Treatment Options for Diagnosed Hernias
Surgical repair is strongly recommended as the definitive treatment for symptomatic hernias, with mesh repair being the first choice using either open or laparoscopic techniques. 1
Timing of Intervention
Emergency cases:
- Immediate surgical intervention is required when intestinal strangulation is suspected 2, 1
- Warning signs of strangulation include:
- Systemic inflammatory response syndrome (SIRS)
- Elevated lactate levels
- Elevated serum creatinine phosphokinase (CPK)
- Elevated D-dimer levels 2
- Delayed treatment beyond 24 hours significantly increases mortality 1
Non-emergency cases:
- For symptomatic hernias: Surgical repair is recommended 1
- For asymptomatic or minimally symptomatic inguinal hernias:
- Watchful waiting may be considered in select patients under 50 years old with ASA class 1 or 2, inguinal hernia, and duration of signs more than 3 months 3
- However, approximately one-third of patients on watchful waiting will require surgery within 3 years, and more than two-thirds within 10 years, primarily due to developing pain 4
Surgical Approach Options
Mesh repair (strongly recommended) 1
- Significantly reduces recurrence rates compared to tissue repair
- Does not increase wound infection rates in clean surgical fields
- Options include:
- Open repair (Lichtenstein technique) - well-evaluated and recommended
- Laparoscopic repair (TEP or TAPP) - recommended when expertise is available
- Advantages: faster recovery times, lower chronic pain risk, cost-effective
- Particularly beneficial for women to avoid missing femoral hernias
Tissue repair
- Shouldice technique is the preferred option when mesh cannot be used 1
- Should only be considered after appropriate discussion with patients about outcomes
Special considerations:
- For diaphragmatic hernias: primary repair with non-absorbable sutures, with mesh for defects larger than 3cm 1
- For femoral hernias: laparoscopic approach is suggested when expertise is available 1
- For recurrent hernias: use the opposite approach from the previous repair (posterior after anterior, anterior after posterior) 5
Surgical Setting and Postoperative Care
- Day surgery is recommended for most hernia repairs 1
- Patients should resume normal activities without restrictions as soon as they feel comfortable 1
- Pain management:
- Multimodal strategy combining non-opioid analgesics (NSAIDs and acetaminophen)
- Local anesthetic field blocks before incision
- Gabapentin or pregabalin for neuropathic pain components
- Opioids reserved for severe, uncontrolled pain 1
Potential Complications
- Chronic postoperative inguinal pain (CPIP) occurs in 10-12% of cases, with debilitating pain in 0.5-6% 5
- Risk factors: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, open repair
- Management should be performed by multi-disciplinary teams
- Recurrence rates are higher with tissue repair compared to mesh repair 5
- Risk of acute hernia incarceration in watchful waiting is approximately 1.8/1000 patient-years 6
Diagnostic Approach for Suspected Hernias
- For non-traumatic cases with respiratory symptoms: chest X-ray (anteroposterior and lateral) as first diagnostic study 2
- For stable trauma patients with suspected diaphragmatic hernia: CT scan with contrast enhancement 2
- For stable trauma patients with lower chest penetrating wounds: diagnostic laparoscopy 2
- For pregnant patients with suspected non-traumatic diaphragmatic hernia: ultrasonography followed by MRI 2
By following these evidence-based guidelines, clinicians can optimize outcomes for patients with diagnosed hernias, minimizing complications and improving quality of life.