What is the recommended management for a left inguinal hernia?

Management of Left Inguinal Hernia

For asymptomatic or minimally symptomatic inguinal hernias, watchful waiting is a reasonable and safe option, while symptomatic hernias should undergo surgical repair with mesh techniques. 1

Initial Assessment and Decision Making

When to Consider Watchful Waiting

• Appropriate for men with asymptomatic or minimally symptomatic inguinal hernias 2, 1
• Delaying surgical repair until symptoms appear is safe 2
• Acute hernia incarcerations are not particularly frequent during watchful waiting 2
• Conversion rate from watchful waiting to elective surgery ranges from 35-58% 2

When to Recommend Surgical Repair

• Symptomatic hernias (pain, discomfort affecting daily activities) 1
• All inguinal hernias in women (watchful waiting not recommended) 1
• Strangulated hernias require immediate surgical intervention 3
  • Early intervention (<6 hours from symptom onset) is associated with lower incidence of bowel resection
  • Preoperative preparation includes fluid resuscitation, broad-spectrum antibiotics, and NPO status

Surgical Approach Options

Open Repair (Lichtenstein Technique)

• Standard approach for open inguinal hernia repair 4
• Can be performed under local anesthesia, making it suitable for day-case surgery 5
• Higher risk of chronic groin pain compared to laparoscopic approaches 6

Laparoscopic Repair

• Associated with shorter recovery time, earlier resumption of activities, less pain 1
• 26-46% reduction in risk of chronic pain compared to open repair 6
• Two main techniques with comparable outcomes 4:
  • Transabdominal preperitoneal (TAPP)
  • Totally extraperitoneal (TEP)
• Recurrence rates similar to open repair 6

Special Considerations

Strangulated Hernias

• Require immediate surgical intervention 3
• Open approach preferred for hemodynamically unstable patients 3
• Mesh repair recommended in clean and clean-contaminated operations 4
• If bowel viability is questionable, visualization via laparoscopy or laparotomy is needed 4

Mesh Selection

• Standard polypropylene mesh remains the standard choice 5
• Partially absorbable lightweight meshes may offer some advantages 5
• Mesh repair recommended for larger defects (>3 cm or >20 cm²) 3
• Mesh should overlap defect edges by 1.5-2.5 cm 3

Postoperative Care and Follow-up

• Monitor for at least 24 hours, focusing on hemodynamic stability and surgical site 3
• Pain management:
  • Acetaminophen 500-1000 mg every 6 hours as first-line treatment 3
  • Avoid NSAIDs due to increased bleeding risk 3
• Educate patients about signs of complications requiring immediate attention:
  • Severe constant pain, redness over hernia site
  • Nausea, vomiting, inability to pass gas or stool
  • Fever or general malaise 3
• Monitor for recurrence (5-year rates: 10.6-12.3% with mesh vs 17.1% without mesh) 3

Diagnostic Tools for Evaluation

• Physical examination is usually sufficient for diagnosis in men 1
• Ultrasonography helpful for women and when complications are suspected 1
• MRI has higher sensitivity and specificity for occult hernias 1
• CT scan of abdomen and pelvis is gold standard for evaluating post-repair complications 3

Common Pitfalls to Avoid

• Delaying surgical intervention for strangulated hernias (should be done within 6 hours) 3
• Using watchful waiting approach in women (not recommended) 1
• Failing to consider chronic pain as a significant postoperative complication (incidence is high) 2
• Not providing adequate patient education about signs of strangulation requiring immediate attention 3