CASE PRESENTATION

Lateral Inguinal Hernia

By :
Cattleya Ananda Vilda 1102011063

Preceptor :
Dr. HERRY SETYA YUDHA UTAMA, SpB, MHKes,FInaCS

Clinical Clerkship of Surgery Department

Faculty of Medicine YARSI University
RSUD Arjawinangun
November 2016

Case Presentation
I.

Identity
Name
Age
Gender
Tribe
Occupation
Address
In hospital since

: Mr. H
: 46 years old
: Male
: Javenese
: Lifter labor
: Arjawinangun
: October 25th 2016

II.

Anamnesis

Main Grievance

: bulge in right thigh groin

Additional Grievance

:-

III.

Historical of Present Disease

Mr. H administrated to Arjawinangun Public Hospital due to a grievance of bulging between

groin of right thigh since one day ago. The bulge cant be disappeared in. Initially, the bulge was
small. If the patient stands and strain, the bulge comes out. But if the patient lying down, the
bulge disappeared in. There is no pain and no change in colour of the skin area in the bulge.
Patient has good appetite and no decreasing body weight. Patient admitted he has habit of
straining during defecating because of hard consistency of the stool. There are no nauseating or
vomitting.
IV.

Historical of Past Disease

Diabetes mellitus (-), Hypertension(-)

V.

Historical of Family Disease

Diabetes mellitus (-), Hypertension(-)

VI.

Physical Examination

General Status
Present Status
General Condition
Awareness
Blood Pressure
Pulse
Breathing
Temperature

: Moderate
: Composmentis
: 120/80
: 88 x/minute
: 20 x/minute
: 36,7 C

Head
Form
Hair
Eye

: Normal, Simetrical
: Black Colour, No hair fall
: Anemic Conjungtival -/-, Icteric Schlera -/-, Light Refleks (+), Isocorpupil right

Ear
Nose
Mouth

= left
: Normal form, cerumen (-), tympani membrane intac
: Normal form, No septum deviation, epitaction -/: Normal

Neck
Enlargement lymph nodes (-)
Trachea in the middle
No mass
Thoraks
Lungs - pulmonary
Inspection
: The chest shape is symmetrical both of left and right
Palpation
: Fremitus tactile and vocal symmetrical right and left, crepitus (-), tenderness (-),
Percussion
Auscultation

Abdomen

rebound tenderness (-)

: Sound of resonant in both lung fields
: Sound of vesicular and bronchial the entire lung field, ronkhi -/-, wheezing -/-

Inspection
Palpation
Percussion
Auscultation
Extremity
Upper

Lower

: Normal
: Tenderness (-), rebound tenderness (-)
: Tympani
: Bowel (+)

: Muscle Tone
Movement
Mass
Strenght
Edema
: Muscle Tone
Movement
Mass
Strenght
Edema
Swelling

normal
: active / active
:-/: 5/5
:-/:normal
: active / active
:- / : 5/5
:-/:-/-

Local status
Regio inguinalis dextra:
Inspection: bulging below inguinal ligament, diameter: 8 cm x 4 cm, flat surface, color similar
with skin, not hyperemic
Palpation: tenderness (-), soft, upper border can not be defined, couldnt be pushed in,
translumination (-), painless
Auscultation: bowel sound (+)
Genitalia

: normal

Laboratory Examination
Normal
Diagnosis
Lateral Inguinal Hernia
Management
RL 1000 cc/24 hours
Ceftriaxon 1 x 2 gram
Antrain 1 x 1 ampule
Pro Hernioctomy
Prognosis

