Importance 

Declining Mortality Rates

In both the UK and the USA, the annual death rate due to inguinal and femoral hernias has significantly decreased over the past two to three decades. In the UK, deaths from these hernias declined by 22% to 55% between 1975 and 1990. Similarly, in the USA, the annual deaths per 100,000 population for patients with hernia and intestinal obstruction decreased from 5.1 in 1968 to 3.0 in 1988. For patients with obstructed inguinal hernias, 88% underwent surgery, with a remarkably low mortality rate of 0.05%. These improvements suggest that elective groin hernia surgery has played a crucial role in reducing overall mortality rates.

Elective Surgery and Strangulation Rates

Supporting this observation, the USA has lower rates of strangulation compared to the UK, possibly due to the threefold higher rate of elective hernia surgeries in the USA. Nevertheless, statistics indicate that the rate of elective hernia surgeries in the USA per 100,000 population decreased from 358 to 220 between 1975 and 1990, although this may be an artifact of data collection rather than a genuine decline.

Mortality Analysis from UK and Denmark Studies

During 1991–1992, the UK National Confidential Enquiry Into Perioperative Deaths investigated 210 deaths following inguinal hernia repair and 120 deaths following femoral hernia repair. This inquiry, which focuses on the quality of surgery, anesthesia, and perioperative care, found that many patients were elderly (45 were aged 80–89 years) and significantly infirm; 24 were ASA grade III and 21 ASA grade IV. The majority of postoperative mortality was attributed to preexisting cardiorespiratory issues.

A nationwide study in Denmark of 158 patients who died after acute groin hernia repair by Kjaergaard et al. also found that these patients were old (median age 83 years) and frail (>80% with significant comorbidity), with frequent delays in diagnosis and treatment. These findings highlight the need for high-quality care by experienced surgeons and anesthetists, especially for patients with high ASA grades.

Postoperative Care Recommendations

Postoperative care for these patients should occur in a high-dependency unit or intensive therapy unit. This might necessitate transferring selected patients to appropriate hospitals and facilities. Decisions about interventional surgery should be made in consultation with the relatives of extremely elderly, frail, or moribund patients, adopting a humane approach that may rule out surgery.

Emergency Admissions and Prioritization

Forty percent of patients with femoral hernias are admitted as emergency cases with strangulation or incarceration, while only 3% of patients with direct inguinal hernias present with strangulation. This disparity has implications for prioritizing patients on waiting lists when these hernias present electively in outpatient clinics.

Risk of Strangulation

A groin hernia is at its greatest risk of strangulation within three months of onset. For inguinal hernias, the cumulative probability of strangulation is 2.8% at three months after presentation, rising to 4.5% after two years. The risk is much higher for femoral hernias, with a 22% probability of strangulation at three months, rising to 45% at 21 months. Right-sided hernias have a higher strangulation rate than left-sided hernias, potentially due to anatomical differences in mesenteric attachment. The decline in hernia-related mortality in both the UK and USA underscores the importance of elective hernia surgery. Ensuring timely surgery, especially for high-risk femoral hernias, and providing high-quality perioperative care for elderly and frail patients are crucial steps in further reducing mortality and improving patient outcomes.

Evidence-Based Medicine 

In a randomized trial, evaluating an expectative approach to minimally symptomatic inguinal hernias, Fitzgibbons et al. in the group of patients randomized to watchful waiting found a risk of an acute hernia episode of 1.8 in 1,000 patient years. In another trial, O’Dwyer and colleagues, randomizing patients with painless inguinal hernias to observation or operation, found two acute episodes in 80 patients randomized to observation. In both studies, a large percentage of patients randomized to nonoperative care were eventually operated due to symptoms. Neuhauser, who studied a population in Columbia where elective herniorrhaphy was virtually unobtainable, found an annual rate of strangulation of 0.29% for inguinal hernias.

Management of Strangulation

The diagnosis of hernias is primarily based on clinical symptoms and signs, supplemented by imaging studies when necessary. Pain at the hernia site is a constant symptom. In cases of obstruction with intestinal strangulation, patients may present with colicky abdominal pain, distension, vomiting, and constipation. Physical examination may reveal signs of dehydration, with or without central nervous system depression, especially in elderly patients with uremia, along with abdominal signs of intestinal obstruction.

Femoral hernias can be easily missed, particularly in obese women, making a thorough physical examination essential for an accurate diagnosis. However, physical examination alone is often insufficient to confirm the presence of a strangulated femoral hernia versus lymphadenopathy or a lymph node abscess. In such cases, urgent radiographic studies, such as ultrasound or CT scan, may be necessary.

The choice of incision depends on the type of hernia if the diagnosis is clear. When there is doubt, a half Pfannenstiel incision, 2 cm above the pubic ramus extending laterally, provides adequate access to all types of femoral or inguinal hernias. The fundus of the hernia sac is exposed, and an incision is made to assess the viability of its contents. If nonviability is detected, the transverse incision should be converted into a laparotomy incision, followed by the release of the constricting hernia ring, reduction of the sac’s contents, resection, and reanastomosis. Precautions must be taken to avoid contamination of the general peritoneal cavity by gangrenous bowel or intestinal contents.

In most cases, once the constriction of the hernia ring is released, circulation to the intestine is restored, and viability returns. The intestine that initially appears dusky or non-peristaltic may regain color with a short period of warming with damp packs. If viability is doubtful, resection should be performed. Resection rates are highest for femoral or recurrent inguinal hernias and lowest for simple inguinal hernias. Other organs, such as the bladder or omentum, should be resected as needed.

After peritoneal lavage and formal closure of the laparotomy incision, specific repair of the hernia should be performed. Prosthetic mesh should not be used in a contaminated operative field due to the high risk of wound infection. Hernia repair should follow the general principles of elective hernia repair. It is important to remember that in this predominantly frail and elderly patient group with a high postoperative mortality risk, the primary objective of the operation is to stop the vicious cycle of strangulation, with hernia repair being a secondary objective.

Key Point

The risk of an acute groin hernia episode is of particular relevance, when discussing indication for operation of painless or minimally symptomatic hernias. A sensible approach in groin hernias would be, in accordance with the guidelines from the European Hernia Society to advise a male patient, that the risk of an acute operation, with an easily reducible (“disappears when lying down”) inguinal hernia with little or no symptoms, is low and that the indication for operation in this instance is not absolute, but also inform, that usually the hernia after some time will cause symptoms, eventually leading to an operation. In contrast, female patients with a groin hernia, due to the high frequency of femoral hernias and a relatively high risk of acute hernia episodes, should usually be recommended an operation.