Inguinal hernias
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Speaker: [00:00:00] Welcome back to the EPA Playbook, our series on entrustable professional activities for general surgery residents.

I'm Dr. Jason Bingham, and with me today are two of our BTK Surgical Education Fellows, Dr. Agnes Prem Kumar from Creighton, and Dr. Emma Burke from Baylor. We're tackling inguinal hernias to recap EPAs matter because they translate the abstract language of competencies into real work you do every day as a surgical resident.

The EPA covers inguinal hernia specifically. There's a separate EPA regarding abdominal wall hernias. Each EPA defines a professional activity. You must eventually be trusted to perform independently. EPAs may also make feedback more meaningful by increasing objectivity and providing more data points across time, specifically case type and case complexity.

When you demonstrate consistent entrustment on EPAs, it accelerates your progression towards independent operating and decision making. That's why we've created the series. It's the perfect way for junior residents to dominate EPAs. So let's start with a case.[00:01:00]

You're in the clinic with Mr. K, a 45-year-old construction worker. He has a bulge in his right groin for a year. It gets more noticeable at the end of the day and when he lifts heavy equipment. He says it's sometimes uncomfortable but not severely painful. Where would we start with this patient?

Speaker 3: So like all of our patients, we're gonna start with getting a good history.

It's really important to ask about symptoms of the hernia, like character and onset. Has he ever experienced any obstructive type symptoms, any urinary symptoms? Ask him if he's able to reduce the hernia on its own, and has it ever been unable to be reduced by himself or somebody in the emergency room, and has he ever had a hernia repair or any other surgery in the past?

If he's had a hernia repair, it's important to understand how it was repaired, open robotically, laparoscopically, and with or without mesh.

Speaker 2: Another component is to understand what his other comorbidities are, and remember to ask about social history. Does he smoke? Does he take any alcohol? And importantly, we also wanna know what his BMI is.

Speaker: Okay, great. [00:02:00] So he denies nausea, vomiting, or other obstructive symptoms. He has no urinary symptoms and no prior abdominal surgeries. So he has well controlled hypertension. His BMI is 28 and he does smoke about a half a pack per day.

Speaker 3: So next up is a really good physical exam. We wanna examine both inguinal regions, so sometimes there are bilateral hernias, but one side's larger than the other and bothers the patient a bit more.

It's also important to look for other abdominal well defects, such as a concurrent umbilical hernia. If we do see a hernia on exam, we need to determine if it's reducible. Is it tender? Does it extend into the scrotum and examine the patient when they're doing a Valsalva maneuver or trying to crunch or cough?

This will increase their intraabdominal pressure and help make the hernia more prominent by pushing the abdominal contents into that weakened area.

Speaker 2: And especially in females. Make sure you distinguish it from a femoral hernia, which carries a higher risk of strangulation. It's often very challenging to reliably confirm that it's a femoral hernia with a physical exam alone.

[00:03:00] And you might need to rely on this imaging. Some patients can also have a chronically incarcerated inguinal hernia, and asking the patient if they've ever been able to reduce it on their own can tell you a lot about the progression of the hernia.

Speaker 3: Inguinal hernias are clinical diagnoses and imaging's rarely needed.

However, if the diagnosis is not clear on exam, possibly due to obesity or if the patient has had a repair in the past and the presentation is concerning recurrence, an ultrasound or CT can be really helpful. Ultrasound can help us differentiate the contents of the hernia sac, namely bowel or a mental fat that's present.

If you see peristalsis, that's a good hint that you have bowel inside of the hernia sac. A CT scan is great to look at the hernia defect size, the contents of the hernia, especially in those larger inguinal skeletal cases, and if the patient has ever had prior mesh in the area. It helps you delineate the layers better to plan your operative approach.

However, most people with small hernias, again, don't need a big imaging workup. It's mainly a clinical diagnose.

Speaker 2: Another essential piece of data is prior op notes. [00:04:00] They're always valuable in all contexts, but especially when you're operating on a prior operated field. So make sure you read through the approach the prior surgeon use, and any complications that might have occurred along the way.

Speaker: Okay, so the meat of this EPA is understanding the indications to operate. So in light of that, do we operate on every patient that has an inguinal bulge?

Speaker 2: No. So repair is contingent on the symptoms and how the hernia is progressing. The European Hernia Society guidelines state that watchful evading is an acceptable option for a minimally symptomatic patient, especially older men.

