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Danmark

Sweden

Norway

England

Netherlands

Finland

Scotland

Belgium

Hong Kong

Germany

Australia

Portugal

France

Percentage of outpatient operations for inguinal hernia inPercentage

18 Ambulatory Hernia Surgery

177

USA

Fig. 18.2 Percentage of outpatient operations for inguinal hernia in selected countries in 2005 [29]

Table 18.2 Percentage of outpatient operations in

European countries (EHS survey 2016)

Country Proportion in % Sweden 80 Netherlands 75 Portugal 70 Spain 60 England 60 Belgium 40 France 40 Germany 15 Poland 10 Russia 10 Turkey 10 Czech Republic 5 Serbia 5 Ukraine 2 Greece 0 Romania 0

Italy

Spain

gery in percent in the respective countries (Table18.2).

The proportion of outpatient hernia operations thus varies between 0% and 80%. In most countries, however, there is no systematic recording of the operations. In Sweden (Fig.18.3, Table18.3) and Denmark, there are national registries, which record nearly all operations statistically because of state funding. In most other countries, there are only estimates.

Healthcare nancing and reimbursement appear to have a decisive inuence on outpatient surgery. It can be assumed that endoscopic operations cause higher perioperative costs a priori [31]. In Germany, the extremely low proportion of endoscopic procedures in the ambulatory area is due to the fact that outpatient endoscopic inguinal hernia surgery is linked to a roughly 20 per

More precise systematic statistics regarding outpatient surgery from the individual countries are lacking. There are usually only studies that consider a short timeframe in individual countries. The European Hernia Society then conducted a survey among the national chapters in 2015. This resulted in the following estimates for outpatient inguinal hernia sur-

cent shortfall in funding [32]. At present, there appears still to be a health policy disincentive in Germany [33].

In an international comparison, the reimbursement situation for hernia surgery appears to differ substantially (Table 18.4): in numerous countries, there are ambulatory DRGs, which enable outpatient payments to be similar to those in the inpatient area.

178

80%

60%

40%

20%

Operation Year

2015

R. Lorenz

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Man

1995

1994

1993

1992

Fig. 18.3 Proportion of outpatient inguinal hernia operations in Sweden compared by year [30]

Table 18.3 Proportion of outpatient inguinal hernia operations in Sweden compared by year 2006–2015 [30]

Year Outpatient 75.7 76.7 78.1 79.7 78.9 78.5 78.4 79.3 78.1 78.5 Inpatient 24.3 23.3 21.9 20.3 21.1 21.5 21.6 20.7 21.9 21.5

2006 (%)

Women Total

1998

1997

1996

2007 (%)

2008 (%)

1999

2000

2009 (%)

2001

2002

2010 (%)

2003

2004

2005

2011 (%)

2006

2007

2012 (%)

2008

2009

2013 (%)

2010

2011

2014 (%)

2012

2013

2015 (%)

2014

Successful performance of outpatient surgery requires the following:

– Correct indication – Precise preoperative diagnosis – Denition of standardised postoperative

care – Denition of an operation standard – Management of complications – Postoperative pain management with

use of local anaesthetics – Emergency contact

A checklist and handout for patients (What

Table 18.4 International comparison of the reimburse-

ment situation [34]

Country aDRG1 /APC2% of inpatient payment Australia Yes <100% Hungary Yes 100% Portugal Yes 72–100% USA Yes=APC 65–85% Sweden Ye s 100% Italy Yes 80–100% Denmark Ye s 100% Finland Ye s 50–67% Norway Ye s 65–100% Germany No 25% (14–38%)

Ambulatory diagnosis relatet groups

Ambulatory payment classications

18.5 Practical Requirements andCurrent Data

happens before and after the operation?) can For outpatient surgery, the same structural and stafng provisions should apply as in a hospital.

greatly facilitate the practical implementation of

outpatient surgery.

