From the Guidelines
Patients with suspected intestinal strangulation should undergo emergency hernia repair immediately, as the benefits of early intervention clearly outweigh the risks. This recommendation is based on the strongest and most recent evidence, including the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. The guidelines emphasize the importance of prompt surgical intervention in cases of suspected bowel strangulation, as delayed diagnosis can lead to septic complications and high morbidity and mortality rates.
Key Recommendations
- Emergency hernia repair is recommended for patients with suspected intestinal strangulation, as it can help prevent septic complications and reduce morbidity and mortality rates 1.
- Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, lactate, CPK, and D-dimer levels can be predictive of bowel strangulation, and should be taken into account when making treatment decisions 1.
- The use of mesh in clean surgical fields is associated with a lower recurrence rate, and is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 1.
- Biological mesh prosthetics may be used in contaminated fields, but the choice between a cross-linked and a non-cross-linked biological mesh should be evaluated depending on the defect size and degree of contamination 1.
Surgical Approach
- Open repair or laparoscopic/robotic approaches may be used, depending on the hernia location, size, patient factors, and surgeon expertise 1.
- Minimally invasive approaches may result in less post-operative pain and faster recovery, but may not be suitable for all hernia types 1.
Post-Operative Care
- Pain management should involve a multimodal approach, including acetaminophen, NSAIDs, and limited opioids if needed for breakthrough pain 1.
- Activity restrictions should include avoiding heavy lifting (>10 pounds) for 4-6 weeks after repair, to minimize the risk of complications such as infection or recurrence 1.
Overall, the management of hernias requires a comprehensive approach that takes into account the type, size, and symptoms of the hernia, as well as the patient's overall health and surgical risks. By following these recommendations and using the most recent and highest-quality evidence, healthcare providers can help improve outcomes and reduce morbidity and mortality rates for patients with hernias.
From the Research
Recommendations for Hernia Management
- The standard treatment for uncomplicated primary hernia repair in Europe is an open anterior approach, while in the USA, 'tension-free' mesh plug repair is commonly used 2.
- Laparoscopic hernia repair is often used for complicated hernias, such as recurrent and bilateral hernias, and is associated with less postoperative pain, decreased time off work, and decreased overall costs compared to open surgical procedures 2.
- The extraperitoneal approach is recommended for laparoscopic hernia repair due to its lower complication rate compared to the transabdominal approach 2.
- For pain management, ibuprofen has been shown to offer equivalent pain control to ketorolac at a lower cost and reduced potential for adverse drug events in patients undergoing laparoscopic hernia repair 3.
- In older adults, the decision to pursue groin hernia repair should be made on a case-by-case basis, taking into account the patient's overall health, symptoms, and risk of complications 4.
- Laparoscopic techniques can also be used to repair incisional lumbar hernias, with good short-term results and decreased morbidity 5.
- Routine contrast radiology on the first or second day following laparoscopic operation can facilitate early diagnosis of relapse of hiatal hernia and decrease morbidity 6.