Herniotomy Procedure: Recommendations and Best Practices
Herniotomy is recommended as a surgical procedure for specific types of hernias, with mesh repair being the preferred technique for most adult patients with defects larger than 3 cm or an area greater than 20 cm². 1
Indications and Patient Selection
For adults:
- Primary repair without mesh (herniotomy) may be appropriate for:
- Mesh repair is strongly recommended for:
For children:
Surgical Approach Selection
Open vs. Laparoscopic Approach:
Factors influencing approach selection:
- Patient stability
- Hernia type and size
- Surgeon expertise
- Need for bowel resection
- Patient comorbidities
Technical Considerations
Primary Repair (Herniotomy)
- For small defects that can be closed with direct suture 1
- Shouldice technique is the preferred tissue repair method when appropriate 3
- Zero recurrence rates reported in patients up to 25 years 2
Mesh Repair
- Recommended for defects >3 cm or area >20 cm² 1
- Mesh should overlap defect edges by 1.5-2.5 cm 7
- Mesh fixation is necessary in large medial (M3) hernias to reduce recurrence 3
- Avoid plug repair techniques due to higher erosion rates 3
Specific Situations
- For diaphragmatic hernias: Primary repair with non-absorbable sutures in two layers 1
- For umbilical hernias in cirrhotic patients: Careful consideration of risks/benefits 7
- For femoral hernias: Timely mesh repair by laparoscopic approach 3
Perioperative Management
Anesthesia
- Local anesthesia is recommended for open repair when surgeon is experienced 3
- General anesthesia is suggested over regional in patients ≥65 years 3
- Perioperative field blocks and subfascial/subcutaneous infiltrations are recommended 3
Damage Control Surgery
- Recommended for patients with intraoperative instability, hypothermia, coagulopathy, significant acidosis, or inability to close the diaphragm 1
- Consider leaving abdomen open to prevent abdominal compartment syndrome in critical patients 1
Postoperative Care
Pain Management
- First-line: Acetaminophen 500-1000 mg every 6 hours (max 4000 mg/day) 7
- Second-line: Tramadol 50-100 mg every 6-8 hours (max 400 mg/day) 7
- Avoid NSAIDs due to increased bleeding risk 7
Monitoring and Discharge
- Monitor patients for at least 24 hours post-surgery 7
- Focus on hemodynamic stability, surgical site complications, and respiratory function 7
- Day surgery is recommended for most groin hernia repairs when appropriate aftercare is organized 3
Activity Recommendations
- Patients should resume normal activities without restrictions as soon as they feel comfortable 3
Complications and Management
Common Complications
- Seroma formation (more common with mesh repair) 7
- Wound infection (4-12%) 7
- Chronic pain (10-12%, decreasing over time) 3
- Recurrence (varies by technique and patient factors) 1, 3
Management of Complications
- CT scan of abdomen and pelvis if pain persists beyond 1 month 7
- Multidisciplinary team approach for chronic postoperative inguinal pain 3
- For recurrent hernia after anterior repair, posterior approach is recommended 3
Special Considerations
Cirrhotic Patients with Umbilical Hernias
- Approximately 20% of cirrhotic patients develop umbilical hernias 7
- Optimal fluid control and appropriate nutrition are important 7
- For transplant candidates, hernia repair should ideally be deferred until during/after transplantation 7
Pregnant Women
- Watchful waiting is suggested as groin swelling often consists of self-limited round ligament varicosities 3
- Emergency repair if incarcerated/strangulated 7
Follow-up Care
- Monitor for recurrence and complications 7
- Educate patients on signs of hernia strangulation and importance of seeking immediate medical attention 7
- 5-year recurrence rates: 10.6-12.3% with mesh repair vs. 17.1% without mesh 7
Herniotomy remains a valuable procedure, particularly for pediatric patients and young adults. For most adult patients, especially those over 30 years of age or with larger defects, mesh repair techniques are preferred due to lower recurrence rates.