Systematic Review of Ischiatic Hernia: Diagnostic Challenges, Surgical Evolution, and Outcomes

Introduction Ischiatic (sciatic) hernias represent one of the rarest forms of pelvic floor herniation, with fewer than 100 documented cases worldwide since first described by Papen in 1750. Their rarity, combined with often-cryptic clinical presentation, contributes to significant diagnostic and therapeutic challenges. Methods Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases from 1947 to 2024, identifying 68 relevant articles. Our search strategy combined terms related to ischiatic/sciatic hernias with various publication types. Data extraction focused on patient demographics, clinical presentation, diagnostic methods, hernia contents, surgical approaches, and outcomes. Results Our analysis revealed striking female predominance (98.5%), particularly among elderly patients (mean age 71 ± 12.8 years). Ureter was the most commonly herniated structure (58.8%), followed by small intestine (20.6%). Most patients (80.9%) lacked an external gluteal bulge, contributing to diagnostic delays. CT emerged as the primary diagnostic modality (63.2%), with the pathognomonic “curlicue sign” representing a key feature in ureterosciatic herniation. Management approaches were evenly distributed between minimally invasive techniques (35.3%), open surgery (35.3%), and conservative management with ureteral stenting (29.4%). Laparoscopic and robotic approaches demonstrated shorter hospital stays (1-2 days vs 5-14 days for open repairs) and reduced postoperative pain, despite slightly longer operative times. Complication rates were low (5.9% surgical site infections), with no reported mortality. Conclusion Ischiatic hernias require a high index of clinical suspicion for timely diagnosis, particularly in elderly females presenting with unexplained pelvic or sciatic pain. The evolution from open to minimally invasive surgical approaches has significantly transformed management outcomes, while ureteral stenting offers an alternative for high-risk patients with ureterosciatic hernias. The optimal approach remains individualized based on patient characteristics, hernia contents, and available surgical expertise.