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## Complete Summary

#### GUIDELINE TITLE

Surgical repair of groin hernias.

#### BIBLIOGRAPHIC SOURCE(S)

Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of
groin hernias. Manchester (MA): Society for Surgery of the Alimentary
Tract (SSAT); 2003. 3 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates the previously issued version: Society for
Surgery of the Alimentary Tract. Surgical repair of groin hernias.
Manchester (MA): Society for Surgery of the Alimentary Tract; 2000. 3 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Groin hernias, including inguinal and femoral hernias

#### GUIDELINE CATEGORY

Diagnosis\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Gastroenterology\
Internal Medicine\
Surgery

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To guide primary care physicians to the appropriate utilization of
surgical procedures on the alimentary tract or related organs

#### TARGET POPULATION

Adult patients with symptomatic or asymptomatic groin hernias

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Physical examination

2.  Ultrasound and x-rays (not recommended)

3.  Referral to surgeon for operative repair

**Treatment**

*Surgical Repair of Groin Hernias*

1.  Elective or emergent repair

2.  Open repair (traditional)

3.  Open tension-free repair (use of mesh)

4.  Laparoscopic repair

#### MAJOR OUTCOMES CONSIDERED

Return to normal activities of daily living

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not applicable

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Society for Surgery of the Alimentary Tract (SSAT) guidelines are
based on statements and recommendations that were overwhelmingly
supported by clinical evidence. Each represents a consensus of opinion
and is considered a reasonable plan for a specific clinical condition.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B,
Levine BA. Practice guidelines for patients with gastrointestinal
surgical diseases. J Gastrointest Surg 1998;2:483-484.)

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were reviewed by several committee members and then by
the entire committee on several occasions. Each guideline was then sent
back to the original author for final comment and reviewed again by the
committee. Each guideline was approved by the Board of Trustees of the
Society for Surgery of the Alimentary Tract and final comments were
reviewed by the committee.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B,
Levine BA. Practice guidelines for patients with gastrointestinal
surgical diseases. J Gastrointest Surg 1998;2:483-484.)

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Symptoms and Diagnosis**

Patients with inguinal hernias typically present with vague groin pain.
Inguinal hernias may be asymptomatic, discovered incidentally during
physical examination or present as a bulge discovered by the patient.
Since most hernias should be repaired, the patient should be referred to
a surgeon for evaluation and operative treatment. Sophisticated tests
are not required, since the diagnosis can usually be made on physical
examination, which is best performed with the patient standing and
straining against a held breath (Valsalva maneuver). Ultrasound and
diagnostic x-rays are also not usually necessary.

More difficult to diagnose is the occasional patient with groin pain but
no history of groin bulge and without physical findings of a hernia by
the primary physician or surgeon. Such a patient may not have a hernia,
but rather a groin muscle strain. In contrast, if a hernia is not found
on physical examination, but the patient describes a groin bulge, a
hernia is likely present. Femoral hernias often present as pain below
the groin crease, rather than a bulge, and are particularly difficult to
diagnose in the elderly or obese female with sudden groin pain but no
physical findings of groin hernia of any type.

The majority of groin hernias are readily reducible, have minimal or no
tenderness, and can be electively referred to a surgeon within a period
of weeks. However, if the hernia is tender and not reducible, the
patient should be referred immediately due to the risk of strangulated
bowel or other viscera. Aggressive attempts to reduce a groin hernia
with sedation, ice packs, or sustained weight or pressure should not be
pursued. Symptoms such as nausea and vomiting suggest bowel obstruction,
which mandates immediate referral to a surgeon.

**Treatment**

Because patients with groin hernias are usually offered and receive
elective repair, the incidence of emergent incarcerated (non-reducible)
hernias is relatively low. Urgent repair is required for a sudden,
non-reducible hernia or a chronically incarcerated hernia that becomes
acutely painful or tender, as this indicates impending strangulation.
While severe morbidity as well as mortality can be avoided by prompt
diagnosis, this clinical emergency causes the death of more than 2,000
patients per year in North America.

