INGUINAL HERNIA (IH) Is a Common Problem Throughout the World

Home , Femoral hernia, Hernia, Inguinal, Inguinal hernia

1.0 ANCC CONTACT HOUR Inguinal

By Vincent M. Vacca, Jr., MSN, RN, CCRN, SCRN, ENLS

INGUINAL HERNIA (IH) is a common problem throughout the world. The lifetime risk is approximately 3% for women and 27% for men. This risk increases with age, with a reported peak incidence in males in their 60s. Eighty-six percent of all IHs occur in men.1,2 Although many patients with IH are asymptomatic, bowel incarceration and strangulation are serious and potentially fatal complications. This article discusses the pathophysiology of IH, diagnosis, management, and nursing considerations for patients with IH.

Hernia basics By definition, a hernia is a protrusion of an organ or other anatomic structure through the body wall that normally contains it.3 Groin hernias can be classified as inguinal (direct or indirect) and femoral. • A direct IH occurs when abdominal tissue protrudes through the posterior wall of the inguinal canal medi- ally and inferiorly to the internal (deep) inguinal ring.4 (See Direct inguinal hernia.) MAGES I EDICAL ./M O C ICTURE P CIENCE S

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. • An indirect IH occurs when abdominal tissue passes through an Direct inguinal hernia3 abdominal wall defect into both the A direct IH bulges directly through the posterior inguinal wall. Unlike indirect her- internal inguinal ring and inguinal nias, direct hernias bulge medial to the inferior epigastric vessels and aren’t associ- 4 canal. (See Indirect inguinal hernia.) ated with a patent processus vaginalis. This is the most common type of groin hernia.5 • A femoral hernia, which appears as a bulge in the upper thigh near the groin, is an extension of bowel or other abdominal structure through a defect in the femoral ring. Abdominal ring Femoral hernia occurs most often in Inferior epigastric artery and vein older multiparous women and typically affects the right side. Due to the narrow femoral canal and rigid Inguinal ligament femoral ring, bowel incarceration Direct hernia and strangulation are possible, mak- ing this presentation an emergency. Posterior wall A femoral hernia is typically painful 6 Spermatic cord and not reducible. Femoral sheath Only about 4% of groin hernias Cooper's ligament are femoral.5 (See Fast facts about groin hernias.) Because most groin hernias are inguinal, IH is the focus of this article. (See Risk factors for developing IH.) 3 Signs and symptoms Indirect inguinal hernia About one-third of patients with IH An indirect IH occurs when bowel, omentum, or another intra-abdominal organ have minimal symptoms or are asymp- protrudes through the internal inguinal ring descending within the continuous tomatic.7 The patient may have a vis- peritoneal coverage of a patent processus vaginalis, which is anteromedial to the ible bulge in the groin area, with or spermatic cord. without pain. The patient may dis- cover it, or a clinician may find it during a routine physical exam. When IH onset is sudden, the pain is usually unilateral, sharp or burning in nature, and radiating to Abdominal ring Inferior epigastric lower abdomen, proximal thigh, low artery and vein back, perineum, or scrotum.8 How- Indirect sac ever, onset is more likely to be insidi- 5,8 ous. Some patients complain of an Posterior wall uncomfortable heavy or dull feeling Inguinal ligament in the groin; women may describe pelvic pain.5 Symptoms may be ex- acerbated by common activities such Spermatic cord as climbing stairs, coughing, sneez- Femoral sheath Cooper's ligament ing, or other Valsalva maneuvers. Athletic activities and certain movements, such as running, kicking a ball, twisting, sit-ups, or side- stepping, can also exacerbate symp-

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. toms. Getting out of bed can cause anti-inflammatory medication, stool pain too, but it rarely wakes patients Risk factors for softeners, and supervised physical from sleep because pain associated developing IH1,2,5 therapy with core strengthening and with an IH is typically activity- stretching exercises. Surgical explora- • related and relieved by rest.8 family history of hernia tion and repair should be considered • If tissue herniates through a rela- history of hernia or prior hernia when the patient is symptomatic repair (including during childhood) tively small opening, it can become and/or when nonsurgical treatment • male gender entrapped. In severe cases, entrap- fails to improve symptoms.1 The • age >60 ment can interrupt the blood supply elective surgical setting is preferred • White race to the bowel (strangulation), leading over an emergency surgical repair • chronic obstructive pulmonary dis- to tissue necrosis and intestinal perfo- as the nonelective repair has higher ease (defective connective tissue ration. (See Signs and symptoms of metabolism and chronic cough) incidence of IH recurrence and is strangulation.) IH is unlikely to cause • chronic constipation associated with increased complica- 10 severe pain unless strangulation has • abdomina l wall injury tions, morbidity, and mortality. 5 occurred. • cigarette smoking (can damage con- Surgical repair of IHs is one of the Although rare, strangulation is a nective tissue in the groin as well as most commonly performed opera- 3 11 medical emergency. However, the lung) tions. With surgical and anesthetic Fitzgibbons et al. showed that seri- • low BMI (overweight or obese technical advances that avoid the ous complications are extremely rare, patients have a lesser risk of devel- need for general anesthesia, it’s often with a reported rate of 2.4%.7 oping an inguinal hernia) performed as a same-day procedure • collagen diseases. at ambulatory surgical centers. Diagnosis Surgical IH repair can improve the IH is diagnosed based on the pa- groin region after the patient per- quality of life for patients with symp- tient’s history and clinical exam forms Valsalva maneuvers. The study tomatic IH regardless of age.2 The findings. The clinical exam consists is positive if the contrast medium primary goals of surgery are to: of inspection followed by palpation flows outside the peritoneum. Al- • repair the IH. of the groin with the patient in though contrast herniography is • minimize the chance of recurrence. standing and supine positions, and used infrequently, it’s considered a • minimize postsurgical discomfort bilateral digital exploration of the safe diagnostic procedure and should and postop complications. inguinal canals. A reducible protru- be considered in the evaluation of • return the patient to normal activi- sion or bulge in the inguinal region patients when the etiology of ingui- ties quickly. is definitive evidence of an IH and nal pain is unclear.1,9 If imaging • improve quality of life. typically requires no further diag- studies are inconclusive, diagnostic Positioning a truss over the her- nostic exploration.2 laparoscopy may be indicated.5 nia was once a common nonsurgi- Due to the close proximity of cal treatment for groin hernias in numerous anatomical structures, Treatment men. This treatment is no longer clinicians must assess for coexist- Following an IH diagnosis, the recommended in most cases due to ing pathologies, including muscle initial nonsurgical treatment consists a lack of evidence supporting effi- injuries; hip pathologies; low back of watchful waiting with activity cacy.2,12,13 In addition, if used inap- problems; nerve entrapments; and modification of 6 to 8 weeks of rest, propriately, a truss may damage intestinal, genitourinary, and gyneco- logic pathologies. In some cases, imaging studies are necessary to rule Fast facts about groin hernias 1 out these and other diagnoses. Dy- Most groin hernias (96%) are inguinal; only about 4% are femoral.5 namic ultrasound can be valuable for • Direct inguinal hernias account for 30% to 40% of groin hernias in men, com- detecting the defect of the posterior pared with 14% to 21% of groin hernias in women. inguinal wall during Valsalva maneu- • Indirect inguinal hernia is the most common groin hernia in both men and women. vers and also allows the size of the • Femoral hernia repairs account for 20% to 31% of all groin hernia repairs in defect to be measured. women, compared with only 1% in men.5 In herniography (peritoneogra- Inguinal hernia repair (inguinal hernioplasty) is the most common elective proce- 2,7,26 phy), a contrast medium is injected dure in general surgery with over 20 million performed worldwide every year. In into the peritoneal cavity and fluoro- the United States, approximately 800,000 inguinal hernioplasties are performed annually at a cost of about $500,000,000.4,14 scopic views are obtained of the www.Nursing2017.com August l Nursing2017 l 31

