What is the recommended treatment for an oblong (indirect inguinal) hernia?

Treatment of Oblong (Indirect Inguinal) Hernia

Mesh repair using the Lichtenstein technique is the gold standard treatment for indirect inguinal hernias due to its lower recurrence rate (50-75% less) and faster recovery compared to non-mesh techniques. 1

Surgical Approach Options

Open Mesh Repair (Preferred)

• The Lichtenstein technique using polypropylene mesh is considered the gold standard for inguinal hernia repair 1
• Benefits include:
  • Direct visualization of the defect
  • Lower recurrence rate (0.14-0.16%)
  • Less postoperative pain compared to non-mesh techniques
  • Recommended mesh placement is preperitoneal with 3 cm overlap of the defect 1

Laparoscopic Approach

• Alternative option when the patient is hemodynamically stable with no signs of peritonitis or bowel ischemia
• Two main techniques:
  • Total Extraperitoneal (TEP) approach - increasingly favored 2
  • Transabdominal Preperitoneal (TAPP) approach
• Benefits include decreased morbidity and shorter hospital stay compared to open repair 1
• May be particularly useful in certain complex cases, such as sliding hernias 2, 3

Preoperative Considerations

• Optimize modifiable risk factors before elective surgery:

  • Smoking cessation
  • Diabetes control (HbA1C <7%)
  • Weight management (BMI <40 kg/m²)
  • Control ascites if present 1

• Emergency surgical intervention is required for:

  • Incarceration with signs of strangulation
  • Intestinal obstruction
  • Perforation 1
  • Note: Mortality significantly increases when treatment is delayed beyond 24 hours in complicated cases 1

Postoperative Management

• Early mobilization to prevent complications

• Appropriate pain management

• Monitor for common complications:

  • Hematoma (1.6-1.86%)
  • Seroma (0.4%)
  • Wound infection (0.4-1.6%)
  • Orchitis (0.48%)
  • Chronic pain
  • Recurrence 1

• Rehabilitation:

  • Progressive core strengthening focusing on the transverse abdominis muscle
  • Avoid exercises that strain the rectus abdominis for first 3-6 months post-surgery 1
  • Adequate protein intake and hydration to support tissue repair 1

Special Considerations

• In cases of diagnostic uncertainty, the inguinal occlusion test combined with a handheld Doppler device can help accurately distinguish direct from indirect inguinal hernias (93% accuracy for indirect hernias) 4
• For pregnant women, emergency repair is indicated if the hernia is incarcerated/strangulated, elective repair if symptomatic, and postponement of repair for asymptomatic hernias until after childbirth 1
• Laparoscopic approaches may require conversion to open techniques in complex cases or when unexpected anatomical variations are encountered 2

Caution and Pitfalls

• Be vigilant for postoperative bleeding, which may present as tachycardia, hypotension, and dropping hemoglobin levels requiring emergency re-exploration 5
• Early recurrences have been reported with laparoscopic techniques (observed in 2 of 46 hernias at 3-month follow-up in one study) 6
• Careful reduction of any protruding structures (e.g., bladder, intestine) from the hernial orifice is essential during repair 3