Hernias

Appendix

History

The police physician should carefully review the gastrointestinal system in the medical history. Positive responses require further follow-up questioning and, in many instances, medical records will be necessary to confirm the history and any prior evaluations of abnormal findings. Other than evaluation for hernias, the routine LEO physical examination and laboratory testing may not be sufficient to assess the severity and stability of gastrointestinal conditions.

Conditions

Hernias

Groin hernias fall into two categories: inguinal and femoral hernias. Inguinal hernias are further divided into either direct or indirect hernias and are more common than femoral hernias and other abdominal wall hernias (e.g., umbilical, epigastric). Indirect inguinal hernia is the most common groin hernia.

Complications from an untreated groin hernia include incarceration and strangulation. Incarceration is when the hernia contents are trapped within the hernia sac and cannot be reduced back into the abdomen or pelvis. Strangulation occurs when the arterial flow to the hernia sac is compromised resulting in ischemia and necrosis of the incarcerated tissue, which may be bowel, omentum, bladder, ovary or other tissues.

The risk of incarceration and strangulation is low overall. One study estimated a 3-month cumulative risk for inguinal events to be 2.8%, increasing to 4.5% after 2 years. For femoral hernias, the cumulative probability of strangulation was 22% at 3 months and 45% at 21 months.1 Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias.2

Risk factors associated with incarceration and the need for emergency hernia surgery; include advancing age, femoral hernia, and recurrent hernia. Although all groin hernias can strangulate, femoral hernias appear to be more predisposed to these complications, oftentimes being the initial presentation. One study estimated that 35.9% of patients with femoral hernias compared with 5.4% with inguinal hernias underwent emergency surgery.1,3 Groin hernias are much less common in females; less than 8% of hernia repairs are performed in women. However, compared with men, women are more likely to have femoral hernias.

Individuals with groin hernias can experience the following symptoms:

• Groin pain with exertion (e.g., lifting)
• Inability to perform daily activities due to pain or discomfort from the hernia
• Inability to manually reduce the hernia (i.e., chronic incarceration)

Surgical repair is indicated for LEOs experiencing any symptoms from a groin hernia. Those individuals with minimal or no symptoms from an inguinal hernia may be managed with elective surgery or watchful waiting. Approximately one-quarter of patients who initially opt for watchful waiting will eventually require surgical repair, usually within 4 to 5 years due to increasing symptoms.

Symptoms of heaviness or a dull uncomfortable sensation in the groin area are common complaints. Women oftentimes experience a vague pelvic discomfort. Heavy lifting, prolonged standing and/or straining exacerbate the symptoms. Typically, the discomfort is more prominent at the end of the day or after prolonged standing. LEOs who spend 6 or more hours during the workday standing or walking may notice the discomfort more frequently than those who don’t. The symptoms can be especially bothersome if the LEO is engaged in tactical procedures such as kicking, lifting, and subduing individuals.

The discomfort is believed to be due to either the constriction of the bowel or fat in the hernia sac or from stretching of the ilioinguinal nerve. If the pain is moderate to severe, incarceration or strangulation should be suspected. Evidence that there is an epidemiological link between occupations involving strenuous activities, especially lifting and the development of an inguinal hernia is limited. A Danish study found that there was a cumulative risk of needing surgery for lateral (indirect) hernia repair in men who lifted frequently or stood or walked 6 or more hours per day. The authors suggest that more studies needed to be done to answer if there is a cause and effect.4

A systematic review of the literature by Patterson et al found that only 4% of hernias reported to be caused by a single event when appropriate criteria such as Smith’s criteria (below) were applied5:

• Official reporting of event contemporaneously
• Severe pain at the time of the event
• No prior history of inguinal hernia
• Diagnosis made by a doctor within 30 days, preferably 3 days.