Quo ad vitam
Quo ad fungsionam
Quo ad sanationam

VII.
1.

: Ad bonam
: Dubia ad bonam
: Ad Bonam

Literature Review
Definition

A hernia is a protrusion or bulging of the contents of a cavity through a defect or weak part of the
wall in question. In abdominal hernia, abdominal contents protrude through a defect or weak
parts of the musculo-aponeurotik layers of the abdominal wall. Hernia consists of rings, bags,
and the contents of the hernia. 1 Inguinal hernias are one of the most common reasons a primary
care patient may need referral for surgical intervention. The history and physical examination are
usually sufficient to make the diagnosis. Symptomatic patients often have groin pain, which can
sometimes be severe. Inguinal hernias may cause a burning, gurgling, or aching sensation in the

groin, and a heavy or dragging sensation may worsen toward the end of the day and after
prolonged activity. An abdominal bulge may disappear when the patient is in the prone position.
Examination involves feeling for a bulge or impulse while the patient coughs or strains.
Although imaging is rarely warranted, ultrasonography or magnetic resonance imaging can help
diagnose a hernia in an athlete without a palpable impulse or bulge on physical examination.
Ultrasonography may also be indicated with a recurrent hernia or suspected hydrocele, when the
diagnosis is uncertain, or if there are surgical complications. Although most hernias are repaired,
surgical intervention is not always necessary, such as with a small, minimally symptomatic
hernia. If repair is necessary, the patient should be counseled about whether an open or
laparoscopic technique is best. Surgical complications and hernia recurrences are uncommon.
However, a patient with a recurrent hernia should be referred to the original surgeon, if possible.
Hernia is a general term describing a bulge or protrusion of an organ or tissue through an
abnormal opening within the anatomic structure. Although there are many different types of
hernias, they are usually related to the abdomen, with approximately 75% of all hernias
occurring in the inguinal region.1 Abdominal wall hernias account for 4.7 million ambulatory
care visits annually. More than 600,000 surgical repairs for inguinal hernias are performed
nationwide each year,2 making it one of the most common general surgical procedures
performed in the United States. Inguinal hernias have a 9:1 male predominance,3 with a higher
incidence among men 40 to 59 years of age. It has been estimated that more than one-fourth of
adult men in the United States have a medically recognizable inguinal hernia.4 Men with a
diagnosed hiatal hernia have been shown to have double the risk of an inguinal hernia. Among
women, taller height, chronic cough, umbilical hernia, older age, and rural residence have been
associated with a higher incidence of inguinal hernia. Neither smoking nor alcohol use has been
shown to affect hernia occurrence. Several studies have demonstrated that men who are
overweight or obese have a lower risk of inguinal hernia than men of normal weight.4,5
Although this article focuses on inguinal hernias, other diagnostic possibilities should be
considered in a patient with groin pain (Table 1). In athletes, groin pain most commonly results
from an overuse injury associated with adductor tendons and muscles, and a specific differential
diagnosis should be considered in these patients (Table 2). 6,7 Any mass palpated in the inguinal

region should prompt a thorough clinical evaluation because there are many possible diagnoses
(Table 3).
-

2.

Epidemiology
Seventy-five percent of all cases of abdominal wall hernia appear around the

groin. Hernia right side is more common than on the left side. Hernia more indirect than direct
hernia is 2: 1, the ratio of male: female in indirect hernia is 7: 1. Femoral hernia kejadiaanya less
than 10% of all hernias but 40% of emergency cases that appear to inkaserasi or
strangulation. Femoral hernias are more common in older people and men who have undergone
surgical inguinal hernia. 2.3

3.

Etiology
The cause of hernia is 1.2:
a. The weakness of the abdominal cavity wall. Can since lahit or acquired later in life
b. As a result of surgery senelumnya
c. Congenital
d. Congenital hernias entirely
The baby is suffering from a hernia due to a defect in certain places
e. Congenital hernias are not perfect
Babies are born normal (abnormalities not visible) but have a defect in certain places
(predisposition) and several months (0-1 years) after the birth will occur through the
defect because it is influenced by the increase in intra-abdominal pressure (straining,
coughing, crying)

d.

A hernia which is not due to a congenital defect but due to other factors of human

experience, among others:

High intra-abdominal pressure, ie in patients who frequent straining during bowel

movement or urination.

Constitutional body. In thin people because jairngan binding hernia slightly, while

in obese people due to fatty tissue much so that adds to the burden of connective tissue backers.

Diding abdominal distension due to increased pressure intaabdominal

A disease that weakens the abdominal wall

Smoking

Diabetes mellitus

4.

Parts of Hernia
The parts of the hernia by:

1.

Pockets hernia. In the form of abdominal hernia parietal peritoneum. Not all hernias have

pockets, eg incisional hernia, adipose hernia, hernia internalizers.

2.

The hernia contents: the form of organ or tissue out through the hernia bag, for example

intestines, ovaries and intestines buffer network (omentum).

3.

Doors hernia: a locus minoris part resi s tance traversed hernia bag.

4.

Neck hernia: hernia bag narrowest part.

5.

Classification of Hernia

According to the nature and circumstances of the hernia can be divided into three:

Hernia reponible: when the hernia contents can exit sign. Intestines out when standing or

straining, and sign in again when lying down or pushed in the stomach, no complaints n yeri or
symptoms of bowel obstruction.

Hernia ireponible: If the contents of the bag can not be repositioned back into the

abdominal

cavity. This

is

usually

caused

by

the

contents

of

the

bag on

peritoneal adhesions hernia bag.

Hernia incarcerated or Strangulated: when it sandwiched by hernia ring so that the bag is

trapped and can not get back into the abdominal cavity. As a result, interference occurs
vascularization. Bowel resection should be done immediately to an menghilangk parts that may
necrosis.
According to Erickson (2009) in Muttaqin 2011, there are several classifications hernia
divided by regionya, namely: inguinal hernia, femoral hernia, umbilical hernia, and hernia
skrotalis.

Inguinal Hernia, namely: conditions prostrusi (protrusion) intestinal organs enter into

cavity through a defect or a part of the wall is thin or weak from the inguinal ring. The material
in more frequently is the small intestine, but it can also be a fatty tissue or omentum. Predispose
to inguinal hernia is a defect or abnormality found in the form of partial cavity wall is weak. The
exact cause of inguinal hernia lies in the weakness of the wall, due to changes in the physical
structure of the wall cavity (elderly), increased intra-abdominal pressure (obesity, a strong cough
and chronic straining due to constipation, etc.).

Femoral Hernia, namely: a protrusion of intestinal organ that go through the funnel

shaped femoral canal and out of the fossa ovalis in the groin. The cause of the femoral hernia as
an inguinal hernia.

Umbilical hernia, namely: a protrusion (prostrusi) when the contents of an abdominal

organ in through the anterior canal bordered by the linea alba, posteriorly by the fascia of the
umbilicus, and the lateral rectus. A hernia occurs when tissue fascia of the abdominal wall at the
umbilicus area experiencing weakness.

Hernia Skrotalis, namely: the lateral inguinal hernia contents into the scrotum

complete. These hernias should be carefully distinguished from the hydrocele or elevantiasis
scrotum.

Classifications in science and medicine are important communication tools.[23] As such, effective
groin hernia classifications provide the following:

serve as an anatomic blueprint for the dissection and functional evaluation of the canal
and its contents

assist in determining the most appropriate repair for the particular problem

help correlate postoperative symptoms, duration of convalescence, and degree of

disability

allow correlation of postoperative results and long-term follow-up with the original
problem.

Many hernia classifications have been proposed in the last 4 decades, which meet these criteria
to varying degrees. The most popular classifications are described below.
Casten[24] divided hernias into 3 stages:

Stage 1: an indirect hernia with a normal internal ring

Stage 2: an indirect hernia with an enlarged or distorted internal ring

Stage 3: all direct or femoral hernias

The Halverson and McVay[25] classification divided hernias into 4 classes:

Class 1: small indirect hernia

Class 2: medium indirect hernia

Class 3: large indirect hernia or direct hernia

Class 4: femoral hernia

Ponka's[26] system defined 2 types of indirect hernia:

