From the Guidelines
Surgical repair is the recommended management option for inguinal hernia, with the choice between open and laparoscopic approaches depending on patient factors, hernia characteristics, and surgeon expertise. The main surgical techniques include open repair (Lichtenstein tension-free mesh repair being most common) and laparoscopic approaches (transabdominal preperitoneal [TAPP] or totally extraperitoneal [TEP] repairs) 1.
Key Considerations
- Open repair is typically performed under local or regional anesthesia as an outpatient procedure, while laparoscopic repairs require general anesthesia but may offer faster recovery and less post-operative pain.
- For asymptomatic or minimally symptomatic hernias, particularly in elderly patients or those with significant comorbidities, watchful waiting may be appropriate 1.
- Non-surgical management includes the use of trusses or hernia belts to temporarily reduce symptoms, though these do not treat the underlying defect.
- Pain management with acetaminophen or NSAIDs may help with discomfort.
- Activity modification to avoid heavy lifting and straining is recommended regardless of treatment approach.
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.
- Local anaesthesia (LA) can be used, providing effective anaesthesia with less postoperative complications for emergency inguinal hernia repair in the absence of bowel gangrene (grade 1C recommendation) 1.
Surgical Techniques
- 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 (grade 1A recommendation) 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 (grade 1A recommendation) 1.
From the Research
Management Options for Inguinal Hernia
The management of inguinal hernia involves several options, including:
- Surgical repair, which is the current approach for most cases 2, 3
- Watchful waiting for asymptomatic or minimally symptomatic hernias 2, 4
- Use of prophylactic antibiotics in centers with high rates of wound infection 2
- Local anesthesia for open repairs, which is a suitable and economic option for day-case settings 2
Surgical Repair Techniques
Several surgical repair techniques are available, including:
- Open repair, which can be performed using various methods, such as the Lichtenstein technique 2, 4
- Laparoscopic techniques, such as the transabdominal preperitoneal (TAPP) repair and the totally extraperitoneal (TEP) repair 3, 4, 5
- Mesh repair, which is recommended as the first choice for most cases, either by an open procedure or a laparo-endoscopic repair technique 4
- Tissue repair, which can be offered in certain cases, such as the Shouldice technique 4
Considerations for Surgical Repair
Several factors should be considered when choosing a surgical repair technique, including:
- The type of hernia (direct or indirect) 3
- The size of the hernia 4
- The patient's age, gender, and overall health 4
- The surgeon's expertise and experience 4
- The availability of resources and equipment 4
Postoperative Care
Postoperative care for inguinal hernia repair includes:
- Resuming normal activities without restrictions as soon as the patient feels comfortable 4
- Using perioperative field blocks and/or subfascial/subcutaneous infiltrations to manage pain 4
- Avoiding heavy lifting and strenuous activities for a period of time after surgery 3
Complications and Recurrence
Complications and recurrence rates for inguinal hernia repair are generally low, but can include: