Surg Clin N Am 83 (2003) 10531063

Classication systems for groin hernias

Robert M. Zollinger Jr, MD
University Hospitals of Cleveland, 11100 Euclid Avenue, LKS 7002,
Cleveland, OH 44106, USA

For the past 100 years, surgeons have traditionally classied inguinal
hernias as indirect, direct, and femoral. The concept of the indirect and
direct areas dates back to Cooper in the 1840s, with Hesselbach using the
inferior epigastrics as the dening boundary between these two areas [1].
Interest in a more scientic classication of groin hernias increased in the
1950s when a new generation of herniorrhaphies appeared, challenging the
Bassini tissue repair that had been dominant since the late 1880s. These new
procedures were based upon an improved anatomic understanding of the
myopectoneal orice in the inguinal region, and each repair tended to proclaim it was more anatomic than its competitors. Signicant numbers
of patients with several years of follow-up were accumulated, with the
hernia experts reporting excellent results for their specic operative techniques. Surgeons in community practice could not replicate these excellent
outcomes, however. The innovative experts were certain their techniques
were not being performed correctly, whereas the practicing general surgeons
suspected that patient selection by the experts might have been biased in
favor of those patients who were expected to have better outcomes. In this
setting, most surgeons believed that certain inguinal hernia repairs almost
always had a good result, hence identifying the patient with a high risk of
failure or recurrence became important. Comprehensive reviews summarizing these issues and the early classication systems have been published by
Read [2] and by Rutkow and Robbins [3].
One of the rst improvements upon the traditional system was created by
Harkins [4], who listed four grades of classication. Although he did not
publish it, this classication system (Table 1) was contained in the closing
discussion given during his discussion of Dr. Nyhus paper on preperitoneal
herniorrhaphy. Dr. Harkins listed Grade 1 as the indirect infant hernia,
whereas Grade 2 contained the simple indirect hernias of older children and
healthy young adults. His Grade 3 hernias were listed as intermediate type
E-mail address: rnz3@po.cwru.edu
0039-6109/03/$ - see front matter 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0039-6109(03)00126-9

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Table 1
Harkins classication, 1959
Grade
Grade
Grade
Grade

I
II
III
IV

Indirect infant
Indirect simple
Intermediate indirect or direct
Advanced femoral, recurrent & others

Adapted from Nyhus LM, Stevenson JK, Listerub MB, Harkins HN. Preperitoneal
herniorrhaphy. West J Surg Obstet & Gynecol 1959;67:4854.

of hernia (larger indirect hernia, inguinal hernias in young adults or small

hernias in older patients with strong tissue; also a few direct inguinal hernias
with narrow-neck sacs). Finally, advanced hernias such as recurrent,
femoral, direct, and indirect hernias not specically falling within the
denitions of Grade 2 or 3 were listed as Grade 4 [4].
In 1967, Casten [5] proposed three categories for groin hernias. Stage I
contained small hernias in infants and children with a normally functioning
external ring. Larger hernias with a distorted internal ring were categorized
as Stage II indirect hernias. Finally he grouped together all the direct and
femoral hernias as Stage III. Casten was the rst to include the concept of
a normally functioning internal ring, versus a dilated one that is presumed to
function poorly.
McVay and Cha published their results for inguinal and femoral
hernioplasties done for primary and recurrent hernias in 1958 [6]. Although
the traditional classication system was used to categorize patients in this
series, they added a new form of analysis in which they categorized the patients
according to primary inguinal, recurrent, or combined hernias that contained
hernias in any two or three of the inguinal-femoral spaces. McVay listed
femoral hernias as a third variation of inguinal hernia. He also partitioned
indirect hernias into small, medium, and large in the discussion section at the
end of this paper. McVay did not use this classication system in the actual
tables published in the paper, however. Halverson and McVay expanded these
categories into ve groups on inguinal hernias in 1970 [7]. Their classication
is summarized in Table 2. First they listed the small indirect hernias seen in
childhood, followed by the medium indirect hernias that have a dilated
internal ring without encroachment or involvement of the tranversis abdominus in the lateral direct area. Third, they combined large indirect and
Table 2
Halverson & McVay classication, 1970
Small
Medium
Large
Femoral
Combined

Indirect
Indirect
Indirect or direct

Any mix of above

Adapted from Halverson K, McVay CB. Inguinal and femoral hernioplasty. Arch Surg
1970;101:12735.