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. abdominal contents or complicate invasive laparoscopic IH repair is an surgical repair.11 Signs and symptoms acceptable alternative to open surgical Based on results of two recent ran- of strangulation5 repairs.14,15 Surgical repair is indicated domized control trials conducted in to treat all IHs in nonpregnant wom- the United Kingdom and in North A strangulated hernia may be painful en and bilateral IHs; a laparoscopic America, watchful waiting for asymp- to the touch and surrounding groin approach is preferable to an open skin may be erythemic. Other possible tomatic, nonprogressive IH in males procedure.1,2 indicators include fever and signs and has become an accepted alternative symptoms of bowel obstruction, such Meta-analyses comparing the lapa- to routine surgical repair in selected as nausea, vomiting, bloating, and roscopic approach with open surgical 2,7 cases. Two other studies, however, abdominal pain. If bowel necrosis IH repairs have found comparable reported that overall quality of life at develops, the patient may have sys- long-term results in relation to IH 1 year was better after surgical repair temic signs and symptoms. Strangula- recurrence, postoperative pain, and than with watchful waiting.12 tion is a medical emergency requiring quality of life. Differences between Although surgery isn’t always in- immediate intervention. laparoscopic and open surgical dicated for asymptomatic IH in approaches in the occurrence of men, surgical repair of groin her- posterior approach with the use of a chronic postoperative numbness nias in nonpregnant women is mesh; open, suture-based operations were reported in one study as 9.2% standard practice.2 Groin hernias are performed through the anterior versus 21.5%, favoring the minimal- are uncommon in women, but approach.2 (See More about mesh.) ly invasive techniques.14,15 these patients are more likely to The transabdominal preperitoneal have femoral hernias, recurrent Surgical options patch (TAPP) and totally extraperito- hernias, and serious hernia com- Surgical IH repair procedures gener- neal (TEP) laparoscopic repair tech- plications such as entrapment or ally fall into one of three categories: niques are becoming more widely strangulation.2,5,11 • open surgical repair with sutures used due to higher patient satisfaction Surgical repair techniques can be (OS); no mesh implant and lower rates of both relapse and suture- or mesh-based, through an • open surgical repair with mesh complications.14,15 With recent ad- anterior or posterior approach, by (OM) vancements in instrumentation as well either open surgery or laparoscopy/ • laparoscopic repair with mesh. as improved surgical techniques, lapa- endoscopy. Minimally invasive pro- Studies comparing OM and laparo- roscopic repairs seem to offer better cedures are always done through a scopic repair show that minimally quality of life, decreasing hospital stay and earlier return to work.10

More about mesh TAPP versus TEP Regardless of approach, the most effective method for an IH repair involves the use Surgeons using either of these of synthetic mesh.2,25 The ideal mesh for IH repair has the following characteristics: minimally invasive laparoscopic • enough strength to withstand physiologic stresses for a long time techniques make two to four small • ability to conform to the abdominal wall keyhole incisions in the abdomen • ability to promote host tissue in-growth, which mimics normal tissue healing through which the laparoscope and • resistance to the formation of bowel adhesions and erosions into visceral surgical tools are passed to repair the structures IH. A single infraumbilical incision • won’t induce allergic reaction or adverse foreign body reactions measuring 1 to 1½ cm can also • resistant to infection used, depending on surgeon experi- • noncarcinogenic. 16 The guidelines of the European Hernia Society and the Danish Hernia Database ence and expertise. clearly state that mesh-based techniques have a lower recurrence rate than suture- A surgeon using the TAPP tech- based techniques.2 In most countries, synthetic mesh is used in almost all IH repairs nique places mesh in the preperito- because of a significantly lower risk of recurrence than with nonmesh suture-based neal space between the abdominal techniques.1,25 wall and peritoneum. Because TAPP The main goal of mesh repair is to strengthen the fascia transversalis and involves accessing the abdominal abdominal wall. Mesh fixation techniques include sutures, glue, or self-gripping cavity, it exposes the patient to the hemoclips or tacks. Each method has its risks and benefits. Physically active risks of an intraperitoneal approach, patients considering a mesh repair should be aware of possible postoperative including potential injury to abdomi- consequences, including chronic pain. The presence of a foreign body or sub- nal organs (especially the bladder), stance may cause exercise and activity to become uncomfortable.12 vascular injuries, adhesions, and

