From the Guidelines
For a patient with a 3.4 cm indirect inguinal hernia in the corrections setting, surgical repair with a tension-free mesh repair is the recommended treatment approach. This approach is supported by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias, which recommends the use of mesh in clean surgical fields (CDC wound class I) for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 1. The guidelines also suggest that prosthetic repair with a synthetic mesh can be performed in patients with complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage (clean-contaminated surgical field, CDC wound class II) 1.
While awaiting surgery, conservative management should include:
- Providing the patient with a truss for hernia reduction
- Activity modification to avoid heavy lifting or straining
- Appropriate pain management with acetaminophen 500-1000 mg every 6 hours as needed or NSAIDs like ibuprofen 400-600 mg every 6 hours if not contraindicated In the corrections setting, coordination with security personnel for transportation to a medical facility capable of performing the surgery is essential. Post-operative care should include wound monitoring, pain management, and gradual return to activities.
The use of laparoscopy may be considered in the management of incarcerated inguinal hernias, as it can be a useful tool for assessing bowel viability after spontaneous reduction of strangulated groin hernias 1. However, the primary approach should be a tension-free mesh repair under local or regional anesthesia when possible, as this has lower recurrence rates compared to tissue repairs. Surgery is necessary because inguinal hernias do not resolve spontaneously, and a 3.4 cm hernia carries risk of incarceration or strangulation, which would constitute a surgical emergency. The timing of surgery should be based on symptom severity, with more urgent intervention for painful hernias or those difficult to reduce.
From the Research
Treatment Approach for Indirect Inguinal Hernia
The recommended treatment approach for a patient with a 3.4 cm indirect inguinal hernia in the corrections setting is surgical repair. The following points summarize the treatment approach:
- Symptomatic groin hernias, such as the one described, should be treated surgically 2.
- Mesh repair is recommended as the first choice, either by an open procedure or a laparo-endoscopic repair technique 2.
- The choice of surgical technique should be tailored to the surgeon's expertise, patient- and hernia-related characteristics, and local/national resources 2.
- Laparo-endoscopic techniques have faster recovery times, lower chronic pain risk, and are cost-effective, provided that resources and expertise are available 2.
Considerations for Surgical Repair
The following considerations should be taken into account when planning surgical repair:
- The EHS classification system can be used to stratify patients for tailored treatment, research, and audit 2.
- Patient health-related, lifestyle, and social factors should influence the shared decision-making process leading up to hernia management 2.
- The use of low-weight mesh may have slight short-term benefits, but it is not associated with better longer-term outcomes like recurrence and chronic pain 2.
- Mesh fixation in TEP is unnecessary in most cases, but it is recommended to fix the mesh in M3 hernias (large medial) to reduce recurrence risk 2.
Postoperative Care
The following points summarize the recommended postoperative care:
- Patients should resume normal activities without restrictions as soon as they feel comfortable 2.
- Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair 2.
- Day surgery is recommended for the majority of groin hernia repairs, provided that aftercare is organized 2.