Treatment of Symptomatic Reducible Hernia
Surgical repair is recommended as the primary treatment for symptomatic reducible hernias to prevent complications such as incarceration and strangulation. 1
Rationale for Surgical Intervention
Symptomatic hernias require prompt surgical attention due to:
- Risk of progression to incarceration or strangulation, which significantly increases morbidity and mortality
- Longer symptomatic periods (>8 hours) are associated with higher morbidity rates 2
- Delayed treatment (>24 hours) significantly increases mortality 2
Surgical Approach Options
1. Open Repair
- Recommended for unstable patients or those with signs of strangulation 1
- Primary repair with non-absorbable sutures should be attempted when possible for small defects (<3 cm) 1
- Mesh repair is associated with lower recurrence rates compared to tissue repair in clean surgical fields 1
2. Laparoscopic/Minimally Invasive Approach
- Preferred for stable patients with reducible hernias 1
- Associated with shorter hospital stays, less morbidity, and faster recovery compared to open surgery 1
- Can be safely performed with low subsequent complication rates 1
Mesh Selection and Use
- Synthetic mesh is recommended for repair in clean surgical fields (CDC wound class I) 1
- For larger defects (>8 cm or area >20 cm²), mesh that overlaps the defect edge by 1.5-2.5 cm is advised 1
- Biological meshes may be preferred in clean-contaminated or contaminated fields 1
Special Considerations
For High-Risk Patients
- PEG (percutaneous endoscopic gastrostomy) or combined PEG/laparoscopy can be considered for high-risk elderly patients 1
- This approach is effective in relieving symptoms, preventing recurrence, and has low morbidity 1
For Diaphragmatic Hernias
- Primary repair with non-absorbable sutures should be attempted when possible 1
- In stable patients with complicated non-traumatic diaphragmatic hernias, a minimally invasive approach is suggested 1
Post-Operative Management
- Patients should resume normal activities without restrictions as soon as they feel comfortable 3
- Monitor for signs of complications including wound infection and recurrence
Potential Complications
- Chronic postoperative pain (10-12% of cases) 3
- Recurrence (varies by technique and patient factors)
- Wound infection (risk is low in clean surgical fields)
Warning Signs Requiring Urgent Attention
- Signs of systemic inflammatory response syndrome (SIRS) including fever, tachycardia, and leukocytosis 2
- Abdominal wall rigidity 2
- Elevated lactate levels, which are predictive of bowel strangulation 1
Early surgical intervention for symptomatic reducible hernias is crucial to prevent progression to complications that significantly increase morbidity and mortality. The specific surgical approach should be based on patient stability, hernia characteristics, and surgical expertise available.