18 Ambulatory Hernia Surgery

179

From today’s perspective, the following her-

nia types can usually be repaired by day surgery:

– Primary inguinal hernias with and with-

out mesh, open and endoscopic – Recurrent inguinal hernias – Umbilical and epigastric hernias – Small incisional hernias

Inpatient hernia surgery is benecial in the

majority of the following patients:

1. Based on the hernia

– Incarcerated and possibly non-reducible

inguinal hernias – Extensive scrotal hernias – Bilateral hernias or multiple operations – Complex hernia operations, reopera-

tions with mesh explantation – Primary ventral hernias with planned

complex procedures – Secondary ventral hernias = incisional

hernias

2. Because of comorbidities

– Comorbidities with serious secondary

conditions such as stroke, diabetes mel-

litus, CHD, cardiac arrhythmias, renal

failure, severe COPD, anticoagulation

3. Because of the patient’s social situation

– Lack of patient compliance – Lack of aftercare in the night after the

operation

Moreover, supporting quality assurance is

useful.

Based on an initiative by a group of surgeons working in outpatient surgery, the Netzwerk Leistenbruch [Inguinal hernia network] was set up in Germany in 2009, an additional quality assurance study of inguinal hernia operations,

www.netzwerk-leistenbruch.de, which is linked

with Herniamed, the German hernia registry. The Netzwerk Leistenbruch records in particular the early postoperative course 1 and 3months after an inguinal hernia operation and evaluates quality of life independent of the surgeon using the Carolinas Comfort Scale, with a hernia-specic quality of life questionnaire for patients. This showed that very good quality with low recurrence and chronic pain rates can be achieved in the ambulatory sector [35].

In addition, a univariate analysis of Herniamed data was performed in 2016 to compare outpatient and inpatient inguinal hernia operations: in the period from 01.09.2009 to 31.10.2016, a total of 353,271 hernias in 577 centres were recorded in Herniamed, the German hernia registry. A total of 71,751 male, primary, fully documented inguinal hernias with complete 1-year follow-up were evaluated for this analysis. There were no signicant differences between outpatient and inpatient operations. The intra- and postoperative complications, postoperative pain and recurrences showed no essential differences despite different operation techniques and different patient selection (Table18.5).

Overall, this analysis permits the conclusion that outpatient inguinal hernia surgery can be performed without signicant detriment for the patients. Further analyses, possibly matched pair

Table 18.5 Distribution of intra- and postoperative

complications and follow-up data—outpatient and inpatient [36]

Outpatient %Inpatient

Intraoperative complications 0.61 1.01 Postoperative complications 2.21 2.40 Recurrence on follow-up 0.77 0.90 Rest pain on follow-up 4.01 4.59 Pain with movement on follow-up Pain requiring treatment on follow-up

9.66 8.86

2.23 2.52

180

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R. Lorenz

or multivariate, are necessary for comparing outpatient and inpatient operations in detail.

Acknowledgment R.Lorenz declares the following con- icts of interest: C.R. BARD: Consultant for Speakers

Bureau, Hands-On Hernia Training Courses.

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2. SMART Books 2007. www.arzt-in-europa.de/pages/

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3. David G, Neumann MD.The changing geography of outpatient procedures. LDI Issue Brief. 2011;16(5):1–4.

4. Farquharson EL.Early ambulation; with special reference to herniorrhaphy as an outpatient procedure. Lancet. 1955;269:517–9.

5. Engbaek J, Bartholdy J, Hjortsø N-C.Return hospital visits and morbidity within 60 days after day surgery: a retrospective study of 18,736 day surgical procedures. Acta Anaesthesiol Scand. 2006;50(8):911–9.

https://doi.org/10.1111/j.1399-6576.2006.01090.x.

6. Dhumale R, Tisdale J, Barwell N. Over a thousand ambulatory hernia repairs in a primary care setting. Ann R Coll Surg Engl. 2010;92(2):127–30. https://

doi.org/10.1308/003588410X12518836439281.

7. Majholm B, Engbaek J, Bartholdy J, et al. Is day surgery safe? A Danish multicentre study of morbidity after 57,709 day surgery procedures. Acta Anaesthesiol Scand. 2012;56(3):323–31.

8. Kurzer M, Kark A, Hussain ST.Day-case inguinal hernia repair in the elderly: a surgical priority. Hernia. 2009;13(2):131–6. Epub 2008 Nov 26.

9. Mattila K, Vironen J, Eklund A, Kontinen VK, Hynynen M. Randomized clinical trial comparing ambulatory and inpatient care after inguinal hernia repair in patients aged 65 years or older. Am J Surg. 2011;201(2):179–85.

