Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

6. Groin Pain Etiology: The Inguinal Hernia, the Occult…
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accepted form of unilateral herniorrhaphy [ 6 ]. Laparoscopic repair,
including both TEP and TAPP repair, is recognized as superior in bilateral
hernia repair and in cases of recurrent hernia. Argument can also be
made to perform a unilateral hernia repair laparoscopically, leading to
less postoperative pain, quicker return to physical activity, lower incidence
of chronic groin pain, and similar recurrence rates [ 7 ].
The main disadvantage of unilateral laparoscopic repair involves the
long learning curve in mastering the delicate laparoscopic dissection
techniques and groin anatomy. It has been said that one becomes confident
with the procedure with 80 cases and mastery comes with 250 cases
[ 7 ]. Other disadvantages include the need for general anesthesia, and the
complications with laparoscopic repair, though rare, can also be more
serious, as they include vascular or visceral injury [ 8 ].
With unilateral repair it is still, therefore, up for debate whether to
perform laparoscopic or open repair. This should depend on surgeon
preference and comfort level. The type of repair also depends on individual
patient needs, including if the patient has any contraindications
for laparoscopic surgery or general anesthesia, in which case open herniorrhaphy
would be preferred.
Occult Inguinal Hernia
Epidemiology/Etiology Inguinal hernias, as discussed above, are
often diagnosed with history and physical exam alone, and treated
accordingly. Occult hernias, which include direct, indirect, femoral, and
obturator hernias, can present with a story consistent with that of a groin
hernia but without the physical exam findings to support the diagnosis
[ 9 ]. This is when radiographic studies may be of assistance. Additionally,
occult hernias can often be discovered at the time of laparoscopic hernia
repair.
In those who present with groin pain, aching, discomfort, or intermittent
groin swelling with equivocal or negative physical exam findings,
it is important to consider occult inguinal hernia as a possible diagnosis
[ 10 ]. The definition of occult inguinal hernia is not well defined in the
literature, and it is often left open to a wide range of interpretations. In
a 2013 study by van den Heuvel et al., there is a distinction made
between true occult inguinal hernia, which is repairable at the time of
surgery, and incipient hernia, which defines a small defect with a shal-