From the Guidelines
Patients with indirect inguinal hernias should undergo emergency hernia repair immediately if intestinal strangulation is suspected, as recommended by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. The treatment of indirect inguinal hernias typically involves surgical repair, with options including open herniorrhaphy or laparoscopic approaches.
- For uncomplicated hernias in adults, a tension-free mesh repair is standard, as it is associated with a lower recurrence rate without an increase in wound infection rate 1.
- Children usually undergo simple closure without mesh. Some key points to consider in the management of indirect inguinal hernias include:
- The use of diagnostic laparoscopy to assess bowel viability after spontaneous reduction of strangulated groin hernias, as recommended by the WSES guidelines 1.
- The importance of early detection and treatment of strangulated hernias, as delayed diagnosis can lead to septic complications and high morbidity and mortality rates 1.
- The role of systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, lactate, CPK, and D-dimer levels in predicting bowel strangulation 1. The laparoscopic approach may be used for the repair of incarcerated hernias in the absence of strangulation and suspicion of the need for bowel resection, as recommended by the WSES guidelines 1. In terms of postoperative care, patients can typically return to desk jobs within 1-2 weeks and resume strenuous activities within 4-6 weeks after repair. It is essential to prioritize the single most recent and highest quality study when making definitive recommendations, and in this case, the 2017 update of the WSES guidelines provides the most recent and relevant evidence 1.
From the Research
Definition and Diagnosis of Indirect Inguinal Hernia
- Indirect inguinal hernias occur when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal wall in the inguinal canal 2.
- Diagnosis is typically made through physical examination, although ultrasonography may be used, especially in women or when a recurrent hernia is suspected 2.
Treatment Options for Indirect Inguinal Hernia
- Laparoscopic repair is a common treatment option, which involves closing the internal ring with nonabsorbable suture or using mesh to reinforce the weakened area [(3,4)].
- Open repair with mesh is also an effective option, especially for unilateral first-time hernias 4.
- Watchful waiting may be considered for asymptomatic or minimally symptomatic inguinal hernias in men, but is not recommended for symptomatic hernias or in nonpregnant women [(5,2)].
Considerations for Surgical Repair
- The choice of surgical technique should be tailored to the individual patient, taking into account factors such as expertise, local resources, and patient- and hernia-related factors 6.
- Laparoscopic repair offers advantages over open techniques for patients with recurrent inguinal hernia, bilateral inguinal hernia, or for women 4.
- Surgeons should be experienced in the chosen technique to ensure optimal outcomes 4.
Outcomes and Complications
- Laparoscopic internal ring closure method has been shown to be simple, safe, and effective in treating indirect inguinal hernias, with low recurrence rates and minimal complications 3.
- Chronic pain after repair is a significant concern, and patients should be carefully selected and informed of the risks and benefits of surgery [(5,6)].
- Postoperative complications and recurrence rates are similar between surgical repair and watchful waiting for asymptomatic or minimally symptomatic inguinal hernias 5.
Guidelines and Recommendations
- International hernia societies have developed evidence-based guidelines and recommendations to improve the outcome of inguinal hernia repair, including standardization of care and tailored treatment approaches 6.
- Surgeons should be familiar with the recommended techniques, including totally extraperitoneal patch plasty (TEP), transabdominal preperitoneal patch plasty (TAPP), and Lichtenstein techniques 6.