What are the treatment options for inguinal hernia?

From the Guidelines

Surgical repair is the definitive treatment for inguinal hernia, with options including open herniorrhaphy or laparoscopic repair, and the use of mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection. The treatment options for inguinal hernia include both surgical and non-surgical approaches. For most patients, surgical repair is the recommended treatment, with options including open herniorrhaphy (Lichtenstein technique using mesh) or laparoscopic repair (either totally extraperitoneal or transabdominal preperitoneal approaches) 1.

Key Considerations

• Surgery typically takes 45-90 minutes and is often performed as an outpatient procedure under local, regional, or general anesthesia.
• Recovery time ranges from 1-2 weeks for desk jobs to 4-6 weeks for physical labor, with restrictions on heavy lifting (nothing over 10 pounds for several weeks).
• Non-surgical management may be appropriate for patients with minimal symptoms, significant comorbidities, or those who decline surgery, and involves using a truss (supportive undergarment) to reduce discomfort and prevent hernia enlargement.
• Watchful waiting is sometimes reasonable for men with minimal symptoms, though hernias will not resolve without intervention and carry a risk of incarceration or strangulation, which would require emergency surgery.

Pain Management

• Pain management during recovery typically includes acetaminophen or NSAIDs like ibuprofen, with stronger medications rarely needed beyond a few days post-surgery.

Use of Mesh

• The use of mesh in clean surgical fields (CDC wound class I) is associated with a lower recurrence rate, if compared to tissue repair, without an increase in the wound infection rate 1.
• For patients having complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage (clean-contaminated surgical field, CDC wound class II), emergent prosthetic repair with synthetic mesh can be performed (without any increase in 30-day wound-related morbidity) and is associated with a significant lower risk of recurrence, regardless of the size of hernia defect 1.

Emergency Situations

• Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected (grade 1C recommendation) 1.
• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are predictive of bowel strangulation (grade 1C recommendation) 1.

From the Research

Treatment Options for Inguinal Hernia

The treatment options for inguinal hernia include:

• Surgical treatment, which remains the main goal to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain 2
• Mesh repair, which is recommended in elective operations, with the Lichtenstein technique being the standard in open inguinal hernia repair 2
• Transabdominal preperitoneal and totally extraperitoneal approach, which have comparable outcomes and clear advantages including minimal invasiveness 2
• Laparoscopic approach, which should be considered, especially in cases of strangulation, as it allows an assessment of bowel viability during the whole procedure 2, 3, 4
• Non-mesh repair techniques, such as the Shouldice method, which is regarded as the best non-mesh repair technique if mesh cannot be used 2

Specific Considerations

• For patients with recurrent inguinal hernia, or bilateral inguinal hernia, or for women, laparoscopic repair offers significant advantages over open techniques with regard to recurrence risk, pain, and recovery 3
• For unilateral first-time hernias, either laparoscopic or open repair with mesh can offer excellent results 3
• The use of the EHS classification system is suggested to improve patient outcomes 2
• In cases of strangulation, mesh repair is recommended, but only in clean and clean-contaminated operations 2

Complications and Recurrences

• Complication rates for open inguinal herniorrhaphy varied from 7% to 12%, with the most frequent complications being wound problems and scrotal and testicular swelling 5
• Recurrence rates for open inguinal herniorrhaphy ranged from 1% to 10% for primary repair to as high as 35% for the repair of recurrent hernias 5
• Laparoscopic series involved 3,178 repairs using the retroperitoneal and onlay techniques, and 61 recurrences (1.92%) were noted in a follow-up greater than 6 months 5