(1) uncomplicated indirect inguinal hernia and (2) sliding indirect inguinal hernia and three types
of direct hernias: (1) small defect in the medial aspect of Hesselbach's triangle near the pubic
tubercle; (2) diverticular hernia in the posterior wall with an otherwise intact inguinal floor; and
(3) a large diffuse direct inguinal hernia of the entire floor of Hesselbach's triangle.
Gilbert[23] designed a classification for primary and recurrent inguinal hernias done through an
anterior approach (Figure 28). It is based on evaluating 3 factors:
1. presence or absence of a peritoneal sac
2. size of the internal ring
3. integrity of the posterior wall of the canal

Figure 28. Gilbert classification. Five types of primary and recurrent inguinal hernias.

Types 1, 2 and 3 are indirect hernias; types 4 and 5 are direct.

Type 1 hernias have a peritoneal sac passing through an intact internal ring that will not
admit 1 fingerbreadth (ie,<1 cm.); the posterior wall is intact.

Type 2 hernias (the most common indirect hernia) have a peritoneal sac coming through a
1-fingerbreadth internal ring (ie, 2 cm.); the posterior wall is intact.

Type 3 hernias have a peritoneal sac coming through a 2-fingerbreadth or wider internal
ring (ie, >2 cm.).

Type 3 hernias frequently are complete and often have a sliding component. They begin
to break down a portion of the posterior wall just medial to the internal ring.

Type 4 hernias have a full floor posterior wall breakdown or multiple defects in the
posterior wall. The internal ring is intact, and there is no peritoneal sac.

Type 5 hernias are pubic tubercle recurrence or primary diverticular hernias. There is no
peritoneal sac and the internal ring remains intact. In cases where double hernias exist, both
types are designated (eg, Types 2/4). Descriptors such as L, Sld., Inc., Strang. Fem. are used
to designate lipoma, sliding component, incarceration, strangulation and femoral
components.

In 1993, Rutkow and Robbins[27] added a type 6 to the Gilbert classification to designate double
inguinal hernias and a type 7 to designate a femoral hernia.
Nyhus[28] developed a classification designed for the posterior approach based on the size of the
internal ring and the integrity of the posterior wall. According to this scheme

Type 1 is an indirect hernia with a normal internal ring;

Type 2 is an indirect hernia with an enlarged internal ring;

Type 3a is a direct inguinal hernia;

Type 3b is an indirect hernia causing posterior wall weakness;

Type 3c is a femoral hernia;

Type 4 represents all recurrent hernias.

Of these and other classifications that have been proposed, a recent survey indicated that the
most commonly used classifications by members of the American Hernia Society are the
classical Indirect/Direct designation, that of Nyhus, and that of Gilbert/Rutkow and Robbins.
Most recently, Zollinger[29] proposed a unified classification of groin hernias that combines one
of the most commonly used individual classifications and is applicable to the anterior and
posterior approaches. The principal feature of Zollinger's combined classification is the
recognition that a large indirect hernia defect also imposes on the posterior wall, and in effect
becomes a combined defect.

6.

Pathophysiology lateral inguinal hernia

The inguinal canal in the normal channels to the fetus. In the 8th month of pregnancy,
there desensus vestikulorum through the channel. Peritoneum testicular descent would
attract to the area of the scrotum, causing the bulge of peritoneum called the processus
vaginalis pritonea. If the baby is generally processus has undergone obliteration, so that the
contents of the abdominal cavity can not pass through the canal. But in some cases often
have not closed, because the left one down first from the right, then the right inguinal canal
is open more often. Under normal circumstances, this open canal will close at 2 months of
age. 1,2
When the process of the open portion, AMKA arise hydrocele. When the channel is
open continuously, because rosesus not berobliterasi will arise lateral congenital inguinal
hernia. Usually hernias in adults This happens because by bartambahnya age, the body's
organs and tissues undergo a process of degeneration.In older people the canal has been shut
down. Namuan because this region is minoris resistance locus, then the circumstances that
led to increased intra-abdominal pressure such as chronic coughing, sneezing strong and
lifting heavy items, push. Channels that are closed can be reopened and the lateral inguinal

