Management principles

Management principles

An abdominal wall hernia does not necessarily require repair. A patient may request surgery for relief of symptoms or for cosmesis. The surgeon should recommend repair when compli cations are likely , the most worrying being bowel obstruction and strangulation. These are most likely in narrow-necked hernias; for this reason all femoral hernias should be repaired, as should symptomatic or irreducible hernias unless coexisting medical factors place the patient at very high risk. Increasing di ffi culty in reduction and increasing size are also indications for surgery . Surgery should be o ff ered to younger adult patients as symptoms and complications are likely over time. Summary box 64.6 Management /uni25CF /uni25CF /uni25CF /uni25CF In elderly patients a policy of ‘watchful waiting’ in asymp tomatic inguinal hernia appears generally safe, with an annual crossover to surgery because of symptoms developing of around 10%. A truss can be used to control a hernia but now adays few surgeons r ecommend this approach. Small umbilical Jerry Gilmore , 1942–2019, surgeon, London, UK, gave his name to a syndrome of chronic groin pain in professional footballers. - they cause few symptoms and usually contain fat or omentum with a very low risk of complications. Large incisional hernias, particularly recurrent, present a - major pr oblem. Surgical repair is a complex procedure with - significant risk of complications and later recurrence. When the neck is wide, the risk of strangulation is low . In obese and elderly patients, these risks may outweigh the benefits of sur - gery and it is common for surgeons to adopt a conservative approach. - A patient who presents with acute pain in a hernia, partic - ularly if it is irreducible, should be o ff ered urgent surger y . It may be reducible by taxis (gentle forceful reduction, perhaps requiring analgesia and/or sedation) and sometimes, after admission to hospital and adequate analgesia, the hernia will reduce as a result of muscle r elaxation. In either case, the like - lihood of similar episodes is very high and surgery should be recommended at the next available opportunity .

Not all hernias require surgical repair Small hernias can be more dangerous than large Pain, tenderness, skin changes and dif /f_i culty reducing imply high risk of strangulation Femoral hernia should always be repaired