10. Sanjay P, etal. Lichtenstein hernia repair under different anaesthetic techniques with special emphasis on outcomes in older people. Australas J Ageing. 2011;30(2):93–7.

11. Amato B, Compagna R, Fappiano F, Rossi R, Bianco T, Danzi M, Accurso A, Serra R, Aprea G, Massa S.Day-surgery inguinal hernia repair in the elderly: single centre experience. BMC Surg. 2013;13(Suppl

2):S28. https://doi.org/10.1186/1471-2482-13-S2-

S28. Epub 2013 Oct 8.

12. Palumbo P, Amatucci C, Perotti B, Zullino A, Dezzi C, Illuminati G, Vietri F.Outpatient repair for inguinal hernia in elderly patients: still a challenge? Int J Surg. 2014;12(Suppl 2):S4–7. https://doi.org/10.1016/j.

ijsu.2014.08.393. Epub 2014 Aug 24.

13. Grifasi C, Calogero A, Esposito A, Dodaro C.Perioperative care of elderly outpatient. A review. Ann Ital Chir. 2015;86(2):100–5.

14. Acevedo A, Leon J.Day case hernia surgery under local anaesthesia is feasible and safe in obese patients. Hernia. 2010;14:57–62.

15. Pere P, Harju J, Kairaluoma P, Remes V, Turunen P, Rosenberg PH.Randomized comparison of the feasibility of three anesthetic techniques for day-case open inguinal hernia repair. J Clin Anesth. 2016;34:166–

75.

https://doi.org/10.1016/j.jclinane.2016.03.062.

Epub 2016 May 8.

16. Cassinotti E, Colombo EM, Di Giuseppe M, Rovera F, Dionigi G, Boni L.Current indications for laparoscopy in day-case surgery. Int J Surg. 2008;6(Suppl

1):S93–6. https://doi.org/10.1016/j.ijsu.2008.12.012. Epub 2008 Dec 13.

17. Ngo P, Pélissier E, Levard H, et al. Ambulatory groin and ventral hernia repair. J Visc Surg. 2010;147(5):e325–8. Epub 2010 Oct 14.

18. Lorente-Herce JM, et al. Incisional hernia repair in an ambulatory surgery-extended recovery centre: a review of 259 consecutive cases. Hernia. 2015;19(3):487–92.

19. Wirth U, Saller ML, von Ahnen T, Köckerling F, Schardey HM, Schopf S.Inguinal hernia repair in TAPP technique in a day-case surgery setting—at what price? Chirurg. 2017;88(9):792–8. https://doi.org/10.1007/

s00104-017-0429-9. [Epub ahead of print].

20. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403.

org/10.1007/s10029-009-0529-7. Epub 2009 Jul 28.

21. Miserez M, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernias in adult patients. Hernia. 2014;18:151–63.

22. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;12:1–165. doi:

10.1007/s10029-017-1668-x. [Epub ahead of print]

PMID: 29330835.

23. Dholakia S, Jeans JP, Khalid U, Dholakia S, D’Souza C, Nemeth K.The association of noise and surgicalsite infection in day-case hernia repairs. Surgery. 2015;157(6):1153–6.

2014.12.026. Epub 2015 Feb 28.

24. Frassanito L, Pitoni S, Gonnella G, Aleri S, Del Vicario M, Catarci S, Draisci G.Utility of ultrasoundguided transversus abdominis plane block for daycase inguinal hernia repair. Korean J Anesthesiol. 2017;70(1):46–51. https://doi.org/10.4097/

kjae.2017.70.1.46. Epub 2016 Oct 25.

25. Jarrett PEM. Day care surgery. Eur J Anaesthesiol. 2001;18(S23):32–5. https://doi.org/10.1046/j.1365-

2346.2001.018s23032.x.

https://doi.org/10.1016/j.surg.

https://doi.

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26. McCormack K, Scott NW, Go PM, Ross S, Grant AM.Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003;(1):CD001785. https://doi.org/10.1002/

14651858.CD001785.

27. Rodriguez-Cuellar E, Villeta R, Ruiz P, etal. National project for the management of clinical processes. Surgical treatment of inguinal hernia. Cir Esp. 2005;77(4):194–202. doi: 13073287.