And there's no real specific time interval for waiting, but you should discuss with your patient on monitoring the hernia and the symptoms they're experiencing.

Speaker 3: Right. Studies show that in men with asymptomatic or minimally symptomatic NAL hernias watch while waiting is safe, the risk of acute incarceration is low at only around two to 4%.

But symptoms do tend to progress over time and most eventually need surgery With some studies citing around [00:05:00] 70% of men going on to receive an eventual hernia repair.

Speaker: That's right. The way I like to think about these and the way I counsel patients is, the risk of incarceration is about 1% per year.

So if you're 90, the risk of having an incarceration or lifetime is relatively low. If you're 40, that's a different story. The cumulative risk of having a serious problem down the road is higher in those patients. And don't forget, women are treated a little bit differently. So what specific things are you worried about in a women and how do you counsel them?

Speaker 2: So female with a groin bulge has a higher probability of it being a femoral hernia compared to men. And since femoral hernias have a higher risk of incarceration and strangulation, watchful weighting is not recommended. And then specifically within our pregnant patients, pregnant patients can develop groin bulges that are round ligament varicosities.

They're not true hernias. And here is where an ultrasound can really help clarify it.

Speaker 3: Exactly, and ultrasound will show you that there are no fascial defects in these patients with round ligament varicosities.

Just some varicosities.

Speaker: Okay, so to recap, our [00:06:00] patient in this case, Mr. K has a three centimeter bulge in the inguinal region that is present on Val Salva.

That's largely uncomfortable at the end of the day. He denies GU or GI symptoms. He's not had any surgeries in the past. We diagnosed it clinically and did not get any additional imaging. He really wants surgery to fix it before it gets bigger. So how do we assess his preoperative risk?

Speaker 3: So inguinal hernia repairs are generally considered a low risk surgery in the elective setting and a good history.

And physical is typically enough for seeing if patients are healthy from a cardiac and pulmonary standpoint, or if they need some additional workup. You can ask about the metabolic equivalence of a task or mets that he can perform without difficulty or do the revised cardiac index. And there's some different tools for assessing pulmonary risks such as pulmonary function test or ACAP for pulmonary complications.

And these can be used, especially if they're active smokers like our patient or have lung disease such as COPD.

Speaker 2: And similar to abdominal wall hernias, we need to ask about their [00:07:00] glycemic control, nutritional status, and BMI as all of these affect their risk profile.

Many surgeons use an A1C of less than seven to eight as a reasonable target before proceeding with elective procedures. And as you can imagine obesity contributes to higher risk of hernia, recurrences, and re-operations

Speaker 3: for our patient. Mr. K. Smoking cessation counseling is key. Ideally, we want 'em to quit smoking at least four to six weeks before surgery because research has shown that if patients quit smoking about four weeks prior, the risk of pulmonary complications and wound complications are reduced by about a third, and each additional week of quitting leads to an incremental benefit.

Speaker 2: Functional status is also an important consideration. Patients who are frail or have poor functional reserve have a higher preoperative risk, even if on paper they're young, there are a variety of validated frailty metrics such as the frailty index, timed up and go tests, et cetera. Be sure you take a look at this before

Offering

Speaker 2: an operation.

Speaker: Alright, so let's do a quick recap of optimal [00:08:00] timing. Timing depends on symptoms for asymptomatic patients. Watchful waiting may be offered. The patient's age and comorbidities must be considered in the risk benefit calculus for asymptomatic or minimally symptomatic hernias for symptomatic, but elective cases.

You need to optimize comorbidities before repair, and of course, emergent repair if there's concern for acutely incarcerated or strangulated hernias. Now, onto the fun part, what will be your surgical approach and what are some considerations that you need to mull over before deciding your approach?

Speaker 2: So the three main techniques for inguinal hernia repair are open, minimally invasive, totally extra peritoneal repair, and minimally invasive, laparoscopic, transabdominal, pre peritoneal repair. And with the open category, there are mesh based and tissue only based repairs. The most common mesh based repair is a Lichtenstein repair and tissue only based repairs, which re approximate the inguinal floor via the different methods or the shouldice, which is a multilayered closure of the floor.

