Hernia
DOI 10.1007/s10029-007-0198-3

R E VI E W

The European hernia society groin hernia classication: simple
and easy to remember
M. Miserez · J. H. Alexandre · G. Campanelli · F. Corcione · D. Cuccurullo ·M. Hidalgo Pascual · A. Hoeferlin · A. N. Kingsnorth · V. Mandala · J. P. Palot ·V. Schumpelick · R. K. J. Simmermacher · R. Stoppa · J. B. Flament

Received: 30 December 2006 / Accepted: 11 January 2007
© Springer-Verlag 2007

Abstract After reviewing the available classiWcations
for groin hernias, the European Hernia Society (EHS)
proposes an easy and simple classiWcation based on theAachen classiWcation. The EHS will promote the general and systematic use of this classiWcation for intraoperative description of the type of hernia and toincrease the comparison of results in the literature.

Keywords Hernia · Inguinal · Femoral · Groin ·ClassiWcation

Introduction
Many diVerent groin hernia classiWcations are available. Most of them are complex and therefore diYcultto remember. The result is infrequent systematic use inR. Stoppa died a few months ago.
M. Miserez (&)
Department of Abdominal Surgery,
University Hospital Gasthuisberg,
Herestraat 49, 3000 Leuven, Belgium
e-mail: Marc.miserez@uz.kuleuven.ac.be
J. H. Alexandre
Paris, France
G. Campanelli
Department of Surgical Sciences,
Policlinico Hospital IRCCS,
University of Milano,
Pad. Beretta Est Via Francesco Sforza,
35, 20122 Milano, Italy
F. Corcione · D. Cuccurullo
Department of General and Laparoscopic Surgery,
Monaldi Hospital, Via Leonardo Bianchi,
80131 Naples, Italy

A. N. KingsnorthPeninsula Medical School, Level 7,
Derriford Hospital, Plymouth, PL6 8DH, UKV. Mandala
Department of General and Emergency Surgery,
Villa SoWa, CTO Hospital, Palermo 90015, Italy
J. P. Palot
Service de Chirurgie Generale et Digestive,
Hopital Robert-Debre-CHU, 51092 Reims, France
V. Schumpelick
Department of Surgery, Medical Faculty,
University Hospital, Rheinish-WestphalianTechnical University (RWTH), Pauwelsstrasse 30,52074 Aachen, Germany
R. K. J. Simmermacher
Department of Surgery, University Hospital,
3584X Utrecht, The Netherlands

M. H. Pascual
Department of Surgery, 12 de Octubre
University Hospital, Madrid, Spain

R. Stoppa
Amiens, FranceA. Hoeferlin
Katholisches Klinikum Mainz SHK,Chirurgische Abteilung, Hildegardstr. 2,55131 Mainz, GermanyJ. B. Flament
Department of Surgery and Anatomy,
Reims University, Service de Chirurgie Generale,
Hopital Robert-Debre-CHU, 51092 Reims, France123

Herniadaily surgical practice. During a meeting of the Boardof the European Hernia Society in Capri (2004), organised by one of the authors (FC), diVerent currently
available classiWcations were critically reviewed. Basedon the fact that a classiWcation should be simple andeducative in order to be adopted by the general surgical community, this group proposes a simpliWed synthesis of the currently available classiWcations for(intraoperative) classiWcation of primary and recurrent
inguinal or femoral hernias.

Materials and methods
Most currently available hernia classiWcations werereviewed one by one with respect to the number ofdiVerent subgroups, relevance of the subgroups,subgroups missing and simplicity. This review was used
to propose a simple classiWcation which is easy toremember.

