Should asymptomatic hernias be repaired during urgent surgery for incarcerated hernia?

From the Guidelines

The decision to repair additional asymptomatic hernias discovered during urgent surgery for an incarcerated hernia should generally be individualized, but in most cases, it is reasonable to repair them during the same operation, considering the patient's overall condition, complexity of the primary repair, operative time, contamination level, and anesthetic risks. When a patient is undergoing emergency surgery for an incarcerated hernia, repairing additional asymptomatic hernias can prevent future complications and eliminate the need for a second operation 1. However, this decision should consider several factors, including the patient's overall condition, the complexity of the primary repair, operative time, contamination level, and anesthetic risks. In unstable patients or those with significant contamination from bowel compromise, it may be prudent to address only the symptomatic hernia and defer repair of asymptomatic hernias to a later date. The surgical approach would typically match that of the primary repair, using either mesh reinforcement or primary tissue repair depending on contamination levels, as recommended by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1.

Key Considerations

• The patient's overall condition and stability
• The complexity of the primary repair and potential for increased operative time
• Contamination level and risk of infection
• Anesthetic risks and potential for complications
• The potential benefits of concurrent repair, including efficiency, cost-effectiveness, and sparing the patient additional anesthesia and recovery periods

Recommendations

• In clean surgical fields (CDC wound class I), prosthetic repair with a synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection (grade 1A recommendation) 1.
• In clean-contaminated surgical fields (CDC wound class II), emergent prosthetic repair with a synthetic mesh can be performed without an increase in 30-day wound-related morbidity and is associated with a significant lower risk of recurrence (grade 1A recommendation) 1.
• The decision to repair additional asymptomatic hernias should be individualized, taking into account the patient's specific circumstances and the potential risks and benefits of concurrent repair.

From the Research

Asymptomatic Hernias Discovered During Urgent Surgery

• The decision to repair additional asymptomatic hernias discovered during urgent surgery for incarcerated hernia is a complex one, and there is no straightforward answer.
• According to a systematic review and meta-analysis 2, watchful waiting (WW) seems to be an acceptable option for patients with asymptomatic or minimally symptomatic inguinal hernias, and delaying surgical repair until symptoms appear is safe.
• Another review 3 suggests that watchful waiting for asymptomatic groin hernias is a safe and cost-effective modality in patients who are under 50 years old, have an ASA class of 1 or 2, an inguinal hernia, and a duration of signs of more than 3 months.

International Guidelines for Groin Hernia Management

• The international guidelines for groin hernia management 4 recommend that symptomatic groin hernias should be treated surgically, but asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with watchful waiting.
• The guidelines also suggest that surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics, and local/national resources.

Management of Incarcerated Hernias

• A review of the management of incarcerated hernias 5 highlights the importance of timely decision-making and patient optimization in the management of these cases.
• Another study 6 compared the outcomes of emergent laparoscopic and open repair of acutely incarcerated and strangulated hernias and found that laparoscopic repair was a safe and feasible approach with better short and long-term results compared to the open approach.

Considerations for Repairing Asymptomatic Hernias

• When deciding whether to repair additional asymptomatic hernias discovered during urgent surgery, surgeons should consider the patient's overall health, the risk of hernia-related emergencies, and the potential benefits and risks of surgical repair 2, 3, 4.
• The decision to repair asymptomatic hernias should be made on a case-by-case basis, taking into account the individual patient's circumstances and the surgeon's expertise.