What is the management approach for a patient presenting with a hernia?

Management of Hernias

The management of hernias should be primarily surgical, with elective repair recommended for symptomatic hernias to avoid the significantly higher morbidity associated with emergency repairs. 1, 2

Types of Hernias and Diagnosis

• Common types:

  • Inguinal (most common)
  • Femoral
  • Umbilical/Paraumbilical
  • Incisional
  • Parastomal
  • Diaphragmatic/Hiatal

• Diagnostic approach:

  • Physical examination is the primary diagnostic method 3
  • Imaging may include:
    • CT scan with oral contrast (gold standard for complex cases) 1
    • Chest radiography (first-line for suspected diaphragmatic hernias) 3
    • Ultrasound (useful for pregnant patients or pediatric cases) 1

Management Algorithm

1. Emergency Presentation

For patients with signs of strangulation, incarceration, or obstruction:

• Immediate surgical intervention is required to prevent life-threatening complications 2

• Signs requiring emergency surgery:

  • Severe pain
  • Irreducible hernia
  • Signs of bowel obstruction
  • Systemic symptoms (fever, tachycardia)
  • Skin changes over hernia (erythema, necrosis)

• Surgical approach:

  • Laparoscopic or open repair based on patient condition and surgeon expertise
  • May require bowel resection if ischemic/necrotic tissue is present 2

2. Elective Management

For reducible, non-emergency hernias:

• Surgical repair is recommended for most symptomatic hernias 2

• Conservative management is generally inappropriate and associated with increased risk of emergency presentation 2

• Surgical options based on hernia type:

  Inguinal/Femoral hernias:

  • Mesh repair is standard of care
  • Local anesthesia can be used in elderly/high-risk patients 2

  Parastomal hernias:

  • Small, reducible hernias: hernia belt may be used 1
  • Elective repair for significant pouching issues, pain, or recurrent bowel obstruction
  • Mesh repair often required to reduce recurrence risk 1

  Diaphragmatic/Hiatal hernias:

  • Laparoscopic fundoplication with hiatal hernia repair is standard 3
  • Nissen fundoplication (360° wrap) most common
  • Toupet fundoplication (270° posterior wrap) may have lower recurrence rates 3

3. Complex Hernias

For hernias with complicating factors:

• Complex hernia criteria include factors related to 4:

  • Size and location
  • Contamination/soft tissue condition
  • Patient history/risk factors
  • Clinical scenario

• Management principles:

  • Mesh reinforcement for defects that cannot be closed with direct suture 3
  • Biosynthetic, biologic, or composite meshes preferred for lower recurrence rates 3
  • Multidisciplinary approach for complex cases

Post-operative Care and Follow-up

• Monitor for complications:

  • Recurrence (3-5% of cases) 3
  • Surgical site infection
  • Chronic pain
  • Mesh-related complications

• Recurrence classification 5:

  • Grade 0: No recurrence
  • Grade I: Asymptomatic recurrence
  • Grade II: Symptomatic recurrence requiring elective or no repair
  • Grade III: Symptomatic recurrence requiring urgent repair
  • Grade IV: Life-threatening complications related to recurrence
  • Grade V: Death related to hernia recurrence

Special Considerations

Parastomal Hernias

• Occur in up to 50% of ostomates within 5 years 1
• Risk factors: obesity, smoking, steroid use, transverse colostomies 1
• Prevention: place stoma through rectus muscle 1
• Most effective repair is ostomy reversal when possible 1
• Recurrence after repair is common (>25% at 2 years) 1

Hiatal Hernias

• Laparoscopic revisional surgery for recurrent hiatal hernias is safe and effective 6
• Proton pump inhibitor therapy should be continued after repair in patients with Barrett's esophagus 3
• Surveillance intervals for Barrett's esophagus: every 3-5 years for non-dysplastic cases 3

Pitfalls and Caveats

• Avoid conservative management for symptomatic hernias as this is a key contributing factor in delayed treatment and increased morbidity 2
• Emergency hernia repair carries significantly higher complication rates, longer hospital stays, and increased risk of bowel resection compared to elective repair 2
• Inadequate mesh fixation can lead to mesh migration and recurrence 3
• Missed diagnosis of short esophagus in hiatal hernias may require additional procedures like Collis gastroplasty 3
• Moving the stoma when repairing parastomal hernias has fallen out of favor due to high risk of hernia at the new location 1