Management of Groin Hernia

- Recommendations

Section 1: Importance and social impact of groin hernia surgery:
·       There is good evidence that surgery effectively reduces symptoms and prevents complications of groin hernia. We recommend it, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
Section 2: Risk factors of groin hernia:
·       We recommend preventive measures to reduce intra-abdominal pressure to lower the risk of hernia. (Strong recommendation, moderate certainty evidence, ⁽⁶⁾). 
·       We recommend appropriate surgical technique and special post-operative management to reduce the risk of recurrence of hernia, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
Section 3: Diagnosis:
·       We recommend physical examination as the primary diagnostic tool for groin hernias, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
·       We recommend US, CT or MRI in certain cases based on clinical circumstances, such as the patient's history or the need for surgical planning, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
·       We recommend proper clinical differentiation between inguinal and femoral hernias, which is vital for accurate diagnosis and appropriate management, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
·       We recommend thorough distinction between abscesses and groin hernias through clinical examination and imaging for guiding appropriate treatment, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
·       We recommend thorough distinction between inguinal lymph node or other soft tissue tumors and groin hernias by clinical examination and imaging for guiding appropriate treatment, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
·       We recommend the use of classification systems in groin hernia to standardize the management, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
Section 4: Surgical treatment options:
·       We recommend the approach of tailoring the surgical technique to the individual patient’s needs and hernia characteristics, (Conditional recommendation, moderate certainty evidence, ⁽⁷⁾). 
·       We recommend  the idea that hernia repair can be successfully performed in low-resource settings with basic tools and techniques,  including the use of non-mesh techniques when necessary, and emphasizes the value of training local surgeons to ensure sustainable healthcare improvements, (Conditional recommendation, moderate certainty evidence, ⁽⁷⁾). 
·       We recommend the use of mesh in hernia repairs due to its superior outcomes in preventing recurrence. (Strong recommendation, high certainty evidence, ⁽⁷⁾). 
·       We recommend the use of open mesh repairs, such as Lichtenstein and TIPP, as effective and reliable methods with low recurrence rates, (Strong recommendation, high certainty evidence, ⁽⁶⁾).  
·       We recommend laparoscopic repair techniques as an option in hernias, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
·       We recommend drain after inguinal hernia repair in special circumstances, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
Section 5: Postoperative care:
·       We recommend early mobilization as it is beneficial for reducing the risk of postoperative complications and speeding up recovery, (Conditional recommendation, moderate certainty evidence, ⁽⁷⁾). 
Section 6: Complicated inguinal hernia:
·       In cases of intestinal incarceration without strangulation or need for bowel resection, we recommend the use of mesh-based repair, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
·       Mesh-based repair is generally not recommended for patients with intestinal strangulation or concurrent bowel resection (clean-contaminated surgical field) or in presence of high risk of infection, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
·       Biological mesh could be considered and recommended in very specific cases, but it is not a routine approach, (Conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
Section 7: Special considerations:
·       We recommend the urgent management of femoral hernias due to the high risk of complications such as strangulation, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
·       We recommend the use of mesh in femoral hernia repair to reduce recurrence, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
·       We recommend the open anterior approach, (Lockwood) for femoral hernia repair, particularly in emergency settings or for incarcerated hernias, (Strong recommendation, high certainty evidence, ⁽⁶⁾). 
·       Open Low, (Lotheissen-McVay) approach, is recommended in resource-limited settings, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
·       The plug or patch technique is recommended as it is a simple and effective method for femoral hernia repair, particularly in elective cases, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾). 
·       Open tissue repair without mesh is recommended in specific cases, (conditional recommendation, low certainty evidence, ⁽⁶⁾). 
·       The laparoscopic TAPP approach is recommended as an option for elective femoral hernia repair, especially in patients with bilateral hernias or those requiring concurrent inguinal hernia repair, (conditional recommendation, moderate certainty evidence, ⁽⁷⁾). 
·       We recommend the TEP approach for femoral hernia repair in patients without prior lower abdominal surgery, (conditional recommendation, moderate certainty evidence, ⁽⁷⁾). 
·       In women with groin hernia, we recommend surgical repair techniques, including open and laparoscopic approaches, as those used in men, (Conditional recommendation, moderate certainty evidence, ⁽⁷⁾). 
·       We recommend the use of advanced diagnostic tools to detect occult hernias and the preference for simultaneous repair of bilateral hernias, (Conditional recommendation, moderate certainty evidence, ⁽⁷⁾).