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

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I.M. Daoud and K. Dunn
In the population of women with chronic pelvic pain, and a story
suggestive of occult hernia, laparoscopy may be the most effect diagnostic
tool. In a single center study done of 365 women with chronic pelvic
pain ranging from 6 months to 20 years, only 2 % had normal findings
on laparoscopy. These patients had suspicion of occult hernia based on
signs and symptoms of inguinal pain radiating to the labia or thigh and
reproduction of pain of the internal ring on external palpation or by
bimanual exam. Of those with abnormal laparoscopic findings, 77 %
indirect hernias were identified, 65 % of which had a large internal ring
with incarcerated fat. Additional findings included direct hernias in
20 % of the patients, femoral hernias in 40 %, obturator hernia in 2 %,
and bilateral hernias in 40 %. Overall, after repair, 74.69 % of the
patients reported complete relief of their pain, 17.83 % noted significant
improvement, and the remainder showed no change [ 13 ].
It is clear that more studies are needed to prove the best means of
diagnosing occult hernia, as everything from ultrasound to diagnostic
laparoscopy has been utilized. It seems, however, that modality of
choice should depend on physician preference, patient body habitus,
suspicion of occult hernia based on symptoms reported, and lack of any
other clear diagnosis.
Treatment Laparoscopic repair is advantageous, as those with a
known inguinal hernia may often be found to have an existing occult
hernia, notably as a femoral or obturator hernia. There is often a low
preoperative detection of femoral and obturator hernias. The dissection
during a laparoscopic hernia repair may more easily identify these
defects and prevent them from causing continued groin pain or becoming
a surgical emergency [ 17 ]. Occult hernia is found between 9 and
36 % of the time on the contralateral side during laparoscopic repair [ 8 ].
Despite longer operative times, Pawanindra et al. proposed bilateral
exploration and repair in all cases of TEP repair for unilateral hernia, as
they found contralateral occult hernia in 25 % of the cases [ 8 ]. They
noted that this should be done only in high volume centers in the hands
of advanced laparoscopic surgeons. With limited data on this matter, it
seems that contralateral exploration and repair are warranted in one
where there are risk factors for hernia development or high clinical
suspicion of an occult contralateral hernia. It is reasonable to offer bilateral
exploration and repair as an option to patients who may wish to
avoid further surgery [ 8 ].