Most inguinal hernias that should be repaired are symptomatic or are
enlarged over time. Hernia belts should be discouraged and should be
limited to patients who are not candidates for elective operation. Their
use can lead to a more difficult repair and higher risk of complications
or recurrence. Femoral hernias should always be repaired because of the
high incidence of bowel strangulation. Patients with groin hernias
should undergo surgical evaluation within a month after detection.
Urgent repair is required for all painful, non-reducible hernias, while
asymptomatic hernias can be repaired electively. Elderly patients with
minor comorbid conditions will easily tolerate an outpatient elective
hernia repair, thus avoiding emergent repair of chronically incarcerated
hernias, which occur primarily in the elderly. The timing of repair is
determined by the symptoms.

The objective of any inguinal or femoral hernia operation is to repair
the defect in the abdominal wall. The three basic approaches are: (1)
open repair (the traditional repair, utilizing the patient\'s own
tissue); (2) open tension-free repair (in which mesh is used to bridge
or cover the defect); and (3) laparoscopic repair, a tension-free repair
also utilizing mesh. Open techniques of hernia repair can be performed
under local, regional, or general anesthesia, while laparoscopic hernia
repair requires general anesthesia.

**Qualifications for Performing Inguinal and Femoral Hernia Repairs**

Surgeons who are certified or eligible for certification by the American
Board of Surgery, the Royal College of Physicians and Surgeons of
Canada, or their equivalent should perform both elective and emergent
inguinal hernia repair. These surgeons have successfully completed at
least five years of surgical training after medical school graduation
and are qualified to perform open inguinal hernia repair, with and
without tension-free techniques. Advanced laparoscopic training is
required for laparoscopic groin hernia repair. The qualifications of the
surgeon should be based on training (education), experience, and
outcomes.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Short-term outcome studies suggest that a quick return to normal
activities can be achieved following both open and laparoscopic hernia
repair. Due to the presently higher cost of laparoscopic repair, open
repair is more frequently performed. Usual daily activities can be
resumed within a few days after surgery, depending on the patient\'s
comfort level. Oral pain medications are needed for only a few days.

#### POTENTIAL HARMS

As with any operation, the risk of infection or a significant hematoma
is approximately 1%. Recurrence of hernias occurs in 5 to 10% of
patients and requires another repair.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines have been written by the Patient Care Committee of the
Society for Surgery of the Alimentary Tract (SSAT). Their goal is to
guide primary care physicians to the appropriate utilization of surgical
procedures on the alimentary tract or related organs and they are based
on critical review of the literature and expert opinion. Both of the
latter sources of information result in a consensus that is recorded in
the form of these Guidelines. The consensus addresses the **range** of
acceptable clinical practice and should not be construed as a standard
of care. These Guidelines require periodic revision to ensure that
clinicians utilize procedures appropriately, but the reader must realize
that clinical judgment may justify a course of action outside of the
recommendations contained herein.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of
groin hernias. Manchester (MA): Society for Surgery of the Alimentary
Tract (SSAT); 2003. 3 p.

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2003 Feb 1)

#### GUIDELINE DEVELOPER(S)

Society for Surgery of the Alimentary Tract, Inc - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Society of Surgery of the Alimentary Tract, Inc.

#### GUIDELINE COMMITTEE

Patient Care Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates the previously issued version: Society for
Surgery of the Alimentary Tract. Surgical repair of groin hernias.
Manchester (MA): Society for Surgery of the Alimentary Tract; 2000. 3 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Society for Surgery of the
Alimentary Tract, Inc. Web
site](http://www.ssat.com/cgi-bin/guidelines.cgi).

Print copies: Available from the Society for Surgery of the Alimentary
Tract, Inc., 900 Cummings Center, Suite 221-U, Beverly, MA 01915;
Telephone: (978) 927-8330; Fax: (978) 524-0461.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Gadacz TR, Traverso LW, Fried GM, Stabile B, Levine BA. Practice
    guidelines for patients with gastrointestinal surgical diseases. J
    Gastrointest Surg 1998;2:483-484.

Electronic copies: Not available at this time.

Print copies: Available from the Society for Surgery of the Alimentary
Tract, Inc., 900 Cummings Center, Suite 221-0, Beverly, MA 01915;
Telephone: (978) 927-8330; Fax: (978) 524-8890.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 28, 2000. The information
was verified by the guideline developer as of May 30, 2000. This summary
was updated by ECRI on September 9, 2004.

#### COPYRIGHT STATEMENT

For terms governing downloading, use, and reproduction of these
guidelines, please contact: <ssat@prri.com>.

### DISCLAIMER

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Date Modified: 11/3/2008