Management of Inguinal Hernias
Surgical repair is the definitive treatment for inguinal hernias, with mesh repair being the recommended standard approach for all non-complicated inguinal hernias due to lower recurrence rates compared to tissue repair. 1
Initial Assessment and Management Decision
- Determine if the hernia is reducible or incarcerated/strangulated, which guides the urgency and approach of surgical intervention 1
- For asymptomatic or minimally symptomatic hernias, watchful waiting may be considered, though long-term follow-up shows high rates of eventual surgery due to symptom development 2, 3
- