The Hernia and Abdominal Wall Surgery Group of the Chinese Medical Association and the Hernia and Abdominal Wall Surgery Committee of the Chinese Physicians’ Association of Surgeons jointly formulated the “Hernia and Abdominal Wall Surgery Group of the Chinese Medical Association and the Hernia and Abdominal Wall Surgery Committee of the Chinese Physicians’ Association of Surgeons”. “Although they have different affiliations, they share the same goal, i.e., to improve the diagnosis and treatment level of hernia and abdominal wall surgery in China. To this end, the two organizations collaborated with each other to prepare the “Guidelines for the Diagnosis and Treatment of Inguinal Hernia in Adults (2014 Edition)”, which was prepared in 2013, revised and discussed together at the beginning of this year. (hereinafter referred to as the “Guidelines”). It should be noted that the predecessor of the “Guidelines” is the “Guidelines for the diagnosis and treatment of inguinal hernia in adults (2012 edition)”, and this revision is based on the progress of the relevant disciplines at home and abroad in recent years and China’s national conditions, with the addition of some articles, and also added some of the annexes in the “Guidelines” (the “Guidelines for the routine repair of inguinal hernia”). The purpose of this revision is to emphasize the specialization and standardization of inguinal hernia surgical treatment and to improve the level of hernia surgery in China. 1, Definition Inguinal hernia is an extra-abdominal hernia that occurs in the inguinal region, that is, in the inguinal region there is a defect in the abdominal wall, there is a hernia sac structure protruding to the body surface, and the abdominal organs or tissues can enter the hernia sac through the congenital or acquired formation of the abdominal wall defect. A typical inguinal hernia has a hernia ring, a hernia sac, hernia contents, and a hernia cover. According to the anatomical concept of “musculopubic foramen”, inguinal hernia includes oblique hernia, straight hernia, femoral hernia, and rare anterior and lateral femoral vascular hernia. 2. Etiology and pathophysiology 2.1 Etiology 2.1.1 Unclosed sheath is a congenital factor in the development of inguinal hernia. 2.1.2 Intra-abdominal pressure Intra-abdominal pressure and instantaneous changes in intra-abdominal pressure are the driving force in the production of extra-abdominal hernia. 2.1.3 Localized weakness of the abdominal wall Various causes of weakness of the abdominal wall in the inguinal region due to alterations in the metabolism or composition of the collagen of the tissues of the abdominal wall are associated with the development of inguinal hernia. 2.1.4 Other genetic factors, long-term smoking, obesity, and low incision in the lower abdomen may be associated with the development of inguinal hernia. 2.2 Pathophysiology When an intra-abdominal organ or tissue enters the hernia sac, the presence of the hernia ring can compress the hernia contents and form an incarcerated hernia. If it is the intestinal tube, it can cause mechanical obstruction of the intestinal tube and produce a series of clinical manifestations and pathophysiological changes. With the prolongation of the pressure time, the intestinal tube appears edema, oozing and the embedded intestinal tube occurs blood flow obstruction, if not treated in time, it can lead to necrosis of hernia content, perforation, resulting in severe peritonitis, or even life-threatening. 3, classification and typing of inguinal hernia classification and typing of the purpose of three aspects: an accurate description of the condition; selection of appropriate treatment options; comparison and evaluation of the therapeutic effect of different methods. 3.1 Classification 3.1.1 According to the anatomical site of hernia, inguinal hernia can be divided into oblique hernia, straight hernia, femoral hernia, composite hernia, etc. 1. 1, oblique hernia: hernia from the inner ring into the inguinal canal. 2, straight hernia: from the straight hernia triangle protruding hernia. 3, femoral hernia: hernia into the femoral canal through the femoral ring. 4, composite hernia: the simultaneous existence of two or more types of hernia. 5, femoral perivascular hernia: hernia located in front of or outside the femoral blood vessels, clinically rare. 3.1.2 According to the status of hernia contents into the hernia sac, it can be divided into: 1, easy to recurring hernia: hernia often appears when standing or activity, after lying down and resting or pushing by hand can be returned to the abdominal cavity. 2.Refractory hernia: the hernia can not be completely retracted, but the hernia contents have not undergone organic pathologic changes. Sliding hernia is a type of intractable hernia, because part of the hernia sac is composed of abdominal viscera (such as, appendix). 3, incarcerated hernia: hernia contents in the hernia ring pressure, can not be returned, there may be some clinical symptoms (such as, abdominal pain and digestive tract obstruction) but has not yet occurred in the blood flow obstruction. 4, strangulated hernia: the continuation of the incarcerated hernia course, the hernia contents appear blood transportation obstacles, if not treated in time can occur serious complications, or even due to intestinal perforation, peritonitis and life-threatening. 