hernia arises for something and encouraged the body's tissues and exit through the
defect. Finally punched in the wall cavity that has sagged due to trauma, prostatic
hypertrophy, ascites, pregnancy, obesity, and congenital abnormalities and can occur in all. 2
Men more than women, because of differences in the reproductive development of
men and women during the fetus. Potential complications occur adhesions between the
contents of the hernia bag wall hernia hernia so that the contents can not be put
back. Suppression of the hernia ring, due to the increasing number of incoming rings
intestinal hernia become narrow and cause interference distribution of intestinal
contents. Edema when necrosis. When there is blockage and hemorrhage will arise
flatulence, vomiting, constipation. When incarcerated is left, then the long run will arise
edema resulting in suppression of blood vessels and necrosis. 2
7.

Clinical Manifestation
A burning sensation in the groin occasionally precedes the development of a palpable hernia.
Patients with hernia commonly report discovering a mass in the groin. Typically, the patient
notes that the mass is gone when he awakens in the morning, but it reappears on arising. A
dull sensation may be experienced as the day progresses and the patient has been upright for
many hours. Patients may also have difficulty getting into or out of an automobile, and some
note a gas bubble in the groin. Changes in work or leisure activities to accommodate the
discomfort are common.
Coughing or severe straining as occurs with constipation or prostatism frequently precipitates
the clinical appearance of the hernia. Any sudden increase in the size of the mass suggests
incarceration or the development of a sliding component. Direct hernias are usually easier to
reduce and are less prone to incarcerate or strangulate than indirect hernias. Sliding hernias
more commonly are indirect, but when any part of the urinary bladder protrudes through a
direct defect, it too is considered a sliding hernia (Figure 29).

8.
a.

Diagnosis
Physical examination

Finger examination test using a finger or fingers 2 to 5, inserted through the

scrotum through the external annulus into the inguinal canal, the patient was told to cough. When
the tip of the finger impulse means ingunalis lateral hernia, when the impulse besides ing
finger uinalis medial hernia. 4
Examination Ziemen test lying down position, if there is a bump first insert,
hernia right-checked with the right hand, the patient was told to cough when
stimulus on the finger of the 2nd hernia ingunalis lateralis, finger 3rd inguinal
hernia medial finger 4th femoral hernia. 4

Examination Thumb test annulus is pressed with the thumb and the patient was

told to push, when out bumps mean medial inguinal hernia, if not out bumps mean lateral
inguinal hernia. 4

The diagnosis of an inguinal hernia is usually made through history and physical examination
findings. Although data are limited, in one report, the sensitivity and specificity of the physical
examination were 75% and 96%, respectively.8 Symptoms of an inguinal hernia may appear
gradually over time or develop suddenly, as with incarceration (i.e., the contents of the hernia sac
cannot be returned to the abdominal cavity). Inguinal hernias may be asymptomatic and found
incidentally on routine physical examination.
Symptomatic patients often present with groin pain, which can be severe. Stretching or tearing of
the tissue at and around the hernia defect can lead to a burning, gurgling, or aching sensation in
the groin. This usually causes localized pain directly at the site of the hernia.
Pain may worsen with Valsalva maneuvers. Patients may experience a heavy or dragging
sensation in the groin, especially toward the end of the day and after prolonged activity.1
Activities that increase intra-abdominal pressure, such as coughing, lifting, or straining, cause
more abdominal contents to be pushed through the hernia defect. As this occurs, the bulge of the
hernia gradually increases in size. If the patient indicates that this bulge disappears while he or
she is in the supine position, clinical suspicion of a hernia should be increased.
Hernias may be easily diagnosed with an adequate physical examination. The physical
examination should begin by carefully inspecting the femoral and inguinal areas for bulges while
the patient is standing. Then, the patient should be asked to strain down (i.e., Valsalva maneuver)
while the physician observes for bulges. This may be accomplished by using the right hand to
examine the patients right side and the left hand to examine the patients left side.
The physician invaginates the loose skin of the scrotum with the index finger on the ipsilateral
side of the patient, starting at a point low enough on the scrotum to reach as far as the internal
inguinal ring. Starting on the scrotum, the examining finger follows the spermatic cord upward
above the inguinal ligament to the triangular, slit-like opening of the external inguinal ring. The
external inguinal ring is medial to and just below the pubic tubercle. The inguinal canal is gently
followed laterally in its oblique course. While the examining finger is in the canal next to the

