Treatment Options for Inguinal Hernia
Mesh repair is recommended as the first choice for inguinal hernia treatment, either by an open procedure (Lichtenstein technique) or a laparoendoscopic approach (TEP or TAPP), with the surgical approach tailored to patient factors, hernia characteristics, and surgeon expertise. 1, 2
Surgical Approaches
Open Repair
- Lichtenstein technique: Standard for open repair using non-absorbable mesh 1, 2
- Shouldice technique: Best non-mesh repair option when mesh cannot be used 3
- Primary repair with non-absorbable sutures: Recommended for smaller defects 1
- Mesh reinforcement: Required for defects >3 cm 1
Laparoendoscopic Repair
- Transabdominal preperitoneal (TAPP) approach 2
- Totally extraperitoneal (TEP) approach 2
- Benefits: Shorter hospital stays, faster recovery, lower chronic pain risk, and cost-effective when expertise is available 2
- During TAPP, inspection of contralateral side is recommended (not suggested during unilateral TEP) 2
Patient Selection Considerations
Factors Favoring Open Repair
- Age ≥65 years (4× more likely to receive open repair) 4
- Use of anticoagulants (38× more likely to receive open repair) 4
- Hemodynamically unstable patients 1
- Limited laparoscopic expertise availability 2
Factors Favoring Laparoendoscopic Repair
- Female patients (to reduce chronic pain risk and avoid missing femoral hernias) 2
- Bilateral hernias 2
- Younger patients (<65 years) 4
- Need for faster recovery 2
Management of Special Cases
Incarcerated/Strangulated Hernias
- Early surgical intervention (<6 hours from symptom onset) is recommended to reduce bowel resection risk 5
- Mesh repair is still recommended in clean and clean-contaminated cases 3, 5
- Laparoscopic approach should be considered as it allows assessment of bowel viability 3, 5
- If bowel viability is questionable, visualization via laparoscopy, hernioscopy, or laparotomy is needed 3
Asymptomatic Hernias
- "Watchful waiting" is reasonable for asymptomatic or minimally symptomatic male patients 2, 6
- Most will eventually require surgery; risks and benefits should be discussed 2
- Not recommended for symptomatic hernias or in nonpregnant women 6
Perioperative Considerations
Preoperative
- Evaluate modifiable risk factors: smoking cessation, diabetes control (HbA1C <7%), weight management (BMI <40 kg/m²) 1
- Consider antibiotic prophylaxis with 1st generation cephalosporin for open repair 1
Mesh Selection
- Synthetic non-absorbable mesh for clean fields 1
- Biologic or biosynthetic meshes for contaminated/dirty fields 1
- Mesh overlap of 1.5–2.5 cm recommended 1
- Plug repair techniques are not recommended due to higher erosion risk 2
Anesthesia Options
- Local anesthesia recommended for open repair if surgeon is experienced 2
- General anesthesia suggested over regional in patients ≥65 years 2
- Perioperative field blocks and/or subfascial/subcutaneous infiltrations recommended for all open repairs 2
Postoperative Care
- Day surgery recommended for most patients with organized aftercare 2
- Patients should resume normal activities without restrictions as soon as comfortable 2
- Multimodal analgesic regimen to minimize opioid use 1
- Non-opioid medications (acetaminophen, NSAIDs) as first-line treatment for pain 1
- Monitor for complications: seroma, surgical site infection, and recurrence 1
Complications and Management
Chronic Pain
- Incidence of clinically significant chronic pain: 10-12% (decreases over time) 2
- Risk factors: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, open repair 2
- Management: multi-disciplinary approach combining pharmacological and interventional measures 2
Recurrence
- For recurrence after anterior repair, posterior approach recommended 2
- For recurrence after posterior repair, anterior approach recommended 2
- After failed anterior and posterior approaches, referral to specialist hernia surgeon recommended 2