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. bowel herniation.10,17 The TAPP eral vascular disease and in older approach is a suitable alternative to patients. Cirrhosis, chronic kidney classic OS or OM repair, but only disease, and medications taken for when performed by an experienced these diseases can interfere with surgeon.14,15 postoperative wound healing. A TAPP can be performed with robot body mass index (BMI) of 25 or assistance to facilitate mesh fixation. greater, which corresponds to ap- Currently, however, little data are proximately 172 lb (78 kg) in a male available on patient outcomes for of average height, and male gender procedures performed with robotic in general, are associated with in- assistance.17 creased risk for postoperative infec- The TEP technique, which is per- tion.20 In addition, IH surgical repair formed outside the peritoneal cavity, of any method is associated with was developed to avoid the risks long-term chronic pain and an IH of an intraperitoneal approach.14,15 recurrence rate of 5% to 10%.21 The surgeon creates a preperitoneal space without entering the abdomi- Nursing considerations nal cavity and uses mesh to seal the Same-day surgery for IH repair has hernia from outside the peritoneum. increased the involvement of nurses Preparation for IH repair done in the throughout the perioperative period, preperitoneal space using the TEP A hernia is a protrusion beginning with preoperative evalua- technique is considered complex, as tion and ending with postdischarge anatomical landmarks are more dif- of an organ or other follow-up.22 The nurse reviews the ficult to identify. TEP is associated anatomic structure patient’s health history, including with longer operating times and through the body wall medications and allergies, obtains vital higher complication rates, especially that normally contains it. signs, and performs a full assessment when abdominal organs are attached of the patients’ cardiac and pulmonary to the peritoneum by adhesions. systems. The nurse also ensures that Evidence generally favors TAPP more severe compared with those the patient has a basic understanding over TEP.12,14 However, both tech- associated with OM (mesh-based) of the procedure during the prepro- niques have a higher IH recurrence repairs. Severe vascular, visceral cedure visit. An evaluation of neck rate (10.1%) compared with an OM complications and deep infections mobility, jaw opening, dentition, and repair (4.9%); this may be because of are more common in laparoscopic airway patency will be conducted by an incomplete repair of the anatomic repairs, whereas in OS repairs, recur- the anesthesia care provider regardless hernia disruption related to restricted rences, and chronic neuropathic pain of the type of anesthesia planned be- visualization with the scope during predominate.12,18,19 Regardless of cause the need to convert to general the minimally invasive technique.1,2 method, postoperative complications anesthesia is always a possibility. Independent risk factors for recur- can also include hematoma, infec- The patient is instructed to shower rence of an IH following open or tions, and wound dehiscence.19,20 A with antibacterial soap the night be- minimally invasive repair include significantly increased risk for hem- fore surgery and told not to eat or direct IH, female gender, history of orrhage or hematoma within 30 days drink for at least 6 hours before the recurrent IH, and cigarette smoking.2 after IH surgery has been associated operation. If the patient must take Following the rising trend of mini- with older age, male gender, cirrho- medication on the day of surgery, it mally invasive IH repair, the medical sis, occlusive peripheral arterial dis- should be taken with a sip of water. device industry is focusing on devel- ease, and connective tissue disease. The nurse reviews and confirms that oping products for minimally inva- Older age (80 or older), previous anticoagulant and anti-inflammatory sive IH repair to improve usability history of peripheral vascular disease drugs, other prescribed medications, for the surgeon and safety for the or connective tissue disease, and and over-the-counter and herbal patient.14,15 male gender are risk factors for supplements have been held unless wound dehiscence.20 directed otherwise by the surgeon. Postop complications A significantly increased risk for Further instructions include obtain- Complications associated with OS superficial infection or bleeding has ing all relevant contact information (nonmesh, suture-based) repairs are been found in patients with periph- and ensuring that a responsible adult www.Nursing2017.com August l Nursing2017 l 33