28. Holzheimer RG.First results of Lichtenstein hernia repair with Ultrapro-mesh as cost saving procedure— quality control combined with a modied quality of life questionnaire (SF-36) in a series of ambulatory operated patients. Eur J Med Res. 2004;9(6):323–7.

29. Toftgaard C, Parmentier G.International Association for Ambulatory Surgery (IAAS). 2005.

30. Swedish Hernia Register—Report. 2015. http://www.

svensktbrackregister.se/images/stories/doc/verksamhetsberattelser/rapport15_160517.pdf.

31. Cariati A, Piromalli E.Cutting costs in inguinal hernia surgery: laparoscopic or ambulatory (or 1-day) open hernia (Lichtenstein) repair? Indian J Surg. 2013;75(5):

409. https://doi.org/10.1007/s12262-012-0599-0.

32. Weyhe D, Winnemöller C, Hellwig A, Meurer K, Plugge H, Kasoly K, Laubenthal H, Bauer KH, Uhl W. (section sign) 115 b SGB V threatens outpatient treatment for inguinal hernia. Analysis of outcome and economics. Chirurg. 2006;77(9):844–55. Brökelmann J.BAO-Depesche Nr. 19, Dez. 2009, 18–19.

33. Schulz G. Kosten und Erlöse des Ambulanten Operierens. Ambulant Operieren. 2008;2008:125–30.

34. Brökelmann J.Ambulant Operieren 4/2000. p.199.

35. Koch A, Lorenz R, Meyer F, Weyhe D.Hernia repair at the groin—who undergoes which surgical intervention? Zentralbl Chir. 2013;138(4):410–7.

36. Lorenz R.Unpublished data from the German Hernia Database Herniamed—Chirurgische Praxis, 2017, in press.

Obscure Groin Pain inWomen

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ShirinTowgh

19.1 History oftheHidden Hernia

The concept of hidden hernias was rst introduced in the 1970s by two separately interested surgeons from the United States: William Webb from Alabama and Jack Herrington from Wisconsin. They each noticed that women were presenting with symptoms suggestive of inguinal hernia; however, the surgeons had a hard time diagnosing hernia on physical examination. Their patients reported intermittent pain along the inguinal canal that was related to physical activity. However, the physical examination was essentially normal and “without detectable impulse.”

Webb reported his experience with 12 women who had symptomatic inguinal hernias without diagnostic examination ndings. Physical examination was mostly normal. He offered them an exploration based on their history alone. They presented similar to most other symptomatic inguinal hernias: groin pain radiating along the inguinal canal. He found that these women typically had small indirect inguinal hernias with preperitoneal fat content only. There was no hernia sac. Repair was successful in all the patients, with resolution of their preoperative pain.

S. Towgh, MD, FACS Beverly Hills Hernia Center, Beverly Hills, CA, USA e-mail: drtowgh@beverlyhillsherniacenter.com

Over a 5-year period of time, Herrington operated on 13 such patients (8% of his practice), all of whom were also women. They suffered with groin pain of undiagnosed etiology. Mean age was 20 years (15–45). Most had undergone a wide range of gastrointestinal, urologic, and gynecologic workups. Operative ndings were of the typical indirect inguinal hernia, and most had a peritoneal sac. At 10 months follow-up, ten (77%) patients had a cure of their symptoms after open inguinal hernia repair, and three patients had signicant improvement. He referred to these as “female occult inguinal hernias” and urged their early diagnosis, as hernia repair was curative.

The concept of the non-palpable, symptomatic, occult, or hidden hernia did not become popular despite these groundbreaking reports. Textbooks continued to report 25% lifetime risk of inguinal hernias among males and only 2% risk among females. It wasn’t until Bendavid’s textbook of Abdominal Wall Hernias that this topic was readdressed in the twenty-rst century.

Similar to their predecessors, Spangen and Smedberg reported on 180 women in an 18-year span with 192 occult hernias. Most were found to have typical inguinal hernias with peritoneal sac. However, 57 (30%) had inguinal hernias with preperitoneal fat content only and no peritoneal extension within the inguinal canal. They had successful outcomes after hernia repair, with relief of preoperative symptoms in 89% of patients, with mean 20 (1–60) months follow-up.

