What is the treatment approach for reducible vs non-reducible inguinal hernias?

Treatment Approach for Reducible vs Non-Reducible Inguinal Hernias

The treatment approach for inguinal hernias should be based on reducibility status, with immediate surgical intervention recommended for non-reducible (incarcerated) hernias with suspected intestinal strangulation, while reducible hernias can be managed with elective repair using mesh techniques. 1

Diagnostic Assessment

• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings showing reduced wall enhancement, elevated lactate, CPK, and D-dimer levels are predictive of bowel strangulation and should guide urgency of intervention 1
• High white blood cell count and fibrinogen levels are significantly predictive of complications in incarcerated hernias 1
• If there is concern about bowel viability after spontaneous reduction of a previously strangulated hernia, diagnostic laparoscopy is recommended to assess intestinal status 1, 2

Treatment Algorithm Based on Reducibility

Reducible Inguinal Hernias

• Elective surgical repair is recommended using mesh techniques 3
• Mesh repair is associated with significantly lower recurrence rates compared to tissue repair without increasing wound infection risk 3, 2
• The Lichtenstein technique is considered the standard in open inguinal hernia repair 2
• Laparoscopic approaches (TEP or TAPP) are viable alternatives with benefits of minimal invasiveness 2

Non-Reducible (Incarcerated) Inguinal Hernias

• Immediate surgical intervention is required when intestinal strangulation is suspected 1
• Early intervention (within 6 hours from symptom onset) is associated with a lower incidence of bowel resection 4
• Treatment approach depends on the CDC wound classification:

Clean Surgical Field (CDC Class I - Incarceration without strangulation)

• Prosthetic repair with synthetic mesh is recommended 1
• Laparoscopic approach may be considered with benefits including:
  • Lower wound infection rates 1
  • Shorter hospital stay 1
  • Ability to assess bowel viability throughout the procedure 2
  • Opportunity to repair occult contralateral hernias (present in 11.2-50% of cases) 1

Clean-Contaminated Field (CDC Class II - Strangulation without gross spillage)

• Emergent prosthetic repair with synthetic mesh is still recommended 1
• Associated with significantly lower risk of recurrence regardless of defect size 1
• No increase in 30-day wound-related morbidity compared to non-mesh repair 1

Contaminated/Dirty Field (CDC Class III/IV - Bowel necrosis or perforation)

• For small defects (<3 cm), primary tissue repair is recommended 1
• When direct suture is not feasible, a biological mesh may be used 1
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1
• For unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 1

Special Techniques and Considerations

• Hernioscopy (a mixed laparoscopic-open technique) is effective for evaluating viability of the herniated loop in incarcerated hernias 1

  • Can be performed by surgeons with less advanced laparoscopic skills 2
  • Associated with decreased morbidity in high-risk patients 1
  • Helps prevent unnecessary laparotomy 1

• When definitive fascial closure cannot be achieved in complex cases, a skin-only closure is a viable option with subsequent eventration managed later 1

• Component separation technique may be useful for large defects 1

Antimicrobial Prophylaxis

• For intestinal incarceration without ischemia (CDC Class I): short-term prophylaxis is recommended 1
• For intestinal strangulation and/or concurrent bowel resection (CDC Classes II and III): 48-hour antimicrobial prophylaxis is recommended 1
• For peritonitis (CDC Class IV): full antimicrobial therapy is recommended 1

Anesthesia Considerations

• Local anesthesia can be used for emergency inguinal hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 1
• General anesthesia should be preferred when bowel gangrene is suspected, intestinal resection is needed, or in cases of peritonitis 1