What is the best management approach for the floor of a hernia, particularly in inguinal hernias?

Management of the Floor of Inguinal Hernia

For defects >3 cm that cannot be closed primarily, mesh reinforcement is essential, with biosynthetic, biologic, or composite meshes preferred due to their lower recurrence rates, higher resistance to infections, and lower risk of displacement. 1

Surgical Approach Selection

The optimal management of the floor of an inguinal hernia depends on several factors:

Open vs. Laparoscopic Approach

• Laparoscopic approach is preferred for stable patients without signs of strangulation or peritonitis 1

  • Offers faster recovery times, lower chronic pain risk, and is cost-effective when resources and expertise are available 2
  • Two main techniques: TEP (totally extraperitoneal) and TAPP (transabdominal preperitoneal)
  • No significant differences found between TEP and TAPP in outcomes 3

• Open approach is recommended for:

  • Patients with hemodynamic instability 1
  • Cases requiring direct visualization of the defect and assessment of potential bowel compromise 1
  • The Lichtenstein technique using polypropylene mesh is considered the gold standard for open repair 1

Mesh Selection and Placement

• For defects >3 cm:

  • Mesh reinforcement is essential 1
  • Biosynthetic, biologic, or composite meshes are preferred 4, 1
  • Heavyweight meshes result in lower recurrence rates in TEP repairs 3

• Mesh positioning:

  • Preperitoneal mesh placement with 3 cm overlap of the defect is recommended 1
  • In TEP repair, mesh fixation is generally unnecessary except for M3 hernias (large medial) 2
  • Double-mesh technique may be considered for very large indirect hernias and extremely large bilateral or recurrent hernias 5

Special Considerations

Repair Techniques for Different Patient Populations

• For women: Laparo-endoscopic repair is suggested to decrease chronic pain risk and avoid missing femoral hernias 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 a specialist hernia surgeon is recommended 2

Management of the Hernia Sac

• Excision of the hernial sac is controversial 4
• Retention of the sac generally has no obvious complications 4
• Sac excision may reduce tissue trauma, fluid collection, and recurrence in specific cases 4

Postoperative Management

• Pain management:

  • Multimodal analgesic regimen to minimize opioid use 1
  • Non-opioid medications as first-line treatment (acetaminophen and NSAIDs) 1

• Complications monitoring:

  • Common complications include hematoma (1.6-1.86%), seroma (0.4%), wound infection (0.4-1.6%), and orchitis (0.48%) 1
  • Drainage may be advantageous for seroma prophylaxis 3

• Activity recommendations:

  • Patients should resume normal activities without restrictions as soon as they feel comfortable 2
  • Progressive core strengthening, emphasizing the transverse abdominis muscle for the first 3-6 months post-surgery 1

Caveats and Pitfalls

1. Risk of chronic pain:

   • Incidence of clinically significant chronic pain is 10-12%, decreasing over time 2
   • Risk factors include young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, and open repair 2

2. Recurrence considerations:

   • Inadequate lateral inferior and medial inferior mesh fixation is a common cause of hernia recurrence 5
   • Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, and surgical inexperience 2

3. Asymptomatic hernias:

   • Watchful waiting may be appropriate for asymptomatic or minimally symptomatic inguinal hernias 6
   • Conversion rate from watchful waiting to elective surgery ranges from 35.03% to 57.8% 6

4. Learning curve:

   • Approximately 100 supervised laparo-endoscopic repairs are needed to achieve results comparable to open mesh surgery 2
   • Case load per surgeon is more important than center volume 2

The management of the floor of an inguinal hernia requires careful consideration of patient factors, hernia characteristics, and surgical expertise to ensure optimal outcomes with minimal recurrence and chronic pain.