What are the steps for hernia management?

Surgical Management of Hernias

Surgical repair is strongly recommended as the definitive treatment for all symptomatic hernias, with mesh repair being the first choice using either open or laparoscopic techniques. 1

Diagnosis of Hernias

• Initial Assessment:

  • For non-traumatic hernias with respiratory symptoms: Chest X-ray (anteroposterior and lateral) is recommended as first diagnostic study 2
  • For suspected hernias with non-specific symptoms: CT scan with contrast enhancement is the gold standard with sensitivity/specificity of 14-82% and 87% 2
  • In stable trauma patients with suspected diaphragmatic hernia: CT scan with contrast enhancement of chest and abdomen 2
  • In pregnant patients with suspected non-traumatic diaphragmatic hernia: Ultrasonography followed by MRI 2

• CT Findings Suggestive of Hernia:

  • Diaphragmatic discontinuity
  • "Dangling diaphragm" sign
  • "Dependent viscera" sign
  • Intrathoracic herniation of abdominal contents
  • "Collar sign" (constriction of herniating organ at rupture level) 2

Treatment Algorithm

1. Emergency vs. Elective Management

• Emergency Surgery Required:

  • Signs of strangulation (pain, erythema, inability to reduce hernia)
  • Intestinal strangulation (SIRS, elevated lactate levels)
  • Note: Delayed treatment beyond 24 hours significantly increases mortality 1

• Elective Surgery Indicated:

  • Successfully reduced hernias (same-admission)
  • Symptomatic hernias without strangulation 1
  • Asymptomatic or minimally symptomatic hernias may be managed with "watchful waiting" in select cases

2. Surgical Approach Selection

• Laparoscopic Approach (preferred when expertise available):

  • Advantages: Faster recovery, lower chronic pain risk, cost-effective 1
  • Particularly beneficial for:
    • Female patients (decreases chronic pain risk, avoids missing femoral hernia)
    • Bilateral hernias
    • Recurrent hernias after anterior repair 1

• Open Approach:

  • Recommended when:
    • Laparoscopic expertise unavailable
    • Patient is hemodynamically unstable
    • Exploratory laparotomy needed
    • Recurrence after posterior repair 2, 1

3. Repair Technique

• Mesh Repair (first choice):

  • Use non-absorbable sutures for primary repair
  • For defects larger than 3cm, mesh should be used 1
  • Mesh fixation in TEP generally unnecessary except in M3 hernias (large medial) 1
  • Avoid plug repair techniques due to higher erosion risk 1

• Tissue Repair:

  • Shouldice technique is preferred when mesh cannot be used 1

• For Diaphragmatic Hernias:

  • Primary repair with non-absorbable sutures for small defects
  • Mesh for defects larger than 8 cm or area more than 20 cm² 2
  • Mesh should overlap defect edge by 1.5-2.5 cm 2

4. Special Considerations

• For Femoral Hernias:

  • Timely mesh repair by laparoscopic approach is suggested 1
  • Higher risk of strangulation (particularly in females) 3

• For Recurrent Hernias:

  • After anterior repair: posterior approach recommended
  • After posterior repair: anterior approach recommended
  • After failed anterior and posterior approaches: referral to specialist hernia surgeon 1

• For Parastomal Hernias:

  • Small, reducible parastomal hernias: manage with hernia belt
  • Elective repair for significant pouching issues, pain, or recurrent bowel obstruction
  • Most effective repair is ostomy reversal when possible 2

Postoperative Management

• Day Surgery:

  • Recommended for most hernia repairs when appropriate aftercare is organized 1

• Pain Management:

  • Multimodal approach combining non-opioid analgesics (NSAIDs and acetaminophen)
  • Local anesthetic field block before incision
  • Scheduled alternating or concurrent ibuprofen and acetaminophen for 5 days postoperatively 1

• Activity Resumption:

  • Patients should resume normal activities without restrictions as soon as comfortable 1

Risk Factors and Complications

• Risk Factors for Hernia Incarceration/Strangulation:

  • Female gender
  • Femoral hernia
  • History of hospitalization related to groin hernia 1, 3
  • Short duration of hernia (less than one year) 3
  • Very young or elderly age 3

• Chronic Pain Management:

  • Incidence of clinically significant chronic pain: 10-12%
  • Risk factors: young age, female gender, high preoperative pain, early high postoperative pain
  • Management by multi-disciplinary teams using pharmacological and interventional measures 1

• Parastomal Hernia:

  • Common complication occurring in up to 50% of ostomates within 5 years
  • Risk factors: obesity, smoking, steroid use, and transverse colostomies 2

By following this evidence-based approach to hernia management, surgeons can optimize outcomes while minimizing complications such as recurrence and chronic pain.