internal inguinal ring, the patient strains down or coughs as the physician feels for any palpable
herniation.9
The diagnosis of an inguinal hernia is confirmed if an impulse or bulge is felt. If no bulge is
detected with a Valsalva maneuver, a hernia is unlikely. However, athletic pubalgia (sports
hernia) may be considered in athletes with groin pain and no bulge. A sports hernia is not a true
hernia, but rather a tearing of tissue fibers. This typically occurs in patients with a history of
high-intensity athletic activity. Although these patients have typical hernia symptoms, there is no
evidence on physical examination. Further follow-up and reexamination are needed to diagnose a
sports hernia. Pain along the symphysis pubis suggests osteitis pubis, whereas pain along the
adductor tendons suggests adductor tendinopathy. It is more challenging to diagnose a hernia in
female patients. Direct palpation with an open hand over the groin area might detect the impulse
of a hernia during a Valsalva maneuver. However, further workup with diagnostic testing or
referral to a surgeonis often indicated. Rarely, diagnostic
laparoscopy is necessary. Incarceration may be managed in the office setting if there is no
associated pain.
The standard of care is to place the patient in the Trendelenburg position while holding gentle
pressure on the area for up to 15 minutes. If acute onset of groin pain occurs, the hernia may
have become strangulated (i.e.,
the blood supply to the entrapped contents is compromised). Strangulation should be suspected
in the presence of tenderness, redness, nausea, and vomiting and is a surgical emergency.10

b.

Supporting investigation

Leukocytes> 10000-18000 / mm 3

Serum electrolytes increases

radiologically

Ultrasound examination is also useful for distinguishing hernia incaserata of a

pathological lymph nodes or other causes of a palpable mass in the groin.

CT scans can be used to mngevaluasi pelvis for the presence of obturator hernia.

Although imaging is rarely needed to diagnose a hernia, it may be useful in certain clinical
situations (e.g., suspected sports hernia; recurrent hernia or possible hydrocele; uncertain
diagnosis; surgical complications, especially chronic pain).8
The clinical use of ultrasonography has shown promise in these situations.11,12 The
sensitivity of ultrasonography
for the detection of groin hernias is greater than 90%, and the specificity is 82% to 86%.8,13
Use of higher resolution axial computed tomography in the diagnosis of inguinal hernia is
being investigated.14 Magnetic resonance imaging may be useful in differentiating inguinal
and femoral hernias with a
high sensitivity and specificity (greater than
95%).8
The use of magnetic resonance imaging is helpful in the diagnosis of athletic pubalgia or
sports hernias, which may occur at any age with potentially more than one cause.
Thephysician may consider magnetic resonance imaging
in the workup of patients with activity-related groin pain when no inguinal hernia can be
identified on physical examination.15

8.

Differential diagnosis

a.

Malignancy: lymphoma, retroperitoneal sarcoma, metastasis, testicular tumor

b.

Primary testicular disease: varicocele, epididymitis, testicular torsion, hydrocele, ectopic

testis, testicular undescenden

c.

The femoral artery aneurysm

d.

lymph node

e.

lymph cyst

f.

sebaceous cysts

g.

psoas abscess

h.

hematoma

i.

ascites

9.

