What is the treatment for a small abdominal hernia?

Treatment of Small Abdominal Hernia

Surgical repair is the recommended treatment for small abdominal hernias, with prosthetic mesh repair being superior to tissue repair for reducing recurrence rates. 1

Diagnostic Assessment

• Careful evaluation should be performed to rule out complications such as strangulation, which would require immediate surgical intervention 1
• CT scanning is valuable for diagnosis, particularly when complications are suspected, with findings of reduced wall enhancement being highly predictive of bowel strangulation 1
• Elevated white blood cell count and fibrinogen levels are significant predictors of complications in incarcerated hernias 1

Treatment Algorithm Based on Hernia Status

For Uncomplicated Small Hernias:

• Prosthetic repair with synthetic mesh is recommended for clean surgical fields (CDC wound class I), as it provides lower recurrence rates without increasing infection risk 1
• Laparoscopic repair is a viable option for uncomplicated hernias, with studies showing feasibility and low complication rates 1
• Local anesthesia can be used effectively for repair, particularly for inguinal hernias, with fewer postoperative complications 1

For Complicated Hernias:

• Immediate surgical intervention is required when intestinal strangulation is suspected 1
• For clean-contaminated fields (CDC wound class II), emergent prosthetic repair with synthetic mesh is still recommended and associated with lower recurrence risk 1
• For contaminated or dirty surgical fields (CDC wound classes III and IV), primary repair is recommended for small defects (<3 cm) 1
• When primary repair isn't feasible in contaminated fields, biological mesh may be used 1

Surgical Techniques

• Mesh repairs are superior to non-mesh tissue repairs for reducing recurrence 2
• The component separation technique may be useful for large midline abdominal wall hernias 1
• Diagnostic laparoscopy can be valuable to assess bowel viability after spontaneous reduction of strangulated hernias 1
• Careful mesh placement with a 5-cm overlap is important for successful outcomes in laparoscopic repair 1

Antimicrobial Considerations

• Short-term prophylactic antibiotics are recommended for intestinal incarceration without evidence of ischemia 1
• 48-hour antimicrobial prophylaxis is recommended for cases with intestinal strangulation and/or concurrent bowel resection 1
• Full antimicrobial therapy is recommended for patients with peritonitis 1

Watchful Waiting Considerations

• While watchful waiting might be considered for asymptomatic or minimally symptomatic inguinal hernias 2, this approach carries significant risks for incisional hernias
• Studies show high crossover rates from watchful waiting to surgical treatment, with increased complications including intestinal perforation and fistulas when surgery is delayed 3
• Emergency repairs due to incarceration during watchful waiting have been associated with higher mortality 3

Post-Surgical Monitoring

• Regular follow-up is essential to monitor for recurrence, particularly in the first 8 weeks when stoma size may change 1
• Parastomal hernias are common complications (up to 50% within 5 years) and may require additional intervention if they cause significant issues 1

Pitfalls to Avoid

• Delaying surgical intervention when strangulation is suspected can lead to bowel necrosis and increased mortality 1
• Inadequate mesh overlap in laparoscopic repairs increases recurrence risk 1
• Failing to recognize the high risk of complications in patients who cross over from watchful waiting to surgical treatment 3