General Surgery

Inguinal Hernia

A groin-wall defect allows fat or bowel to protrude through the inguinal canal; the key clinical decisions are whether it is reducible, whether it is symptomatic, and whether obstruction or strangulation makes it an emergency.

In a nutshell

An inguinal hernia is a groin-wall defect causing a swelling that often enlarges with standing or straining and reduces when lying down. Diagnose most clinically; distinguish an uncomplicated reducible hernia from an acutely irreducible or strangulated emergency, then use shared decision-making for elective repair versus watchful waiting.

Classic presentation

A groin lump or dragging discomfort that changes with position or cough, usually above and medial to the pubic tubercle, with no acute obstruction or systemic illness.

Key points

Clinical examination is usually sufficient for an overt hernia; use dynamic ultrasound when the diagnosis is uncertain.
A suddenly irreducible painful hernia is an urgent surgical problem; do not confuse it with a longstanding, asymptomatic irreducible lump.
Strangulation is suggested by worsening pain, tenderness, skin colour change, vomiting, obstruction or physiological deterioration; normal blood tests do not exclude it.
Attempt gentle manual reduction only when bowel ischaemia is not suspected, then observe after successful reduction; failed reduction or suspected strangulation needs emergency surgery.
Symptomatic or enlarging hernias usually need elective surgical assessment; minimally symptomatic reducible hernias may be watched after shared decision-making and safety-netting.
A groin lump in women or people with female reproductive anatomy needs careful consideration of femoral hernia, which has a higher complication risk.

First-line investigation

Clinical examination standing and lying, with Valsalva and assessment of reducibility; dynamic groin ultrasound if the diagnosis is uncertain.

Management

Identify an acutely complicated hernia

Escalate a painful, tender or newly irreducible hernia, especially with vomiting, obstruction, skin change or physiological deterioration, to urgent general-surgical assessment.^3,2,4

Examine and image only when it helps

Examine standing and lying with cough or strain; use dynamic ultrasound for uncertainty and CT when obstruction, ischaemia or another acute diagnosis is suspected.^6,4

Reduce safely or operate

If there are no signs of ischaemia, an experienced clinician may attempt gentle reduction and observe after success; failed reduction or suspected strangulation requires emergency surgery.^4,3

Plan elective treatment around symptoms and fitness

Offer surgical assessment for pain, functional limitation or enlargement, and discuss open versus laparoscopic repair, mesh, chronic pain and recurrence with the patient.^3,5,1

Use watchful waiting only when appropriate

A reducible asymptomatic or minimally symptomatic hernia may be observed after shared decision-making; consider femoral hernia urgently in women and other people with female reproductive anatomy.^3,6

Safety-net and review recovery

Give explicit advice about new pain, irreducibility, colour change, vomiting or inability to pass stool or flatus, and review persistent postoperative pain, numbness, wound problems or recurrent swelling.^3,6

Exam traps

Inguinal hernias are above and medial to the pubic tubercle; femoral hernias are below and lateral, but examination can be difficult.
Do not force reduction or delay a surgical opinion when strangulation is possible.
A normal lactate or blood count cannot rule out early bowel ischaemia.
Watchful waiting is for selected asymptomatic or minimally symptomatic reducible hernias, not for a painful, tense or newly irreducible lump.
Direct-versus-indirect classification is less important acutely than identifying obstruction, ischaemia and the need for urgent treatment.

Illustrations

Sensitive clinical image, hidden — Clinical photograph of a groin swellingClinical photograph of a right-sided inguinal hernia visible as a groin bulge above and medial to the pubic tubercle, accentuated on standing.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.