What is the recommended treatment for an inguinal hernia?

Treatment of Inguinal Hernia

Mesh repair is the recommended treatment for inguinal hernias, with laparoscopic approaches preferred for most patients due to lower risk of chronic pain, shorter recovery time, and comparable recurrence rates to open repair. 1, 2

Surgical Management Options

Elective Treatment

• Mesh repair is strongly recommended for elective inguinal hernia repair 3
• Surgical approach options:

  1. Laparoscopic repair (TAPP or TEP)

     • Advantages: Less postoperative pain, shorter recovery time, earlier return to activities, and lower risk of chronic pain (26-46% reduction compared to open repair) 1, 2
     • Best for: Bilateral hernias, recurrent hernias, and generally healthy patients

  2. Open mesh repair

     • Lichtenstein technique is the standard open approach 3
     • More commonly used in patients ≥65 years (4.18 times more likely than laparoscopic) 4
     • Preferred for patients on anticoagulants (38 times more likely than laparoscopic) 4

Strangulated/Incarcerated Hernias

• Emergency surgical intervention is required for signs of strangulation, bowel obstruction, or skin necrosis 5
• Mesh repair is recommended even in emergency settings for clean and clean-contaminated operations 3
• If bowel viability is questionable, visualization via laparoscopy, hernioscopy, or laparotomy is necessary 3

Patient Selection Considerations

Factors Favoring Laparoscopic Approach

• Age <65 years 4
• Bilateral hernias 2, 4
• Recurrent hernias 2
• Patients desiring faster return to normal activities 2, 1
• Lower risk of chronic pain 1

Factors Favoring Open Approach

• Age ≥65 years 4
• Anticoagulant use 4
• Hemodynamically unstable patients 5
• Contaminated surgical field 3
• Surgeons with limited laparoscopic experience 3

Watchful Waiting

• Watchful waiting is a reasonable option for men with asymptomatic or minimally symptomatic inguinal hernias 2
• Not recommended for:
  • Symptomatic hernias 2
  • Women (non-pregnant) 2
  • Signs of incarceration or strangulation 5

Diagnostic Considerations

• Physical examination is usually sufficient for diagnosis in men 2
• Ultrasonography is often needed for women or when complications are suspected 2
• MRI has higher sensitivity and specificity than ultrasound and is useful for occult hernias with high clinical suspicion despite negative ultrasound 2

Common Pitfalls to Avoid

1. Delaying surgical intervention for strangulated hernias, as time from onset to surgery is the most important prognostic factor 5
2. Relying solely on clinical signs to differentiate strangulation, as early signs may be subtle 5
3. Choosing open repair by default for all elderly patients without considering individual factors
4. Inadequate mesh overlap (should be 1.5-2.5 cm beyond defect edge) 5
5. Using mesh in contaminated-dirty surgical fields 3

Special Considerations

• For patients unable to undergo laparoscopic repair but wanting minimal incisions, novel open techniques using smaller incisions (e.g., 2-cm) may be considered 6
• If mesh cannot be used, the Shouldice method is regarded as the best non-mesh repair technique 3
• Risk factors for recurrence include poor surgical technique, low surgical volumes, and surgical inexperience 5