The McVey where the transverse [00:09:00] abdominis muscle is suture to the Cooper's ligament and the bisi with a conjoint tendon is taken to the inguinal ligament. The McVey repair is a really good option for femoral hernias too.

Speaker 3: The type of hernia in your comfort with specific procedures are the two main tenants for repair.

For a large, recurrent hernia after failed MIS transabdominal, pre peritoneal repair, you might consider an open approach since those planes have not been disrupted by the previous repair, and vice versa, if a patient's had a failed open repair, tackling it minimally invasively this time, we'll allow you to approach it from the posterior vantage.

Patients with bilateral inguinal hernias are served well with an MIS approach. All this being said, the surgeon's comfort also comes into play. No one method has been shown to be superior to another, and you should do the best type of repair that you're capable of or refer the patient to another surgeon if you believe that is in their best interest.

Speaker 2: The hernia guidelines all agree that inguinal hernia repair should be a mesh based approach, such as the Lichtenstein, but again, the patient is the most important part of the discussion, and some [00:10:00] patients have reservations about. Mesh placement. So be sure to discuss the risks and benefits and also the recommendations for mesh based repair while also respecting the patient's goals of care in emergent setting where the patient has strangulated hernia, contents has dead bowel, or can soon develop it.

In the past, surgeons have refrained away from using mesh in these settings because of the risk of contamination, but there's new data that to adjust that mesh can even be placed in the setting of bowel resection as long as that there's minimal contamination.

Be sure you use a synthetic mesh that is lightweight and macro porous, but nevertheless, the type of repair you get in an emergent setting is never as good as an elective pre-planned setting. So the patients need to understand that there's a higher risk of recurrence, and if the mesh is not used in the initial temporizing operation, they need to have a more definitive operation in the elective setting with mesh.

Speaker 3: I also wanna bring in a quick aside, open inguinal hernia. Repairs can be done under minimal sedation or local anesthesia only, and a lot of times patients have a faster recovery with less narcotic [00:11:00] usage when these methods are used. This can be a great option as well for patients who are not the best surgical candidates.

You just have to be sure to infiltrate local anesthesia into the skin, the deep dermal tissue, the deep subcutaneous tissue, and subfascial tissue underneath the external oblique apo neurosis so that you fill the inguinal canal and you can even do the pubic tubercle and the hernia sac as well. Just think of hitting every single layer that you're going to touch on your repair.

Speaker: That's a great point, Emma. So again, let's do a quick recap of our case with Mr. K. He's a 45-year-old construction worker with a minimally symptomatic right inguinal bulge. We determined that while he was a candidate for watchful waiting with the appropriate counseling, he did opt for surgery. He stopped smoking six weeks before surgery and underwent an uneventful open right inguinal hernia with the Lichtenstein mesh repair.

Let's say he comes in a week later saying his scrotum is swollen and firm. He tried to use some ice packs, but has not noticed any improvement.

Speaker 2: So the most important things I'm thinking of to look out for in this early acute phase is, acute early hernia recurrence, [00:12:00] some testicular ischemia or hematoma or infected seroma.

It sounds like the patient's not sick. His main complaints are due to pain and he doesn't seem to have any infectious type symptoms, so I would make sure that the swelling is not due to an earlier hernia recurrence, and then most likely think that this is due to a hematoma from dissection.

Speaker 3: Hematomas are pretty common after inguinal hernia repair, and their size determines our management. Small hematomas can be managed conservatively with ice supportive underwear and elevation of the scrotum in just some time. If it's a large hematoma that does not resolve, you can consider aspiration or re-operation for hematoma evacuation.

Speaker: Yeah. So it's important to note that hematomas become more organized with time and might be more challenging to evacuate. It really is a risk benefit analysis of the timeframe for watchful waiting versus reoperation. So that's great. But let's do another quick scenario.

Ms. L, who's a 45-year-old patient presents for a follow-up visit three months after her laparoscopic inguinal hernia repair. She reports persistent, moderate to severe right [00:13:00] groin pain that prevents her from resuming her normal activities, including returning to work. What do you think, this could be?

Speaker 3: So I'm thinking about chronic pain after her inguinal hernia repair, which is a big topic for these patients. Acute nerve injury versus chronic pain is differentiated by the time course. If the patient has inguinal pain lasting more than three months, it's termed chronic pain or nerve injury. CPIP. The incidence is relatively high, approximately 10 to 12% of patients.