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. accompanies the patient to the center Scale in the early postoperative period hernia repair may compromise the and provides transportation home are six times more likely to develop patient’s ability to control the car following discharge.22 chronic pain.2 Immediate postopera- safely or perform an emergency stop On the day of surgery, a nurse tive pain delays recovery and dis- even beyond 24 hours. In addition, confirms the patient’s identity using charge.24 If the patient reports severe any prescribed physical activity limi- two unique patient identifiers, settles pain in the postanesthesia care unit, tations should be reviewed. the patient in the preoperative hold- alert the surgeon immediately. This The patient and care companion ing area, and asks the patient to re- may signal a misplaced staple or tack.17 should be given instructions on move all clothing and jewelry and Immediately and up to 1 week whom to call if potentially serious change into a hospital gown. The after IH repair, patients may experi- signs and symptoms develop. The nurse also ensures that informed ence positional-related regional patient should also be given follow- consent has been obtained, that all muscle spasms.24 The administra- up appointment and a summary of allergies and medical and surgical tion of medications that act on cen- medications, including the name, history have been reviewed, and that tral modulation of nociceptive pain indication, dosages, and specific all prostheses have been removed, transmission and muscle relaxation considerations for prescribed drugs including contact lenses, glasses, can both control pain and improve (pain medications, laxatives, and dentures, and hearing aids. overall quality of life following IH stool softeners). The patient should Following Surgical Care Improve- repair. Clonidine has been shown to also receive instructions regarding ment Project recommendations, the relieve pain and decrease opioid when to resume routine medications. nurse administers a prescribed anti- consumption after IH repair.24 Other instructions include: biotic that’s been proven beneficial Once the patient can tolerate oral • Discharge diet. Resume preopera- when the procedure includes im- fluids, the I.V. infusion is discontin- tive diet and advance as tolerated. plants, even when the risk of ued. The patient is then encouraged • Activity instructions. Ambulate as infection is low.23 The nurse also to sit on the side of the bed, stand, able and tolerated without restric- reviews all preoperative instructions and ambulate to a chair. The nurse tion. Don’t lift more than 5 lb until and answers any questions the pa- will advise the patient to avoid cleared at the follow-up appoint- tient or care companion may have coughing and sneezing if possible, ment. Avoid straining and any other about the planned procedure. and teach the patient how to splint Valsalva maneuvers. The nurse confirms that the appro- the incision if a cough or sneeze • Wound-care instructions. For priate surgical site has been properly is unavoidable. The patient should example, remove the dressing in identified and marked, and initiates be told to expect some swelling 24 hours as directed.22 an infusion of the prescribed I.V. fluid and bruising in the groin during at the prescribed rate. recovery.17 On the mend Straining during bowel move- IH is a common problem, and IH Postoperative nursing care ments and other Valsalva maneuvers repair is among the most often- Following the procedure, the patient increase pain and may disrupt the performed surgical procedures in this is transported to the designated re- surgical site. The nurse should ex- country. Knowledgeable nursing care covery area where a nurse provides plain the importance of taking a and patient teaching are essential in- care and assesses the patient’s clinical stool softener and a gentle laxative as gredients for successful recovery. ■ status, including level of conscious- prescribed to prevent pressure on the ness. The patient’s care companion incision during bowel movements. REFERENCES may be present as well. Before discharge, the nurse re- 1. Tschuor C, Metzger J, Clavien PA, Vonlanthen R, Lehmann K. Inguinal hernia repair in Switzerland. The nurse assesses the surgical views postoperative wound care, Hernia. 2015;19(5):741-745. wound site and asks the patient to pain management, and resumption 2. Berger D. Evidence-based hernia treatment in report pain intensity level using a of usual activities, including driving adults. Dtsch Arztebl Int. 2016;113(9):150-158. validated pain rating scale. After and returning to work, with the pa- 3. Lawrence PF. Essentials of General Surgery. 5th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins, providing pain medication as pre- tient. The nurse will make certain to 2013. scribed, the nurse assesses patient discuss with patient and care com- 4. Yoong P, Duffy S, Marshall TJ. The inguinal and response for effectiveness. panion issues specific to safety. For femoral canals: a practical step-by-step approach to accurate sonographic assessment. Indian J Radiol A primary intervention is to provide example, the patient must under- Imaging. 2013;23(4):391-395. adequate analgesia immediately after stand that residual effects of sedation 5. Brooks DC, Hawn M. Classification, clinical features, and diagnosis of inguinal and IH surgery; patients who report pain impair driving ability for 24 hours femoral hernias in adults. UpToDate. 2016. greater than 3 on the Visual Analog and that pain associated with the www.uptodate.com.