3.1.3 Special types of hernia due to the contents of the hernia sac into the relatively special, the development and treatment of the disease has a certain impact, including: 1, Richter hernia: incarcerated contents of only part of the intestinal wall, even if incarcerated or strangulation, but clinically there can be no intestinal obstruction. 2, Littre hernia: incarcerated hernia content is small intestine diverticulum (usually Meckel diverticulum). These hernias are also prone to strangulation. 3, Maydl hernia: a retrograde incarcerated hernia, two or more intestinal collaterals into the hernia sac, between the intestinal collaterals are still located in the abdominal cavity, shaped like a “W”, located in the hernia sac of the intestinal collaterals can be normal, but the abdominal cavity of the intestinal collaterals may be necrotic, need a comprehensive examination. Amyand’s hernia: the contents of the hernia are the appendix, because the appendix can often be complicated by inflammation, necrosis and suppuration, which may affect the repair. 3.2 Typing is a more detailed division of hernia conditions on the basis of hernia classification. At present, there are more than ten types of inguinal hernia classification at home and abroad, and there is still a lack of clinical evidence on the appropriateness of the criteria. Therefore, the existing typing system is still imperfect and has a certain subjective color. At this stage, CHARTS, Nyhus, Bendavid, Stoppa, EHS and other typing systems are still in use. In this revision, it is considered that the existing typing systems can be referred to, but are not recommended as standards. 4. Diagnosis and differential diagnosis 4.1 Diagnosis The diagnosis of typical inguinal hernia can be established based on history, symptoms and physical examination. If the diagnosis is unclear or difficult, imaging studies such as B-mode ultrasound and MRI/CT can be used to help establish the diagnosis. Reconstruction of the hernia sac on imaging can often lead to a definitive diagnosis of inguinal hernia. 4.2 Differential diagnosis It is recommended that when a diagnosis of inguinal hernia is made, a differential diagnosis should also be routinely made to take full account of the situation and to prevent the occurrence of herniorrhaphy in non-herniated patients [8]. 4.2.1 Diseases to be differentiated in the presence of a mass in the inguinal region include enlarged lymph nodes, arteriovenous (static) vein tumors, soft tissue tumors, abscesses, ectopic testes, cysts of the garden ligament, and endometriosis. 4.2.2 Diseases that need to be identified when there is localized pain and discomfort include: adductor tendonitis, pubic osteochondritis dissecans, osteoarthritis of the hip, iliopubic bursitis, radiating lumbar pain, endometriosis, etc. 5, treatment Clinically almost all of the inguinal hernia through surgery and get cured, there are still some non-surgical treatment methods in the domestic medical market, such as “hernia local injection” and other non-surgical treatment, which is not in line with the scientific principles, but also can bring a series of complications and side effects, should be discarded. In terms of surgical methods and approaches, surgeons should choose according to the patient’s condition and their own skills. 5.1 Treatment principles and indications for surgery 5.1.1 Asymptomatic inguinal hernias can be followed and observed, or treated with elective surgery, based on evidence-based medicine. If the hernia is femoral hernia (because of the higher chance of incarceration and strangulation or the recent discovery of the hernia sac enlarged significantly, timely surgical treatment is recommended). For those who cannot tolerate surgery due to old age and infirmity, conservative treatment with a hernia tray is also available.5.1.2 Symptomatic inguinal hernia should be operated on an elective basis. 5.1.3 Incarcerated and strangulated hernias should undergo emergency surgery. 5.1.4 Surgical treatment of recurrent hernias avoiding anatomical difficulties caused by trauma from a previous operation is an option to be considered. (e.g., conventional open surgery for the previous operation, and reoperation after recurrence with posterior access or laparoscopic surgical repair). In addition, the qualification and experience of the surgeon is another factor to be considered in the choice of treatment for recurrent hernia. 5.2 Surgical contraindications and considerations 5.2.1 Inguinal hernia in a non-emergency setting is a sterile procedure; therefore, the presence of infected lesions in the operated area should be considered a contraindication to surgery. 5.2.2 Relative contraindications and precautions: the presence of factors that cause increased intra-abdominal pressure, such as severe ascites, prostatic hypertrophy, constipation and chronic cough, etc., need to be handled accordingly preoperatively to minimize the occurrence of complications such as early postoperative recurrence. 5.2.3 A multidisciplinary treatment model is recommended for patients with large abdominal wall defects and large hernia sac cavities. Multidisciplinary consultation with plastic surgery, respiratory medicine and intensive care department is invited to jointly participate and formulate surgical plan to prevent the occurrence of abdominal compartment syndrome (ACS). 