AB129. SOH21AS019. Outdated terminology in inguinal hernia description: the terms ‘Direct’ and ‘Indirect’ should be abandoned—a literature review

Background: Repair of inguinal hernias remain one of the most routinely performed procedures in general surgery. Despite major advances in technique, we continue to employ classification systems dating back to the 19th century, which classify inguinal hernias as “direct” or “indirect” based on their location with respect to the inferior epigastric artery. The purpose of this review was to examine the clinical sensitivity and utility of classifying inguinal hernias as “direct” or “indirect”.

Methods: The following databases were searched: PubMed, Cochrane Library, JSTOR, JAMA Network and Google Scholar. Reviews published in English, German and Dutch were analysed. To appreciate the historical element, data from 1762 to 2020 was studied. A total of 43 articles were further evaluated.

Results: Several studies have demonstrated poor clinical sensitivity associated with the terms “direct” and “indirect” inguinal hernias at a pre-operative level; with some studies demonstrating a pre-operative accuracy level as low as 56%. These results are further complicated by variable patient anatomy and disparity amongst textbook definitions of the anatomical location of the deep inguinal ring.

Conclusions: Review of the literature would suggest the terms “direct” and “indirect” in relation to the inferior epigastric artery are inaccurate and this vessel is merely a passive anatomical structure in the herniation field. The ongoing utilisation of antiquated anatomical principles is in direct opposition with our enhanced, modern-day understanding of inguinal anatomy. We believe from teaching, practical and comparative research perspectives it is time to revise our classification of inguinal hernias to reflect current anatomical knowledge.

Keywords: Aetiology of inguinal hernias; classification of inguinal hernias; direct and indirect inguinal hernias; inguinal anatomy; inguinal hernias