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1055

direct inguinal hernias. The authors felt that both had destruction of the
aponeurotic fascial posterior inguinal oor in the direct area. This was a new
concept in the denition of large indirect hernias. Femoral hernias were
recognized as a distinct entity and they used the term combined hernia to
represent any mix of the three (indirect, direct, or femoral) hernias.
In 1987 Lichtenstein published his data registry form. It contained his
personal experiences with over 6000 cases and he also included his
classication system [8]. Lichtenstein did not size indirect hernias, but did
separate the direct inguinal hernias into ve specialized subcategories, as
shown in Table 3. Lichtenstein recognized femoral hernias as a distinct
entity, and his registry allowed the listing of principal and secondary
hernias; that is to say, coexisting or combined hernias. Lichtenstein did not
specically use the term combined hernia, but this can be inferred from his
listing of two or more of the indirect, direct, or femoral defects. Finally,
Lichtenstein recognized the need for a category that included specialized
hernias that did not fall within the above classications.
Gilbert created a register in the 1980s called the Cooperative Hernia
Analysis of Types and Surgery (CHATS). Over 50 hernia surgeons contributed data [9]. This registry listed ve types of inguinal herniasthree
indirect and two direct. Gilbert dened Type 1 as having a snug internal
ring, whereas Type 2 had a moderately enlarged internal ring. He dened
this Type 2 hernia opening as less than two ngerbreadths in width and
specied that the direct oor be intact. Type 3 indirect hernias were described
as having an enlarged internal ring of two ngerbreadths or greater.
Although encroachment is not specically described in the article, the Type 3
hernia appears to encroach upon the lateral direct oor as visualized in
Gilberts diagram (Fig. 1). The Type 4 direct hernias are shown as very large
direct ones that involve disruption of the entire direct oor in the presence of
an intact internal ring. Gilbert Type 5 direct hernias are diverticular defects
of no more than one ngerbreadth in the direct oor and in the presence of
an intact internal ring. In 1993, Rutkow and Robbins [10] expanded this
classication, adding a Type 6, the pantaloon or combined indirect and
direct hernia as well as a Type 7 femoral hernia. The Gilbert classication
with modications by Rutkow and Robbins [11] is shown in Fig. 1.
Table 3
Lichtenstein classication, 1987
Indirect
Direct
Whole oor
Lateral 1/2 of oor
Medial 1/2 of oor
Diverticular
Other

Femoral
Combined
any 2 or more
Other

Adapted from Lichtenstein IL. Herniorrhaphy: a personal experience with 6321 cases. Am J
Surg 1987;153:5539.

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R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

Fig. 1. Gilberts classication with additions by Rutkow and Robbins. (From Rutkow IM,
Robbins AW. Classication systems and groin hernias. Surg Clin N Am 1998;78:11224; with
permission.)

In 1993, Nyhus published a new system for the classication of inguinal

hernias that he believed would aid in surgical decision-making thus
matching the type of hernia with specic operations [12]. The Nyhus Type I
indirect inguinal hernia had an internal ring of normal size, conguration,
and structure and was meant to describe the type usually found in infants

R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

1057

or young adults. The direct oor is intact and the hernia sac is contained
within the inguinal canal. The Type II indirect hernias have a enlarged and
distorted internal ring. The sac may occupy the entire inguinal canal, but it
does not extend into the scrotum, nor is the internal ring dilated to the point
of encroachment into the direct oor. Nyhus then created a Type III hernia
with three subcategories. Type IIIA contained all direct hernias in which the
protrusion does not herniate through the internal inguinal ring. Type IIIB
hernias are large indirect ones with a dilated internal ring that has
expanded medially and encroaches on the posterior inguinal wall or direct
oor. These larger hernias are often inguinal-scrotal in nature. This category
also includes the sliding inguinal hernias as they always destroy a portion
of the inguinal oor. Type IIIB also includes the pantaloon hernias with
direct and indirect sacs or components that straddle the epigastric vessels.
Femoral hernias were listed as a separate defect and Type IIIC. All recurrent
hernias are listed as Type IV with the subcategories of IVA, direct; IVB,
indirect; IVC, femoral; and IVD, any combination of these recurrences
(Table 4). The Nyhus classication has been used in the United States and
Europe, where it was modied by Stoppa [13] in 1998. In his modications,
Stoppa added aggravating factors such as the general factors of massive
obesity, abdominal distension, or collagenosis, plus local factors such as
voluminous, multiple, or complex hernias. In the Stoppa system, each
Nyhus hernia type was upgraded by one. That is to say, a Type I Nyhus
hernia with aggravating factors becomes a Type II. Stoppa also listed
additional aggravating factors that included complex injuries related to the
hernia (its size, degree of sliding, multiplicity, etc.); patient characteristics
(age, activity, respiratory diseases, dysuria, obesity, or constipation); special
surgical circumstances (technical diculties, infection risk); or any other
unfavorable factor which could modify the choice of treatments.
In 1993, Bendavid proposed a new system of classication based upon the
anatomic area, the size of the hernia defect, and the length of the sac [3]. He
Table 4
Nyhus classication, 1993 [12]
Type I

