Initial Diagnosis
Direct inguinal hernias are common in the industrial setting. Indirect hernias and femoral hernias are rarely caused by work and are usually congenital. Hernias may be new (60%), recurrent (25%), or bilateral (15%).
Initial Evaluation
First visit: with Primary Care Physician MD/DO (100%)
- Determine the type of lifting episode or incident.
- Determine whether the problem is acute, sub-acute, chronic, or of insidious onset.
- Determine the severity and specific anatomic location of the pain.
- Ask about the ability of the patient to lift.
- Determine any present medication.
- Determine any previous medical history, history of systemic disease, or history of previous hernia or related disability.
- Obtain history of any previous inguinal discomfort or previous hernia repair.
- Investigate non-industrial reasons that commonly exacerbate hernias (i.e., history of chronic cough associated with smoking, history of constipation with straining at stool, and any symptoms of prostatism leading to straining at urination). Note that it is very uncommon for hernias to occur as a result of a fall.
- Obtain family history regarding hernia.
Presumptive Diagnosis (see original guideline document for International Classifications of Diseases, Ninth Revision [ICD-9] codes)
- Direct or Indirect Inguinal Hernia
- Femoral Hernia
- Umbilical and Other Abdominal Hernia
It is unnecessary to differentiate between direct and indirect inguinal hernias; both are treated surgically with similar techniques.
Examine the patient in the standing position and determine the presence or absence of a hernia impulse on coughing or straining.
If a hydrocele is suspected, use transillumination: a hydrocele will transilluminate; a hernia will not. A hydrocele is not usually industrially compensable.
If a hernia is found, examine the patient in the supine position to ascertain whether it is reducible.
An irreducible hernia is not always strangulated. In the standing position, an irreducible hernia will increase in size with straining while a strangulated one will not. There will be other signs and symptoms with strangulation, including the presence of a firm, painful, tender mass in the inguinal region, which is irreducible. It may be associated with signs of bowel obstruction (i.e., nausea and vomiting, abdominal/visceral pain, abdominal distention, absent bowel sounds, history of infrequent bowel movements), fever, and elevated white blood cell count.
Examine for signs of a Richter's hernia (a strangulated hernia involving part of the circumference of the bowel wall)
Imaging techniques such as magnetic resonance imaging (MRI), computed tomography (CT) scan, and ultrasound are unnecessary except in unusual situations.
Examine the opposite inguinal (femoral) region for signs of bilaterality.
Classify the hernia into one of the following diagnoses:
- Reducible hernia
- Irreducible non-strangulated hernia
- Suspected strangulated or Richter's hernia (strangulated hernia in which only a part of the caliber of the gut is involved)
Initial Therapy
- Reducible Hernia
- Surgery is not emergent.
- Consider symptom control with an elastic support or truss, if effective, on a temporary basis (during the preoperative period or within several weeks, not recommended as a long-term treatment).
- Otherwise, refer for surgical consultation.
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Official Disability Guidelines (ODG) Return-To-Work Pathways
Without surgery (truss), light work: 0 days
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Note: No time is recommended for heavy work since the truss is not recommended as a long-term treatment.
- Irreducible Hernia (Not Strangulated or Richter's)
The treatment of irreducible hernia is surgical, and referral to a surgeon is appropriate.
- Suspected Strangulated or Richter's Hernia
These are emergent conditions and require prompt referral to a surgeon.
Surgery
Performed by General Surgeon (95%), Specialist (5%)
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.
Repair of almost all groin hernias is recommended. Inguinal hernias should ultimately be repaired because they enlarge, leading to a more difficult repair and higher risk of complications or recurrence. However, if symptoms are not severe, watchful waiting may be appropriate for as much as a year or two. 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.
The three basic approaches are: (1) open repair (the traditional repair, utilizing the patient's own tissue), (2) open tension-free repair using mesh (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. Advanced laparoscopic training is required for laparoscopic hernia repair.
For repair of primary inguinal hernia, open (mesh) should be the preferred surgical procedure, unless the surgeon is experienced in the laparoscopic technique.
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ODG Return-To-Work Pathways
With open surgery, clerical/modified work: 14 days
With open surgery, manual work: 21 to 28 days
With open surgery, heavy manual work: 42 to 56 days
(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary of the original guideline document)
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For the repair of recurrent and bilateral inguinal hernia, laparoscopic surgery should be considered. Laparoscopic surgery for inguinal hernia should only be undertaken in those units with appropriately trained operating teams which regularly undertake these procedures.
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ODG Return-To-Work Pathways
With endoscopic surgery, clerical/modified work: 7 days
With endoscopic surgery, manual work: 14 days
With endoscopic surgery, heavy manual work: 28 days
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Surgery should be performed on an outpatient basis in most cases.