Though the degree of pain is variable, having severe pain that impacts daily activity is not as common and only seen in about two to 4% of patients. The biggest contributing factors are the type of approach with laparoscopic approaches, having lower incidents and taking care not to tack the mesh along the nerves or the triangle of pain as it's called.

Okay,

Speaker: great. So as a refresher, what are the boundaries of that triangle of pain you mentioned?

Speaker 3: So the boundaries are gonna be the IOP pubic tract as the superior border, the [00:14:00] testicular vessels as the medial border, and then the peritoneal reflection as the inferior border.

Speaker: Okay. So what should we do for Miss L? First to diagnose and then to manage.

Speaker 2: The biggest thing for diagnosis is a good history and physical. You really wanna understand where the distribution of the pain is and what inciting factors there are. You can potentially also use an ultrasound or an MRI to identify if the nerve is entrapped or if there's any mesh issues.

But a good history and performing a good nerve map can tell you which nerve is most likely injured.

Speaker: So let's go a little deeper into that. What nerves can be injured and what is their distribution?

Speaker 3: So the main nerves involved are the ileal inguinal nerve that goes across the lower abdomen, groin, and upper scrotum, or labia, the ileal hypogastric nerve, which does, supra pubic and lateral gluteal areas.

The genital femoral nerve, which is the genital branch, goes to the scrotum or the labia, and then the femoral branch goes to the upper thigh. And then the lateral femoral cutaneous nerve, which is less [00:15:00] common, but presents with pain on the outer edge of the thigh. You can do a comprehensive dermatome map in just a few minutes and identify your culprit.

Speaker 2: And once you know which nerves might be causing the issue, you can refer to interventional pain docs or radiologists who can numb that particular nerve with local anesthesia. It's not a permanent solution, but if it works, it's both diagnostic and therapeutic. Also, patients should be encouraged to take multimodal pain regimen strategies with a focus on non-opioid medication, and interventional pain.

Doctors can also perform minimally invasive nerve ablation for a more permanent effect. But there are cases that are refractory to these treatments and might require surgery for neurectomy or mesh removal. A study that was actually published in 2025 by al studied outcomes of Reve surgery and found that 89% of patients underwent a neurectomy, and 68% had their mesh removed.

Fortunately, 98.5% said that their inguinal pain improved after the surgery, and [00:16:00] over 70% of them noting greater than 50% reduction in pain.

Speaker: Good. So unfortunately, chronic al pain is relatively common complaint, and it's important to understand the time presentation and further workup that can be done to ascertain if it's a nerve issue or musculoskeletal, et cetera.

Let's just close out with a few last minute points regarding recovery. What's a normal postoperative course after inguinal hernia repair?

Speaker 3: Most of our elective patients will go home from the PACU and they can resume their daily activities. It's important to encourage ambulation and because many patients are hesitant to mess up their repair, so it's important to emphasize how walking helps generally with the recovery process.

While weightlifting restrictions should be there in the first few weeks, there are a lot of differing opinions regarding what the optimal restrictions look like. Once the repair is about a month healed, patients should be encouraged to exercise and lift weights.

Often the fear of lifting weights translates into months down the line and them limiting their exercise based off [00:17:00] of the repair, which should not happen in an emergent setting where the patient has a strangulated hernia or a bowel resection, their recovery will be longer, and they're typically in the hospital for a few days recovering.

But there is similar emphasis on ambulation once the patient is stabilized.

Speaker 2: All right, so as a quick recap in preoperative management, always assess the patient's comorbidities, optimize their risks, and counsel the patients on smoking cessation, weight loss, and functional health for non-operative management.

It's safe in men with minimum symptoms, but it's not recommended in women. And for operative management, make sure you review their prior operations and look at the hernia size and symptoms to dictate your specific operative approach.

Speaker: And that's EPA number 11 in action, evaluate and manage a patient with an inguinal hernia.

Thanks for joining us. Next time, we'll tack another core EPA. Until then, keep learning and keep caring.

Speaker 3: Just a reminder, this is only one episode in a series entitled the EPA Playbook, where we [00:18:00] delve into each of the EPAs outlined by the American Board of Surgery. You can find more information about the EPA descriptions and specific competencies for each one on the a BS website.

Hope you join us for the next episode, and as always,

Speaker: dominate the day.