Results
All the diVerent classiWcations have some drawbacks.
Table 1 illustrates most of the currently available hernia classiWcations. The Nyhus classiWcation is one of
the most frequently used classiWcations, but is not soeasy to remember [1], like the Stoppa classiWcation,
which is derived from the Nyhus classiWcation, withspecial attention to the aggravating factors [2]. The
Bendavid type, staging, dimension (TSD) classiWcationis very complex, with 20 diVerent subtypes [3]. Moreover, some of the available classiWcations, such as theGilbert classiWcation [4] lack the description of femoral
hernias or combined hernias (e.g. pantaloon hernia). A
simple and easy-to-remember classiWcation is the
Aachen classiWcation [5], making a distinction between

the anatomic localisation (indirect or lateral vs. director medial) and the size of the hernia oriWce defect incm (<1.5, 1.5–3, >3 cm).
Our proposed classiWcation resembles largely theAachen classiWcation. In order to further increase
simplicity and accuracy, we decided to modify the latter classiWcation only with respect to some minor
points, thereby adhering to the major criteria of theAachen classiWcation. In the Aachen classiWcation,
1.5 cm is used as reference for the size of the hernia oriWce. We propose the index Wnger as the reference inopen surgery, since the usual size of the tip of the index
Wnger is mostly around 1.5–2 cm. This dimension is also
reported to be identical to the length of the branches ofa pair of most laparoscopic graspers, dissectors or scissors, enabling the surgeon to use the same classiWcation
during laparoscopic surgery.
As can be seen in Table 2, the size of the hernia oriWce is registered as 1 (·1 Wnger), 2 (1–2 Wngers) and 3(¸3 Wngers). Thus a hernia oriWce of 2.5 cm is depicted
as a size 2 hernia. For the anatomic localisation, thesame criteria are used as in the Aachen classiWcation(L = lateral, M = medial, F = femoral). For a combined
hernia we propose to mention the diVerent hernias in
the table by ticking the appropriate box instead ofusing the term Mc as in the Aachen classiWcation.
In addition, the letter P or R can be encircled todepict, respectively, a primary or recurrent hernia.

Discussion
Hernia classiWcations are useful for pre- or intra-operative description of the anatomy and size of a groin hernia. This objective description is a prerequisite in thecase of tailored surgery, e.g. suture repair versus meshrepair in small indirect inguinal hernias without attenuTable 2 The EHS groin hernia classiWcation

Table 1 Overview of the heterogeneity of diVerent inguinal hernia classiWcations
IndirectDirectFemRec

GilbertStoppaNyhus
Bendavid TDS
AlexandreTOS
Schumpelick
Corcione
Cost
Porrero12311II1232IIIIIb12 39L cm0; cmL I L II L III
1123
1
2
343IIIaII2MI
21
554IVVRIIIII R

234IIIcIII IV
34F3

Herniaation of the posterior wall of the inguinal canal (typeL1). Objective hernia classiWcation is also necessary inorder to compare outcome after surgery in speciWc subgroups.
Many diVerent classiWcations, all based on the presence of a direct, indirect or femoral hernia, have been
described, from as early as 1967–1970 [6, 7] and later byGilbert [4] (modiWed by Rutkow and Robbins [8]) andNyhus [1] (modiWed by Stoppa [2]). The problem withthese classiWcations is that they are based on the Wndings during open (anterior) approach [9, 10], they are
not so easy to remember, lack an objective determination of the hernia oriWce (e.g. clear diVerentiation
between a small and medium-sized direct hernia) orlack a clear description of a combined or femoral hernia. This has limited their widespread use both in everyday practice (clear description in operation reports) andeven in the literature, with the Nyhus classiWcation
being the most widely used, especially in the USA.
We agree with Zollinger [11] that the ideal classiWcation system should be based on anatomic location, beapplicable to anterior and posterior approaches andeasy to remember. Zollinger also mentioned thedescription of anatomic function (competency of internal ring, integrity of the Xoor, defect size and descentof the sac). Zollinger has made an attempt to overcome
the aforementioned shortcomings, though we believethat this so-called updated traditional classiWcation [12]is diYcult to remember for general surgeons withoutgraphic representation of the diVerent types.
Schumpelick et al. [5] described in 1994 the most
simple Aachen classiWcation, based on type and size ofthe hernia defect, currently available for widespreaduse. In order to further increase simplicity and accuracy, we propose some minor alterations: clear description of combined or femoral hernias, primary or
recurrent hernia, the largest diameter to be used forquantiWcation of hernia oriWce size and clear deWnitionof the 1.5 cm reference, both in open and laparoscopic
surgery.
Of course a simple classiWcation with only these twovariables is a compromise and lacks a very detailed
description of the hernia. We did not include the factor
of anatomic function as proposed by Zollinger [11], since
it would increase the complexity of the classiWcation.
Scrotal extension of the hernia sac (especially if irreducible) represents a major challenge for the surgeon[13] and might inXuence the early outcome after surgery, e.g. the incidence of postoperative seroma formation. Although our proposal does not include size ordescent of the hernia sac, most irreducible scrotal hernias are large indirect hernias (L3). Thus, this subgroupis clearly identiWed in the proposed classiWcation.