II

III

IV

Indirect, small
Normal internal ring
Sac in canal
Indirect, medium
Enlarged internal ring
Sac not in scrotum
A Direct
Floor only
B Combinedindirect large
Encroaching into direct oor
C Femoral
Recurrent
A Direct B Indirect C Femoral
D Combinations of ABC

STOPPA MODIFICATION 1998 [13]

Aggravating factors
Local or systemic
Upstage type by 1

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R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

called this the TSD (Type, Staging, and Dimension) classication and used
the four anatomic regions of the groinmedial or lateral and above or below
the inguinal ligamentto create four individual types of groin hernia. The
inguinal ligament separated the anterior from the posterior region, and the
epigastric vessels separated the medial from lateral. Accordingly, Bendavids
Type 1 is anterior lateral (indirect); Type 2 is anterior medial (direct); Type 3
is posterior medial (femoral); and Type 4 is posterior lateral (prevascular).
The Bendavid stages reect the descent of the hernia sac into the scrotum. In
Stage I the sac is contained within the inguinal canal; in Stage II the sac has
extended outside of the external ring, but has not entered the scrotum; and
in Stage III the sac is within the scrotum. The Dimension measures the
diameter of the abdominal wall defect at its widest in centimeters.
Additionally, Bendavid modied his Type 2 anterior medical (direct) hernia
with a description as to the area involved in the direct oor; that is to say,
medial, lateral, central, or the entire oor. Finally, he proposed several modiers that could be added after each type such as R for recurrence; S
for slider; I for incarcerated; and N for necrosis (Table 5).
In 1998, Alexandre and colleagues [14] published a very similar
classication. This system uses a TOS (Type, Orice, and Sac) classication.
In this system, the types are indirect, direct, femoral, or other. The orice
and the sac lengths are each measured in centimeters, which are recorded.
Finally, it was suggested that the classication be modied with a letter I
for incarcerated; B for bilateral; or R for recurrent (Table 6).
Drs. Schumpelick and Arit [15] published the Achen classications
system in 1995 (Table 7). In this classication, they used L for lateral
(indirect); M for medical (direct); and F for femoral. An additional
modier C was added to dene the combined hernia involving the direct
and indirect areas. They also measured each abdominal wall defect size with

Table 5
Bendavid classication, 1994
Type I
Anterolateral
II
Anteromedial
III
Posteromedial
IV
Posterolateral
Stage 1
Sac in canal
2
Sac beyond external ringnot
3
Sac in scrotum
Dimension
Max diameter defect in cm
Modied Type II by Area
Medial, lateral, central or entire
Modiers
Recurrence Slider Incarcerated Necrosis

(Indirect)
(Direct)
(Femoral)
(Prevascular)
in scrotum

From Rutkow IM, Robbins AW. Classication of groin hernias. In: Bendavid R, editor.
Prostheses and abdominal wall hernias. Austin (TX): RG Landes; 1994; with permission.

R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

1059

Table 6
Alexandre classication, 1998
Type
Orice
Sac
Modiers

Indirect-Direct-Femoral-Other
Max diameter in cm.
Length in cm.
I Incarcerated
B Bilateral
R Recurrent

Adapted from Alexandre JH, Bouillot JL, Aouad K. Le Journal de Carlio Chirugie 1996;
19539.