183

184

S. Towgh

19.2 Anatomical Explanation fortheHidden Hernia

Women naturally have a narrower inguinal canal than men. Essentially, it contains a thin round ligament and perhaps the genital branch of the genitofemoral nerve. Conversely, males begin with a naturally wider inguinal canal that houses the spermatic cord. Meanwhile, the female pelvis is broader and shallower. As a result, the insertion of the internal oblique and transversus abdominis muscles is broader along Cooper’s ligament and further onto the rectus muscle. Also, the round ligament pierces the abdominal wall more laterally and follows a more oblique path within the inguinal canal. Lastly, the natural forces from gravity and from internal abdominal pressure are distributed more evenly along the pelvic oor, as compared to that in the narrow pelvis of men.

As a result, women tend not to present with wide palpable defects or signicant bulging from their hernia. Instead, they present with groin pain, sometimes with the very smallest amount of preperitoneal fat entering the narrow inguinal canal.

On physical examination, men typically have a palpable if not visible bulge. When standing, an impulse may be generated by Valsalva or cough. Using the redundancy of the scrotal skin, the spermatic cord can be followed toward the external ring, and the rest of the pelvic oor in this region can be directly palpated. In women, there is no direct access to the external ring and the inguinal canal contents. Palpation is made directly over the inguinal canal at the level of the skin. Any hernia must be noted through the layers of skin, soft tissue, and external oblique aponeurosis. If a vaginal examination is performed, the examiner can sometimes detect a mass via the vaginal sidewall. This is another reason for the occult non-palpable hernia.

19.3 Symptoms inWomen

Hernias among women tend to present with a wide variety of symptoms. As many of these symptoms are not similar to those typical of men,

it can delay their diagnosis. In my practice, I have shown that the typical hernia was diagnosed by me after 20 weeks of presentation. Those with hidden hernias averaged 96weeks of symptoms. Typically, the dominant symptoms for hernias among women are activity-related, such as pain with lifting heavy objects. Normal daily routines that cause increased pressure onto the inguinal canal may also cause pain, such as prolonged sitting, prolonged standing, and bending. The pain is often worse at the end of the day. Pain may also be distributed along the distribution of the ilioinguinal and genital nerves, and this can be misinterpreted as primary neuropathic pain. In my experience, some of these patients undergo local nerve block to address the neuropathic pain. If a hernia is the cause of the neuropathic type pain, I have noted that patients report an increase in their groin pain after the nerve block, whereas a nerve block should improve pain in the case of a true primary nerve injury without a hernia.

Though men do not typically present with pain as their primary complaint from their inguinal hernia, such is not the trend with women. Among women, groin pain is often the rst presenting symptom. Many surgeons are trained to believe that pain alone cannot be due to an inguinal hernia. This may be true among most male patients; it is not the case in women. As a result, many women are labelled as having chronic pelvic pain, and inguinal hernia is not considered to be the cause of their groin pain.

As we already know, smaller hernia defects tend to present with more pain and less bulging, whereas larger hernia defects tend to present with a bulge without as much pain. So it may be the case that women with inguinal hernias, many of which are hidden hernias, present with pain as their original symptom and not with a palpable bulge. The patient may complain of radiating pain, which I found to be seen among almost half (48%) of my patients (Table19.1). This includes pain radiating pain from the groin into the vagina, to the upper inner thigh, to the anterior thigh— but never below the level of the knee—and/or wrapping around laterally toward the hip and back. In my experience, 20% of patients have associated lower back pain that resolves after

19 Obscure Groin Pain inWomen

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185

hernia repair. Such patients may be misdiagnosed with spinal pathology. Notably, patients with lower back pain do not have groin pain, with the exception of sacroiliitis, which can cause pain radiating from the back to the groin and upper inner thigh.

Also, 39% of my female patients have radiating pain into the vagina (Table19.1). This is analogous to the pain radiating to the base of the penis and/or testicle in men. Such a complaint can trigger a gynecologic workup of obscure diagnoses such as vulvodynia, pudendal neuralgia, and chronic pelvic pain. These diagnoses often have complex syndromes that are not seen among patients with inguinal hernia.

