Surgical Repair of Right Inguinal Hernia
Recommended Treatment Approach
Mesh repair is strongly recommended as the first-choice treatment for right inguinal hernia repair, using either an open Lichtenstein technique or a laparoscopic approach (TEP or TAPP), with the specific approach tailored to surgeon expertise and patient characteristics. 1
Treatment Algorithm
Initial Assessment
- Confirm diagnosis through physical examination (sufficient in most cases)
- Rarely, ultrasound, MRI, CT scan, or herniography may be needed for confirmation
- Classify hernia using EHS classification system to guide treatment approach
Surgical Approach Selection
Open Mesh Repair (Lichtenstein)
- Advantages:
- Best for:
- Patients preferring local anesthesia
- Older patients with comorbidities
- Recurrent hernias after posterior approach failure 1
Laparoscopic Repair (TEP or TAPP)
- Advantages:
- Faster recovery time
- Lower risk of chronic pain
- Cost-effective when performed as day surgery
- Allows inspection of contralateral side (during TAPP) 1
- Best for:
- Younger, active patients
- Bilateral hernias
- Recurrent hernias after anterior repair
- Female patients (reduces risk of missing femoral hernia) 1
Mesh Considerations
- Standard flat mesh is recommended for most repairs
- So-called "low-weight" mesh may offer slight short-term benefits but no long-term advantages
- Mesh fixation in TEP is generally unnecessary except in large medial (M3) hernias
- Plug repair techniques are not recommended due to higher erosion risk 1
Anesthesia Options
- Local anesthesia recommended for open repair when surgeon is experienced with this technique
- General anesthesia suggested over regional anesthesia for patients ≥65 years
- Perioperative field blocks and subfascial/subcutaneous infiltrations recommended for all open repairs 1
Recurrent Hernias Management
- After anterior repair failure: posterior approach (laparoscopic) recommended
- After posterior repair failure: anterior approach recommended
- After both approaches have failed: referral to specialist hernia surgeon 1
- Laparoscopic repair of recurrent hernias shows acceptable recurrence rates (4.7% in one study) 3
Postoperative Care
- Day surgery recommended for most patients with organized aftercare
- Patients should resume normal activities without restrictions as soon as comfortable
- Monitor for complications: wound infection (4-12%), chronic pain (10-12%), recurrence 1
Special Considerations
Chronic Postoperative Inguinal Pain (CPIP)
- Occurs in 10-12% of cases, with debilitating pain in 0.5-6% of patients
- Risk factors: young age, female gender, high preoperative pain, early high postoperative pain
- Prevention: nerve recognition in open surgery and selective prophylactic pragmatic nerve resection
- Management: multi-disciplinary approach combining pharmacological and interventional measures 1
Surgical Expertise
- Learning curve for laparoscopic repair requires approximately 100 supervised procedures
- Surgeon case load may be more important than center volume
- Certification as expert hernia surgeon recommended 1
Common Pitfalls to Avoid
- Selecting surgical approach based solely on surgeon preference rather than patient factors
- Underestimating the risk of chronic pain (occurs in 10-12% of patients)
- Inadequate mesh fixation in large medial hernias, increasing recurrence risk
- Unnecessary mesh fixation in TEP for small or lateral hernias
- Using plug repair techniques (higher erosion risk)
- Restricting patient activities unnecessarily during recovery 1
The evidence strongly supports mesh-based repair as the gold standard for inguinal hernia treatment, with both open and laparoscopic approaches showing good outcomes when performed by experienced surgeons. The choice between techniques should consider surgeon expertise, patient characteristics, and available resources.