Management

Most groin hernias are clinically important and should be repaired electively, before they begin
to enlarge. Hernia enlargement is associated with higher surgical failure rates and adjusted
lifestyle. This holds true for all indirect, femoral, recurrent, and most direct hernias. When a
hernia does begin to enlarge or is no longer reducible, repair should be planned promptly.
Today, most hernia surgery is performed on an outpatient basis under regional or local anesthesia
(see below), generally with adjunctive sedation managed by an anesthesiologist. Only patients
who refuse a regional anesthetic or those undergoing laparoscopic surgery receive general
anesthesia. As a result, factors such as very young or old age, obesity, and coexisting cardiac,
respiratory, or malignant disease are no longer considered contraindications to elective hernia
repair. In addition, extensive or elaborate preoperative laboratory testing is no longer routine and
is only done when specifically indicated or required by hospital regulations. Young, healthy
adults can usually have a hernia repair performed with minimal preoperative laboratory work,
provided they have a normal preoperative history and physical examination.

Elective surgery is done to relieve symptoms and prevent complications such as

inkeserasi and strangulation. Pngobatan recommended only on a non-operative hernias are
asymptomatic. The main principle is herniotomy hernia operation: opening and cutting bag
hernia. Herniorraphy: fix the posterior abdominal wall ingunalis canal. 1.2
Herniotomy
The incision 1-2 cm above the inguinal ligament and aponeurosis obliqus external inguinal
canal is opened all external. Hernia pouch separated from m.creamester carefully up to the
internal inguinal canal, hernia pouch is opened, view the contents and then returned to the
abdominal cavity hernia cut. In children enough to just do herniotomy and does not require
herniorrhapy. 1.2
Herniorrhapy
The posterior wall is strengthened by stitching or non-absorbable mesh with different
techniques. Although the techniques of surgery can vary Bassini and Shouldice technique
most widely used. Liechtenstein surgical technique using mesh above the defect has a low
recurrence rate. 1.2
In the past, surgical repair was recommended for all inguinal hernias because of the risk of
complications such as incarceration or strangulation. However, recent studies have proved that
small, minimally symptomatic, first occurrence hernias do not necessarily require repair, and
these patients can be followed expectantly. However, they should be counseled on the symptoms
of incarceration and strangulation, and to seek prompt evaluation if these
occur.16,17 Patients with symptomatic, large, or recurrent hernias should be referred for repair,
generally withinone month of detection.18 Hernia repair almost always involves some type of
prosthetic material (i.e., mesh), with the possible exception of women of childbearing age
because stretching of tissues during pregnancy may result in a recurrent hernia. The choice of
mesh material used in the repair is based on the surgeons preference.
The choice of open vs. laparoscopic repair depends on surgeon preference, but only about 10
percent of inguinal hernia repairs in the United States are performed via a laparoscopic
technique.19 Open repair may be particularly beneficial in older, less healthy patients.20
Laparoscopic repair is usually reserved for recurrent. or bilateral hernias. Open and laparoscopic
techniques have similar results (Table 4). 21-24 Both procedures are effective if performed by an

experienced surgeon, and have a recurrence rate from 0% to 9.4%.25,26 The most common
complications of hernia repair are hematomas, including penile or scrotal ecchymosis; seromas;
and wound infection. Although these are uncommon, family physicians should be vigilant
because patients may present to them postoperatively. Chronic pain is the most common longterm problem after hernia repair, occurring in 5% to 12% of patients, and is related to nerve
scarification, mesh contraction, chronic inflammation, or osteitis pubis.27,28 Treating hernia
repair complications can be challenging, and these patients are often referred to the operating
surgeon.29 Postoperative Care The current standard of care after hernia repair is general wound
care. The length of required inactivity varies greatly based on the surgeons preference, but
activity is usually permitted within two to four weeks for laborers and within 10 days as tolerated
for professionals.30,31
10.

prognosis
Depending on the age of the patient, the size of the hernia and the condition of the
contents of the hernia bag. The prognosis is good if wound infection, bowel obstruction be
addressed. Postoperative complications such as postoperative pain herniorraphy, testicular
atrophy and hernia recurrence can generally be overcome.