a grading system that listed Grade I being less than 1.5 cm, II being 1.5 to 3
cm, and III being greater than 3 cm.
In 1999, this author sought to bring together the best features of these
classications and a unied classication [16] was proposed that has since
been modied in Nyhus and Condons Hernia, 5th edition [17]. Analysis
of the existing groin hernia classications in these articles showed many
features that were in common (Table 8). The anatomic sites, namely,
indirect (lateral), direct (medial), and femoral appear to be universal, as is
the recognition of the combined hernia (pantaloon) with defects in both the
direct and indirect area. Additionally, most systems quantify the indirect
and direct defects as being small (\1.5 cm, or approximately the tip of the
fth nger) or medium ([34 cm, or less that two ngerbreadths in width). I
concluded that the ideal classication system for inguinal hernias should be
based upon: (1) anatomic location, (2) anatomic function, (3) reproducibility of categories by both hernia specialists and general surgeons, and that it
should be useable for both anterior and posterior approaches, and most
important, that it should be easy to remember (See Box 1).
My unied classication [17] attempted to build upon these ideals and the
traditional indirect, direct, and femoral anatomic locations, while recognizing the defect size, competence of the internal ring, and the integrity of direct
oor (Fig. 2). In this unied system the Indirect (Small) hernia has a size of
less than 1.5 cm (ngertip) and it is usually found in infants, children or
young adult males. The sac stays within the canal and the internal ring is
functional such that the hernia often stays reduced. The Indirect (Medium)
hernia has an enlarged internal ring of up to 3 or 4 cm or 2 ngerbreadths

Table 7
Schumpelick Aus AritAachen classication
L
M
Mc
F

Lateral (indirect)
Medial (direct)
Medial combined
Femoral

Orice Size
Grade I
II
III

\1.5 cm
1.53 cm
[3 cm

Adapted from Schumpelick V, Arit G. In: Problems in general surgery. Philadelphia:

Lippincott-Raven Publications; 1995. p. 578.

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R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

Table 8
Common features among hernia classications
Anatomic sites

Sizes

Indirect/Lateral
Direct/Medial
Femoral
Combined indirect & direct (pantaloon)
Indirect
Small
Medium
Direct
Small
Medium

\1.5 cm
\3 or 4 cm
\1.5 cm
\3 or 4 cm

Adapted from Zollinger RM Jr. Classication of ventral and groin hernias. In: Fitzgibbons
RJ Jr, Greenburg AG, editors. Nyhus and Condons hernia. 5th edition. Philadelphia:
Lippincott Williams & Wilkins; 2002.

diameter and the sac usually extends to or through the external ring, but not
into the scrotum. The Indirect (Large) hernia is dened as having a disrupted
internal ring that is greater than 4 cm or two ngerbreadths in width, plus it
has a long sac with inguino-scrotal presentation.
For the Direct hernias, the unied classication lists Small as ngertip in
diameter, and its exact location in the direct oor is not specied. Direct
(Medium) hernias are approximately thumb-sized defects whose key dening feature is the preservation of a rim of transversalis oor about its
perimeter. Direct (Large) hernias are dened as having a complete blowout
of the entire direct oor. Finally, the unied system adds a category
of Other that includes mixtures of femoral, indirect and direct hernias;
massive hernias; and complex or rare ones.

Box 1. Ideal classification system for inguinal hernias

1. Based upon anatomic location
Indirect
Direct
Femoral
Other
2. Includes anatomic function
Competency of Internal Ring
Integrity of Direct Floor
Defect Size
Descent of Sac
3. Reproducibility of classifications
Hernia specialists and general surgeons
4. Useable in anterior and posterior approaches
5. Easy to remember

R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

1061

Fig. 2. Proposed modied traditional classication.

Classications for groin hernias were reviewed at a Consensus Conference

Hernia Surgery workshop of the German Surgical Society in November
2002 in Magdeburg, Germany. The workshop moderator, Andreas
Hoeferlin, felt that there might be ve principal categories for groin hernias;
namely: (1) indirect, (2) direct, (3) combined, (4) femoral, and (5) recurrent.
Also the defect sizes might be listed as postscripts A for \1.5 cm; B for 1.5 to
3 cm; and C for [3 cm (Andreas Hoeferlin, personal communication, 2003).
To this I would add the category of Other, as listed in Table 9, where this

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R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

Table 9
Comparison of hernia classications
Modied
traditional

Nyhus-Stoppa
[12,13]

Modied Gilbert
[9]

Schumpelick/Arit
Aachen [15]

I
II
IIIB
IIIA
IIIA

IIIB
IIIC

IV A, B, C, D

1
2
3
5

4
6
7

L1
L2
L3
M1
M2
M3
Mc
F

II

A
B
C
A
B
C

Indirect small
Indirect medium
Indirect large
Direct small
Direct medium
Direct large
Combined
Femoral

III
IV
0 Other
R Recurrent

proposed Modied Traditional classication is compared with those of

Nyhus and Stoppa, Gilbert, and Schumpelick and Arit. The advantage of
this Modied Traditional classication is that it includes all the classes or
grades within the Nyhus-Stoppa, Gilbert, and Schumpelick-Arit systems. It
separates the Nyhus IIIA and IIIB groups into distinct components and it
adds the Direct (Medium) hernias to the Gilbert. Finally, this Modied
Traditional method categorizes the hard-to-describe but important Other
group and it allows classication of recurrent hernias, as does Nyhus.
Although this Modied Traditional system classies the basic defects in
groin hernias, multiple authors have also proposed several important
modiers. These should be considered in any new classication system that
attempts to be comprehensive (Table 10).