The authors did note that robust studies examining the association between a single strenuous event and the development of an inguinal hernia are lacking. This would be an important area for investigation because of the number of workers compensation claims related to this assertion.5 There is also insufficient evidence to implicate physical activity as a contributing factor for hernia incarceration or clinical worsening of an existing hernia.6

Sports Hernia or Athletic Pubalgia is a syndrome of chronic lower abdominal and groin pain that typically affects young males who actively participate in sports. Both females and non-athletes can also be affected, but less frequently. This condition can occur in individuals who are involved in activities that include running, kicking and sudden acceleration while twisting or turning. Players of soccer, ice hockey, martial arts and American football are most notably affected. The individual can usually recall the moment during activity that the symptoms began. The symptoms improve during extended periods of rest of weeks or months but recur when activities are resumed. Dynamic ultrasound can detect inguinal wall deficiency when clinical examinations are negative in presence of persistent groin pain.7

There is debate about the cause and pathogenesis of a sports hernia and whether it represents a true hernia. One current hypothesis is that sports hernias represent a group of injuries to the abdominal and pelvic musculature resulting in weakness to the posterior wall of the inguinal canal. Operative management may be recommended if the symptoms fail to resolve upon returning to activities following a 6-12-month restriction period.8 Prior to surgery, non-operative management may include core stabilization and avoid extreme hip range of motion. Associated pathology including femoracetabular impingement or adductor tears should be addressed to maximize both non-operative and operative management.9

For an individual with a femoral hernia, elective surgical repair rather than watchful waiting is strongly advised because of the much higher risk of complications. However, for the LEO who has a long-standing (>3 months) asymptomatic femoral hernia, watchful waiting may be an option when recommended by the surgeon.

Ventral Hernia: Ventral hernias are typically categorized as being either primary ventral hernias (epigastric or umbilical) or incisional. Rarer forms of hernias (e.g., Spigelian) will not be discussed in this chapter.

Primary Ventral Hernias:

Epigastric Hernias

Epigastric hernias are defects in the abdominal midline between the umbilicus and the xiphoid process. Although they can be asymptomatic, most individuals experience a visible, tender bulge under the skin around the abdomen area. Risk factors linked to epigastric herniation include extensive coughing, heavy training and lifting. These maneuvers increase intra-abdominal pressure and can cause protrusion of pre-peritoneal or peritoneum through the linea alba. Epigastric hernias are more often seen in men age 20 to 50. Athletes, soldiers, and those with lung disease are predisposed to this occurrence.10

An umbilical or periumbilical hernia is located at or near the umbilicus. In adults, umbilical hernias are more commonly acquired and are more common in women. Among women, obesity and pregnancy are major contributing factors. Men, however, are more likely to develop bowel incarceration or strangulation.11

Incisional Hernia, also a type of ventral hernia, develops at sites of previous abdominal surgery. Failure of fascial tissues to heal and close can be the result of poor wound healing, infection, or technical issues during closure. These hernias have approximately 10-15% risk of bowel obstruction by incarceration. Compromise to the blood supply of omentum or bowel can also occur and should be repaired immediately.

Acute diaphragmatic hernia is a result of diaphragmatic injury that accompanies severe blunt or penetrating thoracoabdominal trauma. Ventral hernias should be considered an elective procedure unless incarcerated or strangulated. Relative contraindications to elective repair include smoking, obesity with a BMI >50 kg/m2, and poorly controlled diabetes.

Return to Work After Surgical Repair of Groin Hernias

Returning to full duty should be made on an individualized basis following hernia repair. However, typically the convalescence period after inguinal herniorrhaphy is 3-4 weeks.12 To date, there has been no evidence that early return to work following inguinal hernia repair increases the risk of recurrence or of complications.

This was seen in both laparoscopic and open repair. The most common reasons for prolonged convalescence were pain and wound complications.13 Several studies have demonstrated that allowing patients who have either laparoscopic or open hernia repair to return to full activity when postoperative discomfort resolves does not increase recurrence or complications.12,14 Many surgeons still tell patients who undergo non-mesh repairs to limit activity for 4-6 weeks to allow the repair to strengthen. However, the International Guidelines for Groin Hernia Management has a “strong recommendation” to recommend that patients resume normal activities without restrictions within 3-5 days or as soon as they feel comfortable.15