What is the recommended treatment for inguinal hernia?

Surgical Management of Inguinal Hernia

Surgical repair is the recommended treatment for inguinal hernias to prevent complications such as incarceration and strangulation. 1

Indications for Surgical Intervention

• Symptomatic hernias: All symptomatic inguinal hernias should be surgically repaired 1
• Asymptomatic hernias: Watchful waiting may be considered for asymptomatic or minimally symptomatic male patients, with understanding that most will eventually require surgery 2
• Emergency situations: Immediate surgical intervention is required when intestinal strangulation is suspected 3

Surgical Approach Selection

For Non-Emergency (Reducible) Hernias:

1. Mesh repair is preferred over tissue repair due to lower recurrence rates 1
2. Surgical options:
   • Open mesh repair (Lichtenstein technique): Standard approach, especially in resource-limited settings 1, 2
   • Laparoscopic approaches (TAPP or TEP): Associated with faster recovery, less post-operative pain, and shorter hospital stays 1

For Emergency (Incarcerated/Strangulated) Hernias:

1. Timing: Early intervention (<6 hours from symptom onset) is crucial to reduce bowel resection risk 4

2. Approach based on CDC wound classification:

   • Clean surgical field (CDC Class I): Prosthetic repair with synthetic mesh is recommended 3
   • Clean-contaminated field (CDC Class II): Emergent prosthetic repair with synthetic mesh can still be performed without increased 30-day wound complications 3
   • Contaminated/dirty field (CDC Classes III/IV): Primary repair for small defects (<3cm); biological mesh may be used when direct suture is not feasible 3

3. For unstable patients: Open management is recommended to prevent abdominal compartment syndrome 3

Mesh Selection and Placement

• Synthetic mesh: Preferred for clean surgical fields 1
• Biological mesh: Consider for contaminated fields or when synthetic mesh is contraindicated 3
• For large defects: Mesh should overlap the defect edge by 1.5-2.5 cm 1

Laparoscopic vs. Open Approach

Benefits of Laparoscopic Approach:

• Faster recovery time and return to normal activities 1
• Lower risk of chronic pain 2
• Shorter hospital stays 4
• Allows visualization of bowel viability during the entire procedure 5
• Permits assessment of contralateral side during TAPP procedure 2

When to Choose Open Approach:

• Unstable patients or severe sepsis/septic shock 3
• Limited surgical expertise with laparoscopic techniques 2
• Resource-limited settings 2

Antimicrobial Considerations

• Clean surgical field: Short-term prophylaxis recommended 3
• Intestinal strangulation/bowel resection: 48-hour antimicrobial prophylaxis recommended 3
• Peritonitis: Full antimicrobial therapy recommended 3

Special Considerations

For Femoral Hernias:

• Higher risk of strangulation compared to other hernia types 2
• Laparoscopic approach suggested when expertise is available 2

For Recurrent Hernias:

• After anterior repair, posterior approach is recommended 2
• After posterior repair, anterior approach is recommended 2
• After failed anterior and posterior approaches, management by specialist hernia surgeon is recommended 2

Postoperative Care

• Patients should resume normal activities without restrictions as soon as they feel comfortable 2
• Monitor for signs of SIRS (fever, tachycardia, leukocytosis) which may indicate strangulation 1
• Watch for chronic pain, which occurs in approximately 10-12% of patients 2

Common Pitfalls to Avoid

1. Delayed intervention: Mortality significantly increases when treatment is delayed >24 hours in emergency cases 1
2. Overlooking femoral hernias: Especially in women, where laparoscopic approach helps identify femoral hernias 2
3. Inadequate mesh fixation: Particularly important in large medial (M3) hernias to reduce recurrence 2
4. Ignoring elevated lactate levels: Predictive of bowel strangulation 1

By following these evidence-based recommendations, surgical management of inguinal hernias can achieve optimal outcomes with low recurrence rates and minimal complications.