Summary
All groin hernia classications are somewhat arbitrary and articial.
Currently, there is no consensus among either general surgeons or hernia
specialists as to a preferred system. A survey by Zollinger [15] in 1998 of
hernia specialists in North American and Europe showed that although the
Table 10
Potential modiers
Reducible
Slider
Colon
Sac Contents
Bowel
No Sac
Preperitoneal Fat
Associated Abnormality
Lipoma Cord

Incarcerated Strangulated (Necrotic)

Small bowel Bladder

Other

Omentum

Fluid

Other

Hydrocoele

Varicocoele

Other

R.M. Zollinger Jr. / Surg Clin N Am 83 (2003) 10531063

1063

Nyhus, Gilbert, and Schumpelick-Arit systems were commonly used, the

majority of these specialists still used the traditional classication for groin
hernias. It is apparent that only the traditional classication of groin hernias
has stood the test of time. As stated by Fitzgibbons [16], the primary
purpose of a classication system for any disease is to stratify for severity so
that reasonable comparisons can be made between various treatment
strategies. Given the multiplicity of operative techniques and approaches
for the repair of groin hernias, it appears that no one classication system
can satisfy all. With time, it is likely that we surgeons will settle upon a given
operation for a specic type of inguinal hernia. For that given operation to
be accepted as proven best, however, it is essential the competing operations
be applied to similar (classied) groups of groin hernia patients.

References
[1] Schumpelick V, Treutner KH. Classication of inguinal hernias. In: Bendavid R, editor.
Abdominal wall hernias: principles & management. New York: Springer-Verlag; 2001.
p. 12830.
[2] Read R. The development of inguinal herniorrhaphy. Surg Clin N Am 1984;64:18596.
[3] Rutkow IM, Robbins AW. Classication of groin hernias. In: Bendavid R, editor.
Prostheses and abdominal wall hernias. Austin (TX): RG Landes; 1994. p. 10612.
[4] Nyhus LM, Stevenson JK, Listerub MB, Harkins HN. Preperitoneal herniorrhaphy. West
J Surg Obstet & Gynecol 1959;67:4854.
[5] Casten DF. Functional anatomy of the groin area as related to the classication and
treatment of groin hernias. Am J Surg 1967;114:9849.
[6] McVay CB, Cha JD. Inguinal and fermoral hernioplasty. Ann Surg 1958;148(4):499512.
[7] Halverson K, McVay CB. Inguinal and femoral hernioplasty. Arch Surg 1970;101:12735.
[8] Lichtenstein IL. Herniorrhaphy: a personal experience with 6321 cases. Am J Surg 1987;
153:5539.
[9] Gilbert AI. An anatomic and functional classication for the diagnosis and treatment of
inguinal hernia. Am J Surg 1989;157:3313.
[10] Rutkow IM, Robbins AW. Tension-free inguinal herniorrhaphy: a preliminary report
on the mesh plug technique. Surgery 1993;114:38.
[11] Rutkow IM, Robbins AW. Classication systems and groin hernias. Surg Clin N Am
1998;78:11224.
[12] Nyhus LM. Individualization of hernia repair: a new era. Surgery 1993;114:102.
[13] Stoppa R. Hernias of the abdominal wall. In: Chevrel JP, editor. Hernias and surgery of
the abdominal wall. Berlin: Springer; 1998. p. 171277.
[14] Alexandre JH, Bouillot JL, Aouad K. Le Journal de Carlio Chirugie 1996;12:19539.
[15] Schumpelick V, Arit G. The Aachen classication of inguinal hernia. In: Problems in
general surgery. Philadelphia: Lippincott-Raven Publications; 1995. p. 578.
[16] Zollinger RM Jr. A unied classication for inguinal hernias. Hernia 1999;3:195200.
[17] Zollinger RM Jr. Classication of ventral and groin hernias. In: Fitzgibbons RJ Jr,
Greenburg AG, editors. Nyhus and Condons hernia. 5th edition. Philadelphia: Lippincott
Williams & Wilkins; 2002. p. 719 .