What is the recommended treatment for inguinal hernia?

Treatment of Inguinal Hernia

Mesh repair is the recommended treatment for inguinal hernias, with elective surgical intervention advised for all inguinal hernias, even asymptomatic ones, to prevent complications such as incarceration and strangulation. 1, 2

Diagnosis and Classification

• Use the European Hernia Society (EHS) classification system to categorize the hernia 2
• Evaluate for signs of complications:
  • Incarceration: irreducible hernia
  • Strangulation: severe pain, tenderness, erythema, systemic inflammatory response syndrome (SIRS), peritoneal signs, leukocytosis 1

Treatment Algorithm

For Uncomplicated Inguinal Hernias:

1. Elective surgical repair with mesh is recommended for all patients, including those with asymptomatic hernias, unless there are serious comorbidities or limited life expectancy 2, 3

2. Surgical approach options:

   • Open repair: Lichtenstein technique is the standard open approach 2
   • Laparoscopic repair: Either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approaches 2

   Note: For patients ≥65 years, open repair is more commonly performed (4.2 times more likely than laparoscopic), especially in those on anticoagulants 4

For Complicated Inguinal Hernias (Incarcerated/Strangulated):

1. Immediate surgical intervention without delay for strangulated hernias 1

2. Preoperative preparation:

   • IV fluid resuscitation
   • Broad-spectrum antibiotics
   • NPO status
   • Type and cross-match blood if significant bowel compromise is suspected 1

3. Surgical approach:

   • Laparoscopic approach for hemodynamically stable patients
     • Benefits: shorter hospital stay, lower recurrence rates, allows assessment of bowel viability throughout procedure 1, 5
     • Technique: 3-4 trocars in triangular/diamond configuration, IPOM technique for mesh placement 1
   • Open approach for hemodynamically unstable patients
     • Midline incision over hernia
     • Identification and isolation of hernia sac
     • Fascial closure with non-absorbable sutures 1

4. Mesh use in emergency settings:

   • Recommended even in emergency settings for clean and clean-contaminated fields 1, 2
   • Synthetic non-absorbable mesh for clean fields
   • Biologic or biosynthetic meshes for contaminated/dirty fields
   • Mesh overlap of 1.5-2.5 cm 1

Special Considerations

Bilateral Hernias

• If one hernia is symptomatic, treat both hernias in the same surgical session 3
• Laparoscopic approach is particularly advantageous for bilateral hernias 4

High-Risk Patients

• Elderly patients: Higher risk of complications with emergency repair (58% vs 22% for elective) 6

  • Mortality rate of 10% reported for emergency repair in elderly vs 0% for elective repair 6
  • Early elective repair strongly recommended to avoid emergency situations 6

• Patients on anticoagulants:

  • Require inpatient admission with specialized perioperative management 1
  • Open approach more commonly used (38 times more likely than laparoscopic) 4
  • Complete medication review to manage anticoagulants appropriately 1

When Mesh Cannot Be Used

• If mesh placement is contraindicated (e.g., contaminated-dirty field), the Shouldice method is regarded as the best non-mesh repair technique 2

Timing Considerations

• Early intervention (<6 hours from symptom onset) for complicated hernias reduces the incidence of bowel resection 1
• Delayed diagnosis significantly increases mortality 1
• Average hospital stay: 3.8 days for laparoscopic approach 5

Common Pitfalls

• Delaying surgical treatment: Waiting for symptoms to develop before repairing asymptomatic hernias increases risk of emergency surgery with higher complications 3, 6
• Relying solely on clinical signs to differentiate strangulation, as early signs may be subtle 1
• Inappropriate surgical approach selection: Not considering patient factors (age, anticoagulation) when choosing between open and laparoscopic approaches 4