What is the recommended treatment for an inguinal hernia?

Recommended Treatment for Inguinal Hernia

Surgical repair with mesh is the definitive treatment for inguinal hernias, with laparoscopic approaches (TAPP or TEP) and open Lichtenstein repair being the recommended techniques. 1

Initial Assessment and Classification

• Determine if the hernia is reducible or incarcerated/strangulated, as this guides the urgency and approach of surgical intervention 1
• Patients with suspected intestinal strangulation should undergo emergency hernia repair immediately to reduce morbidity and mortality 2
• Delayed treatment (>24 hours) is associated with higher mortality rates in complicated hernias 2

Treatment Algorithm for Uncomplicated Inguinal Hernias

• Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias due to lower recurrence rates compared to tissue repair 1, 3
• Three recommended techniques per international guidelines 3:
  • Laparoscopic Totally Extraperitoneal (TEP) repair
  • Laparoscopic Transabdominal Preperitoneal (TAPP) repair
  • Open Lichtenstein technique

Surgical Approach Selection

• Surgeons should provide both an anterior open (Lichtenstein) and a posterior laparoscopic (TEP or TAPP) approach option 3
• Laparoscopic repair offers advantages including 1:
  • Reduced postoperative pain
  • Lower wound infection rates
  • Ability to identify occult contralateral hernias (present in 11.2-50% of cases)
  • Particularly beneficial for bilateral hernias
• Local anesthesia can be used effectively for emergency inguinal hernia repair in the absence of bowel gangrene 4
• Open repair may be preferred in patients with significant comorbidities 1

Management of Complicated Inguinal Hernias

For Clean Surgical Fields (CDC Wound Class I)

• Prosthetic repair with synthetic mesh is recommended for patients with intestinal incarceration but no signs of strangulation or need for bowel resection 4
• Laparoscopy can be used to assess bowel viability in incarcerated hernias 5, 1

For Clean-Contaminated Fields (CDC Wound Class II)

• Emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or concomitant need for bowel resection without gross enteric spillage 4
• This approach is associated with a significantly lower risk of recurrence regardless of hernia defect size 4

For Contaminated/Dirty Fields (CDC Wound Classes III and IV)

• For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair is recommended 4
• When direct suture is not feasible, a biological mesh may be used 4
• The choice between cross-linked and non-cross-linked biological mesh depends on defect size and degree of contamination 4
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 4

Special Considerations

• Hernioscopy (laparoscopy through hernia sac) can be used to evaluate bowel viability, avoiding unnecessary laparotomy 4, 1
• For unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 4
• Component separation technique may be useful for large midline abdominal wall hernias 4
• Antimicrobial prophylaxis recommendations 4:
  • Short-term prophylaxis for intestinal incarceration without ischemia (CDC class I)
  • 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection (CDC classes II and III)
  • Full antimicrobial therapy for patients with peritonitis (CDC class IV)

Postoperative Monitoring

• Monitor for potential complications including wound infection, chronic pain (occurs in 10-12% of patients), recurrence (occurs in 11% of patients), and testicular complications in males 1, 3
• Early definitive fascial closure should be attempted when possible; when not feasible, progressive closure can be gradually attempted 4

Common Pitfalls to Avoid

• Delaying repair of strangulated hernias can lead to bowel necrosis and increased morbidity/mortality 1
• Overlooking contralateral hernias, which can be avoided by considering a laparoscopic approach 1
• Failure to restrict activities that increase intra-abdominal pressure in patients awaiting repair, which can lead to incarceration and strangulation 2