Symptoms unique to women include pain during menses. In my practice, 25% of women with symptomatic inguinal hernias report exacerbation of their symptoms during their menses (Table19.1). This is considered to be due to uctuations in hormones. As estrogen levels plummet at the onset of menstruation, pain levels increase. This phenomenon has been shown in multiple other disease processes, including joint disorders, autoimmune disorders, and gastrointestinal diseases. In such cases, women are commonly worked up for endometriosis, which is a cyclical disease. Unlike endometriosis, hernias are not pain-free in between menstrual periods.

Table 19.1 Key history and examination ndings pre-

dictive of female symptomatic occult inguinal hernia, with expected outcomes after hernia repair

Symptoms Prevalence Pain as primary symptom 87% Radiating quality to the groin pain 48% – Radiating pain to the vagina 39% – Radiating pain to lower back 20% Worse with menses 25% Pain during intercourse Pain with orgasm

Examination ndings

Point tenderness over deep internal ring 96–100% Hyperalgesia along ilioinguinal nerve 63% Subtle fullness overlying inguinal canal 52% Pelvic oor spasm

Operative ndings

Preperitoneal fat only, no hernia sac >30% Signicant improvement in preoperative symptoms after hernia repair

78–87%

In women, hernias can be painful during sexual intercourse as well as with orgasm. The reason for pain with intercourse is often a simple phenomenon of direct contact and pressure on the groin. Similarly, vaginal penetration can cause pain by direct pressure onto the external ring, which we noted earlier could be palpable transvaginally. Pain with orgasm is considered to be due to pelvic oor contraction against a full inguinal canal.

19.4 Subtle Physical Examination

Findings

The concept of the occult inguinal hernia is based on the nding of a symptomatic inguinal hernia without obvious ndings on physical examination. This includes no visible bulge and no detectable impulse. For example, a cough or Valsalva will typically not generate a bulging mass on external examination in this population. That said, in my experience, 96% of these patients have point tenderness at the level of the internal ring upon direct pressure. Spangen similarly reported 100% with point tenderness overlying the deep internal ring upon Valsalva. He also reported 63% with hyperalgesia along the ilioinguinal nerve distribution (Table19.1).

With a very sensitive touch, the examiner can feel a subtle fullness in the area overlying the deep internal ring among those with a symptomatic hidden hernia. I have noted this in 52% of my patients with symptomatic occult inguinal hernias. This represents content and probably inammation in the area of the inguinal canal. It is also often tender over the same area. If this area of vague fullness correlates with the area of pain, which correlates with the area over the deep internal ring, we have shown this to be the most sensitive predictor of a hidden hernia (Fig.19.1).

Many women are rst evaluated for their groin pain by their gynecologist. Pelvic exam can be painful on the side of the inguinal hernia. There may be nding of pelvic oor spasm as well. Some patients are referred to pelvic oor physical therapy for this reason. In my experience, I have noted that such therapy exacerbates the

186

Fig. 19.1 Area of maximal tenderness and vague fullness

notable in patients with symptomatic occult inguinal hernias. This area is approximately halfway between the anterior superior iliac crest and pubic tubercle on each side

patient’s pain if she has an inguinal hernia and not primary pelvic oor dysfunction. Also, I have noted that the pelvic oor spasm resolves after successful inguinal hernia repair.

Thus, I have come to the conclusion that inguinal hernias can cause pelvic oor spasm in women. This results in the sequelae seen with this entity, including chronic pelvic pain, pain with sexual intercourse, urinary frequency, feeling of pain, or pressure at the vagina or rectum. The workup and treatment can be highly varied, and patients may be misdiagnosed with interstitial cystitis or pelvic oor dysfunction. These disorders are multifactorial and are dened by a series of objective ndings, such as with cystos-

S. Towgh

copy or dynamic pelvic imaging, respectively. The workup would be normal in those with inguinal hernia.

Conclusion

Women can have inguinal hernias, and it is much more prevalent than we are led to believe historically. Women are more likely than men to present with groin pain without bulging mass, hence the term female occult inguinal hernia or hidden hernia. Carefully listening to the patient will allow the examiner to identify key details in their history that are suggestive of inguinal hernia. The most sensitive examination nding is that of point tenderness over the area of the deep internal ring. Operative ndings may show preperitoneal fat content only, without peritoneal extension.

As more attention is placed on this entity, more women will be diagnosed, without delay, with a potential for improvement in their quality of life.