inguinal Hernia

Risk factors
Positive family history, prolonged increased abdominal pressure (COPD, constipation, prostatism, peritoneal dialysis), aortic abdominal aneurysm, smoking.

Examination
Basically only physical examination; groin mass cranially from Poupart's ligament. Differentiate between a lateral or medial hernia with physical examination is unreliable. Describe testicles, contralateral side and reducibility. Further test are rarely necessary but in doubt a herniography, US or MRI can be considered.

Differential diagnosis
Femoral hernia, varicosis, lymph node, aneurysm, abscess, soft tissue tumor.

Treatment
Asymptomatic hernia; consider conservative treatment
Symptomatic hernia; planned surgery
Incarcerated hernia; acute surgery

Surgical technique
Unilateral; Mesh-repair.Extensive research has been done for the Lichtenstein's and the endoscopic technique. Lichtenstein's technique is recommended.
Bilateral; Mesh-repair. Lichtenstein or endoscopy if enough expertise is available. When endoscopically treated, the TEP is superior to the TAPP.
Recurrent hernia; Technique depends on earlier treatment. In case of an earlier anterior approach, a pre-peritoneal mesh or TEP should be performed. In case of an earlier posterior approach, an anterior mesh or TAPP should be performed.

Antibiotics
Antibiotic prophylaxis does not prevent the occurrence of wound infection after groin hernia surgery and should therefore not routinely be given. Prophylactic antibiotics is only recommended in high risk patients.

Literature
1. Kark A, Kurzer M, Waters KJ. Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg 1994;81(7):1081-2
2. McIntosh A, Hutchinson A, Roberts A, Withers H. Evidence-based management of groin hernia in primary care - a systematic review. Fam Pract 2000;17(5):442-7
3. Ralphs DN, Brain AJ, Grundy DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J 1980;280(6220):1039-40.
4. Simons MP, Obertop H. Lichamelijk onderzoek geeft uitsluitsel over een mediale dan wel een laterale liesbreuk. In:van Everdingen JJE, editor. Medische misvattingen. Houten: Bohn Stafleu Van Loghum; 2001
5. Taylor EW, Byrne DJ, Leaper DJ, Karran SJ, Browne MK, Mitchell KJ. Antibiotic prophylaxis and open groin hernia repair. World J Surg 1997;21(8):811-4; discussion 814-5
6 T. J. Aufenacker, M. J. W. Koelemay, D. J. Gouma, M. P. Simons. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg. 2006 Jan;93(1):5-10
7. The EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized
controlled trials. Ann Surg 2002;235(3):322-32