5.2.4 Surgical risk assessment, recommended use of the American Society of Anesthesiologists (ASA) surgical risk assessment standards. 5.3 Surgeon qualifications and training 5.3.1 Routine inguinal hernia repair is not a “simple minor operation” and surgeon qualifications include a license to practice medicine, a residency, and appropriate surgical training. 5.3.2 Physicians who perform laparoscopic hernia repair are required to complete and pass the appropriate laparoscopic skills training in addition to the above, and to pass an examination. 5.3.3 The training of hernia and abdominal wall surgeons is completed in appropriately qualified training centers (in accordance with the relevant regulations of the medical societies or physician associations). 5.4 Inguinal hernia repair materials Tension-free hernia repair using repair materials is currently the mainstay of surgical treatment. Evidence-based medicine has shown that surgery using repair materials reduces postoperative pain, shortens recovery time, and decreases hernia recurrence rates. 5.4.1 Hernia repair materials are categorized into various types such as absorbable, partially absorbable, and non-absorbable materials. 5.4.2 The implantation of repair materials requires strict implementation of the principle of asepsis. The use of materials is not recommended for emergency surgery of incarcerated hernia, and the use of non-absorbable materials for repair is not recommended for surgery with the possibility of contamination. 5.5 Surgical methods Inguinal hernia surgery can be divided into two categories: conventional surgery and lumpectomy. 5.5.1 Conventional surgery can be further divided into tissue-to-tissue tension suture repair (also called classical surgery), such as the Bassini and Shouldice styles, and tension-free hernia repair using hernia repair materials. Tension-free hernia repairs include those that reinforce the posterior inguinal wall, such as the simple flat sheet repair (Lichtenstein, Trabucco, et al.) and the mesh plug-flat sheet repair (Rutkow, Millikan, et al.), and tension-free hernia repairs targeting the anterior peritoneal space of the “musculo-pubic foramen”: e.g. Kugel, Gilbert, Stoppa and others. (For details, please refer to the Appendix.) 5.5.2 Laparoscopic inguinal hernia repair is divided into the following three categories according to the surgical route and principle (For details, please refer to the Appendix.) 1. Transperitoneal extraperitoneal route (TEP), which does not enter the peritoneal cavity, and has the advantage of less interference with the organs in the abdominal cavity. 2. 2. Transperitoneal preperitoneal repair (TAPP) is more likely to detect bilateral hernias, composite hernias and occult hernias because it enters the peritoneal cavity. For incarcerated hernia and hernia content is not easy to return the case, but also easy to observe and treatment. 3, intraperitoneal patch repair (IPOM) as the above two methods are difficult to implement when used, not recommended as the preferred method of laparoscopic surgery. When repairing by this method, the repair material should be anti-adhesion material. 5.6 Perioperative treatment 5.6.1 General treatment 1. In addition to the routine preoperative examination, elderly patients should be informed of and examined for cardiac, pulmonary and renal functions and blood glucose levels. 2. 2. Elderly patients with chronic medical diseases should be evaluated for risk before surgery, especially for patients with respiratory and circulatory disorders, which need to be treated and dealt with before surgery. 5.6.2 On the use of antibiotics Whether or not antimicrobials are routinely applied prophylactically in inguinal hernia surgery is currently debated. There is evidence that prophylactic application of antibiotics to high-risk groups may reduce the chance of infection. 1, High-risk factors include advanced age, diabetes, obesity, wasting, multiple recurrent hernias, post-chemotherapy or radiotherapy and other immunocompromised conditions. 2. The timing of prophylactic antibiotic application is recommended to start intravenous administration 30min to 1hr before skin incision. 5.7 Complications 5.7.1 Early complications include hematoma and seroma at the surgical site, scrotal hematoma, scrotal effusion, bladder injury, vas deferens injury, urinary retention, early wound pain, and incisional infected wounds. 5.7.2 Late complications chronic pain, spermatic cord and testicular complications (ischemic orchitis, testicular atrophy, etc.), delayed patch infection, patch migration, etc. 5.7.3 Recurrence The various surgical methods currently available for the treatment of inguinal hernia still have the possibility of recurrence, and the overall surgical recurrence rate is about 1-3%. The causes of hernia recurrence can be summarized into two aspects of surgical operation and the patients themselves: such as incomplete separation of the hernia sac during the operation, improper fixation of the patch, postoperative hematoma, infection and so on are the factors of recurrence; patients with collagen metabolism disorders, chronic metabolic diseases and increased abdominal pressure are also the factors of recurrence.