What is the treatment for hernia?

Treatment of Hernias

Surgical repair is the definitive treatment for hernias, with mesh repair being the recommended approach for most hernias due to lower recurrence rates compared to non-mesh repairs. 1, 2

Types of Surgical Approaches

Elective Repair

• Mesh repair is recommended for:

  • Larger defects (>3 cm or >20 cm²) with mesh overlap of defect edges by 1.5-2.5 cm 1
  • Most adult hernias to reduce recurrence rates (mesh reduces recurrence by 54% compared to non-mesh repair) 3

• Surgical approach options:

  • Laparoscopic repair:

    • Preferred for Morgagni's hernia due to lower morbidity rates (5% vs 17% for open) and shorter hospital stays 1
    • May result in shorter hospital stay (by approximately 0.6 days) 3
    • Patients may return to normal activities approximately 2.87 days sooner 3

  • Open repair:

    • May be preferable for very large defects (>15 cm) 4
    • Open sublay mesh position independently decreases risk of recurrence compared to other open mesh positions 4
    • Preferred for hemodynamically unstable patients or when bowel resection is anticipated 1

Emergency Repair

• Immediate surgical intervention is mandatory for strangulated hernias 1
• Preoperative preparation includes:
  • Fluid resuscitation
  • Broad-spectrum antibiotics
  • NPO status 1
• Early intervention (<6 hours from symptom onset) is associated with lower incidence of bowel resection 1
• Open approach is preferred for emergency cases, especially in hemodynamically unstable patients 1, 5

Special Considerations

Cirrhotic Patients

• Approximately 20% of patients with cirrhosis develop umbilical hernias due to increased abdominal pressure from ascites 1
• Repair is NOT contraindicated but requires careful consideration of risks and benefits 1
• Management recommendations:
  • Optimal fluid control
  • Appropriate nutrition
  • Conservative management with binders to minimize hernia progression 1
  • For transplant candidates, hernia repair should ideally be deferred until during or after transplantation 1

Pregnant Women

• Emergency repair if incarcerated/strangulated
• Elective repair if symptomatic
• Postpone repair for asymptomatic hernias until after childbirth 1

Children

• Surgical repair is recommended for all children with inguinal hernia due to substantial risk of incarceration (7% overall, 11% in preterm infants) 6
• Delaying surgery unnecessarily is not recommended due to incarceration risk 6

Postoperative Care

Monitoring

• Inpatient monitoring for at least 24 hours, focusing on:
  • Hemodynamic stability
  • Surgical site complications
  • Respiratory function 1

Pain Management

• First-line: Acetaminophen 500-1000 mg every 6 hours (maximum 4000 mg/day) 1
• Second-line: Tramadol 50-100 mg every 6-8 hours (maximum 400 mg/day) 1
• Avoid NSAIDs due to increased risk of bleeding 1

Potential Complications

• Wound infection (4-12%)
• Seroma formation (more common with mesh repair)
• Incisional/port site hernia
• Respiratory complications (atelectasis)
• Bleeding and ileus 1
• Recurrence rates: 10.6-12.3% with mesh repair vs 17.1% without mesh 1

Follow-up Care

• CT scan of abdomen and pelvis if pain persists beyond 1 month 1
• Patient education on signs of hernia strangulation requiring immediate medical attention:
  • Severe and constant pain
  • Redness or skin changes over the hernia
  • Nausea, vomiting, or inability to pass gas or stool
  • Fever or general malaise 1

Clinical Pitfalls to Avoid

1. Delaying emergency repair for strangulated hernias - Emergency repair has up to 15 times higher risk for postoperative complications than elective repairs 4
2. Underestimating parastomal hernias - These have poor outcomes with 25% risk for 30-day mortality after emergency repair 4
3. Improper mesh sizing - Insufficient overlap of mesh (less than 1.5-2.5 cm) increases recurrence risk 1
4. Ignoring comorbidities - Especially in cirrhotic patients where careful risk assessment is needed 1
5. Using NSAIDs for pain management - Increases risk of bleeding complications 1