Treatment of Inguinal Hernia
Symptomatic inguinal hernias should be surgically repaired with mesh, preferably using the Lichtenstein technique for open repair or laparoscopic approaches (TEP/TAPP) when expertise is available. 1
Surgical Approach Options
Open Repair
- Lichtenstein technique is considered the gold standard for open inguinal hernia repair due to:
Laparoscopic Repair
- Transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches offer:
- Faster recovery times
- Lower chronic pain risk
- Cost-effectiveness when expertise and resources are available 3
- Shorter hospital length of stay (mean difference -3.00 days) 4
- Lower recurrence rates (OR 0.75) compared to open repairs 4
- Ability to assess bowel viability during the procedure in emergency cases 5
Patient-Specific Considerations
Age Considerations
- Patients ≥65 years are more likely to undergo open repair (4.1 times higher odds) 6
- General anesthesia is suggested over regional anesthesia in patients ≥65 years to reduce complications like myocardial infarction, pneumonia, and thromboembolism 3
Gender Considerations
- For women, laparoscopic repair is suggested to decrease chronic pain risk and avoid missing femoral hernias 3
Special Populations
Asymptomatic or minimally symptomatic hernias:
- "Watchful waiting" may be appropriate in male patients with low risk of hernia-related emergencies 3
- Most will eventually require surgery, so risks should be discussed with patients
Pregnant women:
- Watchful waiting is suggested as groin swelling often consists of self-limited round ligament varicosities 3
Patients on anticoagulants:
- 38 times more likely to undergo open rather than laparoscopic repair 6
Emergency Cases (Incarcerated/Strangulated Hernias)
- Early intervention (<6 hours from symptom onset) is strongly associated with lower incidence of bowel resection (OR 0.1) 4
- Mesh repair is still recommended in clean and clean-contaminated operations 5
- Laparoscopic approach should be considered when expertise is available as it allows assessment of bowel viability 5
- Immediate surgical exploration via laparotomy is recommended when signs of peritonitis, hemodynamic instability, or evidence of bowel ischemia/perforation are present 1
Mesh Considerations
- Mesh repair is recommended as first choice for both open and laparoscopic techniques 3
- For defects >3 cm that cannot be closed primarily, mesh reinforcement is essential 1
- In TEP repair, mesh fixation is usually unnecessary except in large medial (M3) hernias 3
- The incidence of mesh erosion appears higher with plug versus flat mesh; plug repair techniques are not recommended 3
Postoperative Care
- Multimodal analgesic regimen to minimize opioid use:
- First-line: acetaminophen and NSAIDs
- Limited opioid prescription (maximum 15 tablets of oxycodone 5mg or equivalent) 1
- Early mobilization is recommended 1
- Patients should resume normal activities without restrictions as soon as they feel comfortable 3
- Progressive core strengthening exercises focusing on transverse abdominis muscle are recommended for the first 3-6 months post-surgery 1
Complications to Monitor
- Chronic postoperative inguinal pain (CPIP): 10-12% incidence, decreasing over time 3
- Risk factors: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, open repair
- Other complications include hematoma (1.6-1.86%), seroma (0.4%), wound infection (0.4-1.6%), and orchitis (0.48%) 1
Recurrent Hernias
- After anterior repair failure, posterior repair is recommended
- After posterior repair failure, anterior repair is recommended
- After failed anterior and posterior approaches, management by a specialist hernia surgeon is recommended 3
Prompt surgical intervention is critical for incarcerated/strangulated hernias, as mortality significantly increases when treatment is delayed beyond 24 hours in complicated cases 1.