Recommended Treatment for Inguinal Hernia
Mesh repair is the recommended first-line treatment for inguinal hernia, using either an open Lichtenstein technique or a laparoscopic approach (TAPP or TEP), with laparoscopic approaches preferred when expertise is available due to faster recovery times and lower chronic pain risk. 1, 2
Treatment Algorithm
Initial Assessment and Decision-Making
- Symptomatic hernias: Surgical repair is recommended
- Asymptomatic/minimally symptomatic hernias in men: "Watchful waiting" may be considered as risk of emergency is low, though most will eventually require surgery 2
- Femoral hernias: Should be repaired promptly due to high strangulation risk 3
- Pregnant women: Watchful waiting is suggested as groin swelling often consists of self-limited round ligament varicosities 2
Surgical Approach Selection
Mesh repair techniques (preferred over tissue repair):
- Open Lichtenstein technique: Standard approach, especially for surgeons with less laparoscopic experience
- Laparoscopic approaches (TAPP or TEP): Recommended when expertise available due to:
Tissue repair (only after appropriate discussion with patient):
- Shouldice technique: Best non-mesh repair option when mesh cannot be used 4
Special considerations:
- For women: Laparoscopic approach recommended to reduce chronic pain risk and avoid missing femoral hernias 2
- For recurrent hernias: Use posterior approach after failed anterior repair and vice versa 2
- For bilateral hernias: Can be safely repaired simultaneously via open or laparoscopic approach 5
- For incarcerated/strangulated hernias: Early intervention (<6 hours from symptom onset) recommended to reduce bowel resection risk 6
Evidence-Based Recommendations for Specific Scenarios
For Elective Repairs
- Mesh repair is strongly recommended over tissue repair 4, 2
- Day surgery is recommended for most patients 1, 2
- Local anesthesia for open repair has advantages when surgeon is experienced 2
- General anesthesia suggested over regional in patients ≥65 years 2
For Emergency/Strangulated Hernias
- Early intervention (<6 hours from symptom onset) is crucial to reduce bowel resection risk 6
- Mesh repair is still recommended even in emergency settings for clean and clean-contaminated fields 1, 4
- If bowel viability is questionable, visualization via laparoscopy, hernioscopy, or laparotomy is recommended 4
Mesh Considerations
- So-called "low-weight" mesh may offer slight short-term benefits but doesn't improve long-term outcomes 2
- Mesh selection should not be based on weight alone 2
- Plug repair techniques are not recommended due to higher erosion risk 2
- Mesh fixation generally unnecessary in TEP but recommended for large medial (M3) hernias in both TEP and TAPP 2
Common Pitfalls and Caveats
- Delayed diagnosis significantly increases mortality in complicated hernias 1
- Relying solely on clinical signs to differentiate strangulation is risky as early signs may be subtle 1
- Inadequate mesh overlap (<1.5-2.5 cm) increases recurrence risk 1
- Inappropriate patient selection for watchful waiting may lead to emergency situations
- Insufficient surgical experience, particularly for laparoscopic repairs (approximately 100 supervised repairs needed to achieve proficiency) 2
- Age bias: Patients ≥65 years are 4 times more likely to receive open rather than laparoscopic repair, though this may not always be clinically justified 5
Risk Factors for Poor Outcomes
- For recurrence: Poor surgical technique, low surgical volumes, surgical inexperience, local anesthesia 2
- For chronic pain: Young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, open repair 2
- For incarceration/strangulation: Female gender, femoral hernia, history of hospitalization related to groin hernia 2
The evidence strongly supports mesh repair as the standard of care for inguinal hernias, with the choice between open and laparoscopic approaches depending on surgical expertise and patient factors.