This classiWcation does not allow evaluation of thefunction of the internal ring or posterior wall of theinguinal canal. This is diYcult to assess in any intervention under general anesthesia. Moreover it is not clear
if this information adds substantially to the outcome incomparison with a pure anatomical description of thehernia oriWce type and size.
At Wrst sight, the classiWcation also does not takeinto account the presence of bulging or weakness of theposterior wall of the inguinal canal [14] or the presenceof a cord lipoma [15]. These two aspects may nonetheless be important in the repair of an inguinal hernia,
especially if they were not recognised and as a consequence not treated, leading to an early (pseudo) recurrence. We suggest a herniating preperitoneal lipoma orcord lipoma should be described as a lateral hernia L1(which it is).
With respect to weakness of the posterior wall, wesuggest this should qualify as a medial hernia, if it
could be imbricated by plication of the transversalis
fascia, whether this is done or not. In our opinion, thisreXects the fact that a true defect is present. In cases ofsome diVuse bulging of the posterior wall (without anobvious well-circumscribed defect) where imbricationof the transversalis fascia is not possible, we suggest theuse of the terminology of a direct hernia adding the letter x (=Mx). Since alterations in the transversalis fascia
might be linked to a possible biological factor in thedevelopment of a hernia [16, 17], a systematic description of the posterior wall on a uniform basis must bepromoted. In our opinion, this deWnition can be usedboth in open and laparoscopic surgery. Most importantly, the fact that a surgeon may be in doubt whether
or not (and how) to describe the defect already indicates that a defect is present, which should be reported.
This also opens the problem of how to reconstructfrom the depicted class the fact that the femoral canal
was not examined intraoperatively, e.g. during a Lichtenstein repair, versus the absence of a hernia. We propose to use the appendix x if unclear [e.g. noexamination of the femoral canal during a Lichtenstein
repair for a large indirect scrotal hernia = L3Fx vs.
L3F0 if no femoral hernia is present]. This again allows
the classiWcation to be used both in open and laparoscopic surgery.
Other characteristics such as the type of anesthesia
or whether a hernia is incarcerated or irreducible, or
has a sliding component can easily be added. However,the large majority of hernias seen in the real world will
be easily, clearly and objectively described with thecurrent classiWcation. For recurrent hernias, a further
detailed description could be done using a speciWc subclassiWcation, as proposed by Campanelli [18].

123Hernia

Ideally, journals should stimulate authors reportingon (groin) hernias to use a classiWcation systematically,
especially if the endpoints (mainly recurrence rate) areor might be related to the type and/or size of hernia.
This should increase the comparability of diVerent
papers (e.g. meta-analysis) on the same subjects andallow further studies in speciWc clearly deWned subgroups.
However, the major task to accomplish will be toconvince all surgeons practicing hernia surgery toreport the class of the groin hernia systematically in theoperative report for later analysis. To support this, theEHS will provide classiWcation forms to be downloaded on its website (http://www.herniaweb.org/)
soon. Ideally, these data, together with patient-related
data and the type of repair should be collected in aprospective nationwide registry securing patient andsurgeon anonymity.

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