What is the recommended treatment for an inguinal hernia?

Inguinal Hernia Treatment Recommendations

For inguinal hernias, mesh repair is the recommended treatment, with the Lichtenstein technique considered the gold standard due to its low recurrence rate (50-75% less) and faster recovery compared to non-mesh techniques. 1

Diagnosis and Initial Assessment

• Inguinal hernias are typically diagnosed through physical examination in men
• For women, ultrasonography is often necessary for accurate diagnosis 2
• MRI may be used for occult hernias if clinical suspicion remains high despite negative ultrasound findings 2

Treatment Algorithm Based on Presentation

Asymptomatic or Minimally Symptomatic Hernias

• In men: Watchful waiting is a reasonable and safe option for asymptomatic or minimally symptomatic inguinal hernias 2

  • However, long-term follow-up shows high rates of eventual surgery due to symptom development 3
  • Recent studies question watchful waiting based on cost-effectiveness, quality of life, and mortality data 3

• In women: Surgical repair is recommended even for asymptomatic hernias 2

Symptomatic Hernias

• Surgical repair is indicated for all symptomatic hernias 2
• Timing: Early intervention (<6 hours from symptom onset) for incarcerated/strangulated hernias is associated with lower incidence of bowel resection 4

Complicated Hernias (Incarcerated/Strangulated)

• Emergency surgical intervention is required for:
  • Strangulation (signs: severe pain, tenderness, erythema, SIRS)
  • Incarceration that cannot be manually reduced 1
  • Delayed treatment beyond 24 hours significantly increases mortality 1

Surgical Approach

Elective Repair

1. Mesh repair is strongly recommended over non-mesh techniques 5, 4

   • Lichtenstein technique (open approach with polypropylene mesh) is considered the gold standard 1, 5
   • Associated with significantly lower recurrence rates 4

2. Laparoscopic approaches (TAPP or TEP) are recommended when expertise is available 5

   • Advantages: shorter recovery time, earlier resumption of daily activities, less pain 2
   • Lower recurrence rates compared to open repair (OR 0.75) 4
   • Shorter hospital length of stay (mean difference -3.00 days) 4

Emergency Repair for Complicated Hernias

1. Mesh repair is still recommended even in emergency settings, but only in clean and clean-contaminated operations 5, 4

2. Laparoscopic approach should be considered when feasible 5

   • Allows assessment of bowel viability throughout the procedure
   • Results in lower bowel resection rates compared to open surgery 5

3. If mesh cannot be used (contaminated field), the Shouldice method is regarded as the best non-mesh repair technique 5

4. For concerns about bowel viability: Visualization via formal laparoscopy, hernia sac laparoscopy (hernioscopy), or laparotomy is recommended 5

Special Populations

Children

• Surgical repair is recommended for all children with inguinal hernia due to risk of incarceration 6
• The crude incarceration rate is approximately 7% for all children and 11% for preterm children 6
• Delaying surgery unnecessarily is not recommended due to substantial incarceration risk 6

Postoperative Management

• Multimodal analgesic regimen to minimize opioid use
• Early mobilization
• Non-opioid medications (acetaminophen, NSAIDs) as first-line treatment for pain 1
• Progressive core strengthening exercises, emphasizing transverse abdominis muscle, after recovery 1

Common Pitfalls and Caveats

1. Delayed intervention risk: Delaying treatment for incarcerated/strangulated hernias beyond 24 hours significantly increases mortality 1

2. Mesh selection: For defects >3 cm that cannot be closed primarily, biosynthetic, biologic, or composite meshes are preferred due to higher resistance to infections and lower risk of displacement 1

3. Recurrence monitoring: Patients should be monitored for chronic pain and possible recurrence between 3-6 months post-surgery 1

4. Surgical expertise: Laparoscopic approaches require appropriate surgical expertise; hernioscopy may be a viable alternative for surgeons with less laparoscopic experience 5