeed activity should be encouraged because there is anecdotal evidence that the sooner the patients get active, the quicker their overall recovery.
I allow patients to do as much lifting as they need to because if the repair is properly done it should be as strong as it needs to be from the first week. A common sense approach is all that is needed – of course, entering a weight-lifting competition in the first fortnight isn’t advisable, but if patients can lift a heavy suitcase or shopping bag without significant discomfort after a week, then I would be delighted and not in the least concerned.
Watch a video I have produced for patients on inguinal hernias and treatment options.
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Epidemiology Inguinal hernias are much more common in men than women. Clinical features - If the inguinal hernia first appears as a rupture through a weakness in the abdominal wall - in a sudden, acute event - they can be very painful. But after this, once the ‘tearing’ has occurred, they may not be uncomfortable because the hernia freely moves in and out with changes in intra-abdominal pressure. - Alternatively the hernia may first appear as a gradual pushing through the abdominal wall weakness. Such hernias are usually not at all uncomfortable from the start. - Sportsmen and sportswomen are particularly prone to hernias if their activities involve sharp turns or kicking. These are known as ‘sports hernias’ and are quite different from inguinal hernias - there will be no hernia lump.3. They should be treated by experts with a special interest in diagnosing and treating them. Management - Hernias will never spontaneously cure themselves, but many, once noticed, may have only a very slow growth rate and cause little interference. - It is important to distinguish femoral hernias from inguinal hernias. Femoral hernias are rare but are much more likely to strangulate. As a rule femoral hernias should all be referred for a surgical opinion. - There are really no non-surgical methods for managing hernias. Off-the-shelf trusses or hernia support belts are rarely effective and often create more issues than they solve .4 Properly fitted ones - measured by a surgical appliance officer in a hospital - are far superior to off-the-shelf trusses or supports, but these may take several weeks to be made. These can reduce discomfort as the hernia is ‘held in’, but they are not really practical substitutes for surgery except as in cases where surgery is not possible or desired. - All patients who are fit enough for surgery and who want it should be allowed to discuss the situation with a surgeon. - Possible episodes of irreducibility should be taken seriously as strangulation is more common after such events. - Patients who are comfortable and not inconvenienced by their hernias can be safely managed ‘conservatively’. - When deciding on surgery, the key is the balance of benefit against risk and weigh this against the benefits and risks of not operating.
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Further reading
Hair A, Paterson C, Wright D, et al. What effect does the duration of an inguinal hernia have on patient symptoms? J Am Coll Surg 2001 Aug; 193(2): 125-9
Flich j, Alfonso JL, Delgardo E, et al. Inguinal hernia and certain risk factors. Eur J Epidemiol 1992 Mar; 8(2): 227-82
References
1.Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg 2012 Mar; 147(3): 277-81
2. O’Dwyer PJ, Norrie J, Alani A, et al. Observation or operation for patients with an asymptomatic inguinal hernia: a randomised clinical trial. Ann Surg 2006; 244: 167-173
3. Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. Br J Sports Med 2008 Dec; 42(12): 954-64
4. Law NW, Trapnell JE. Does a truss benefit a patient with inguinal hernia? BMJ 1992; 304: 1092
Mr Nicholas Markham is a consultant general surgeon at North Devon District Hospital.
This article was produced with The Royal College of Surgeons - a professional body that sets the highest possible standards for surgical practice and training, leading to the delivery of safe and high quality patient care. They have expertise, authority and independence, allowing them to act in the best interests of patients and in support of those providing their care.
