Classification of Inguinal and Abdominal Wall Hernia

  • Diego Cuccurullo
  • Stefano Reggio


Since 1840, when Hesselbach used the inferior epigastrics vessels as the defining boundary between indirect and direct hernias, surgeons have always tried to classify the inguinal hernias. This first classification resisted for years; nowadays the interest in a more accurate and scientific classification of groin hernias is increasing. The general opinion is that one standardized system must be adopted, and since 2009 the EHS recommended that its classification system should be used [1]. The primary objective of any classification system is to stratify the pathology in study (groin hernia) for severity in order to allow reasonable comparisons between treatment strategies [2]. Moreover, a classification must be simple and easy to use. Several operative techniques with their variations for herniorrhaphy have been described, but no one classification system can satisfy all presently. The EHS overpass this problem, developing a brand new classification system by consensus [2–9]: in effect an expert panel analyzed the known systems to date and proposed classification that resembles largely the Aachen classification [10]. This latter makes a distinction between the anatomical localization (indirect or lateral vs. direct or medial) and the size of the hernia orifice defect in cm (<1.5, 1.5–3, >3 cm) (Table 4.1). Moreover Miserez et al. [2] decided to modify to some minor aspects this classification, proposing the “index finger” rule as the reference in open surgery (normally the size of the tip of the index finger is mostly around 1.5–2 cm). This size is also identical to the length of the branches of a pair of most laparoscopic graspers, dissector, allowing the surgeon to use the same standardized classification during mini-invasive procedures [11, 12]. For recurrent hernias, a detailed description could be used as proposed by Campanelli et al. [13]. The recurrent hernias are divided into three types:
  • Type R1: first recurrence “high,” oblique external, reducible hernia with small (<2 cm) defect in nonobese patients, after pure tissue or mesh repair

  • Type R2: first recurrence “low,” direct, reducible hernia with small (<2 cm) defect in nonobese patients, after pure tissue or mesh repair

  • Type R3: all other recurrences or anyway not easily included in R1 or R2, after pure tissue or mesh repair (femoral, big defects, multirecurrent, non-reducible, obese patient)


  1. 1.
    Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13:343–403. Scholar
  2. 2.
    Miserez M, Alexandre JH, Campanelli G, et al. The European Hernia Society groin hernia classification: simple and easy to remember. Hernia. 2007;11(2):113–6. Scholar
  3. 3.
    Campanelli G, Pettinari D, Nicolosi FM, Cavalli M, Avesani EC. Inguinal hernia recurrence: classification and approach. Hernia. 2006;10(2):159–61. Scholar
  4. 4.
    Chowbey P, Khullar R, Mehrotra M, Sharma A, Soni V, Baijal M. Sir Ganga Ram Hospital classification of groin and ventral abdominal wall hernias. J Minim Access Surg. 2006;2(3):106. Scholar
  5. 5.
    Holzheimer RG. Inguinal hernia: classification, diagnosis and treatment—classic, traumatic and sportsman’s hernia. Eur J Med Res. 2005;10(3):121–34.PubMedGoogle Scholar
  6. 6.
    Zollinger RM. An updated traditional classification of inguinal hernias. Hernia. 2004;8(4):318–22. Scholar
  7. 7.
    Kingsnorth AN. A clinical classification for patients with inguinal hernia. Hernia. 2004;8(3):283–4. Scholar
  8. 8.
    Nyhus LM. Classification of groin hernia: milestones. Hernia. 2004;8(2):87–8. Scholar
  9. 9.
    Zollinger RM. Classification systems for groin hernias. Surg Clin North Am. 2003;83(5):1053–63. Scholar
  10. 10.
    Schumpelick V, Treutner KH, Arlt G. Classification of inguinal hernias. Chirurg. 1994;65:877–9.PubMedGoogle Scholar
  11. 11.
    Chevrel JP, Rath AM. Classification of incisional hernias of the abdominal wall. Hernia. 2000;4:7–11.CrossRefGoogle Scholar
  12. 12.
    Korenkov M, Paul A, Sauerland S, Neugebauer E, Arndt M, Chevrel JP, Corcione F, Fingerhut A, Flament JB, Kux M, Matzinger A, Myrvold HE, Rath AM, Simmermacher RK. Classification and surgical treatment of incisional hernia. Results of an “experts” meeting. Langenbecks Arch Surg. 2011;386:65–73.CrossRefGoogle Scholar
  13. 13.
    Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nahadi I, Hauters P, Hidalgo Pascual M, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13:407–14.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Śmietański M, Szczepkowski M, Alexandre JA, Berger D, Bury K, Conze J, Hansson B, Janes A, Miserez M, Mandala V, Montgomery A, Morales Conde S, Muysoms F. European Hernia Society classification of parastomal hernias. Hernia. 2014;18(1):1–6.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.AO dei Colli, Ospedale Monaldi, U.O.C. di Chirurgia GeneraleCentro di Chirurgia Laparoscopica e RoboticaNaplesItaly

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