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 6. Akrami M, Karami M, Zangouri V, Deilami I, 14. Klobusicky P, Feyerherd P. Innovation in the management and treatment of inguinal hernias Maalhagh M. Small bowel obstruction secondary laparoscopic inguinal hernia reparation— in a community setting. Am Surg. 2015;81(3): to femoral hernia; case report and review of the initial experiences with the Parietex Progrip 300-304. literature. Bull Emerg Trauma. 2016;4(1):51-53. Laparoscopic™—Mesh. Front Surg. 2015;2:28. 22. Hammond CB. Care of patients undergoing 7. Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. 15. Gass M, Scheiwiller A, Sykora M, Metzger day case inguinal hernia repair. Nurs Stand. Long-term results of a randomized controlled J. TAPP or TEP for recurrent inguinal hernia? 2014;28(31):53-59. trial of a nonoperative strategy (watchful waiting) Population-based analysis of prospective data on 23. Simons MP, Aufenacker T, Bay-Nielsen M, for men with minimally symptomatic inguinal 1309 patients undergoing endoscopic repair for et al. European Hernia Society guidelines on the hernias. Ann Surg. 2013;258(3):508-515. recurrent inguinal hernia. World J Surg. 2016; treatment of inguinal hernia in adult patients. 8. Dimitrakopoulou A, Schilders E. Sportsman’s 40(10):2348-2352. Hernia. 2009;13(4):343-403. hernia? An ambiguous term. J Hip Preserv Surg. 16. Reiner MA, Bresnahan ER. Laparoscopic total 24. Yaziciog˘lu D, Caparlar C, Akkaya T, Mercan 2016;3(1):16-22. extraperitoneal hernia repair outcomes. JSLS. 2016; U, Kulaçog˘lu H. Tizanidine for the management 9. Ng TT, Hamlin JA, Kahn AM. Herniography: 20(3). of acute postoperative pain after inguinal hernia analysis of its role and limitations. Hernia. 17. Sarosi GA, Ben-David K. Laparoscopic inguinal repair: a placebo-controlled double-blind trial. 2009;13(1):7-11. and femoral hernia repair. UpToDate. 2016. www. Eur J Anaesthesiol. 2016;33(3):215-222. 10. Pahwa HS, Kumar A, Agarwal P, Agarwal AA. uptodate.com. 25. Löfgren J, Nordin P, Ibingira C, Matovu A, Current trends in laparoscopic groin hernia repair: 18. Kouhia S, Vironen J, Hakala T, Paajanen H. Galiwango E, Wladis A. A randomized trial of a review. World J Clin Cases. 2015;3(9):789-792. Open mesh repair for inguinal hernia is safer than low-cost mesh in groin hernia repair. N Engl J Med. 11. Brooks DC. Overview of treatment for inguinal laparoscopic repair or open non-mesh repair: a 2016;374(2):146-153. and femoral hernia in adults. UpToDate. 2017. nationwide registry study of complications. World J 26. Bakota B, Kopljar M, Baranovic S, Miletic M, www.uptodate.com. Surg. 2015;39(8):1878-1884. Marinovic M, Vidovic D. Should we abandon 12. Treadwell J, Tipton K, Oyesanmi O, Sun F, 19. Maisonneuve JJ, Yeates D, Goldacre MJ. regional anesthesia in open inguinal hernia repair Schoelles K. Surgical Options for Inguinal Hernia: Trends in operation rates for inguinal hernia over in adults? Eur J Med Res. 2015;20:76. Comparative Effectiveness Review. AHRQ Publication five decades in England: database study. Hernia. No. 12-EHC091-EF. Rockville, MD: Agency for 2015;19(5):713-718. Vincent M. Vacca, Jr., is a clinical nurse educator in Healthcare Research and Quality; 2012. www. 20. Rühling V, Gunnarsson U, Dahlstrand U, the Neuroscience Intensive Care Unit at Brigham & Women’s Hospital, Boston, Mass. effectivehealthcare.ahrq.gov/inguinal-hernia.cfm. Sandblom G. Wound healing following open groin hernia surgery: the impact of comorbidity. World J 13. Picco MF. Hernia truss: can it help an inguinal The author and planners have disclosed no potential hernia? Mayo Clinic. 2016. www.mayoclinic. Surg. 2015;39(10):2392-2399. conflicts of interest, financial or otherwise. org/diseases-conditions/inguinal-hernia/expert- 21. Williams ZF, Mulrath A, Adams A, Hooks WB answers/hernia-truss/faq-20058111. 3rd, Hope WW. The effect of watchful waiting on DOI-10.1097/01.NURSE.0000521020.84767.54

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