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INTRODUCTION

In the 20th century the diagnosis and management of an inguinal hernia was based on the following 2 concepts: (1) all groin hernias should be repaired at diagnosis to prevent a hernia accident (defined as strangulation and/or bowel obstruction) and (2) the Bassini classical sutured repair or one of its modifications, such as the Shouldice technique, is the preferred operation by most surgeons. However, the past 25 years have seen a dramatic shift in many aspects of groin hernia management, including indications for surgery, replacement of the tissue repair with the prosthetic-based tension-free repair, and the application of laparoscopic and now robotic principles. In this chapter, we will try to emphasize some important concepts in the management of inguinal hernia as discussed by the authors and provide a different point of view in certain other areas.

ETIOLOGY

Male gender, increasing age, and a family history of groin hernias are proven risk factors for groin hernias in adults.1,2 Smoking, thoracic or abdominal aortic aneurysm, history of open appendectomy, and peritoneal dialysis have also been implicated as causes of hernia.1-3 Intra-abdominal tumor, ascites, chronic obstructive pulmonary disease, chronic constipation, pregnancy, and chronic urinary retention may lead to progression. Surprisingly, the role of obesity does not seem to be as significant and may actually be protective.4,5 At the molecular level, disorders of collagen metabolism in the extracellular matrix can lead to a decreased type I (strong) to type III (weak) collagen ratio. Similarly, abnormal protein metabolism related to the matrix metalloproteinases responsible for collagen degradation and restoration can lead to connective tissue disorders such as osteogenesis imperfecta, Marfan syndrome, and Ehlers-Danlos syndrome.6-9

Whether weight lifting is a risk factor remains controversial. A recent systematic review revealed inconclusive results about whether occasional heavy lifting, repeated heavy lifting, or a single strenuous lifting episode can lead to the development of groin hernia.10 The fact that weight lifters do not have increased incidence of inguinal hernias supports this result.4

PREGNANCY AND GROIN HERNIA

Pregnant patients occasionally present with a swelling in the groin that by physical examination appears to be an obvious inguinal hernia. Before recommending surgical correction, it is imperative that varicosities of the round ligament be ruled out by ultrasound. There have been multiple case reports and small series of pregnant patients undergoing groin exploration only to find this condition.11

DIAGNOSIS

None of the currently available groin hernia classification systems have been accepted as a gold standard, and differentiating a direct from indirect hernia is now more of an exercise for medical students and trainees. Imaging helps differentiate an inguinal from a femoral hernia in clinically occult hernias, but significant operator variability mars the utility of ultrasonography in these cases. Studies support the use of magnetic resonance imaging (MRI) over ultrasonography ...

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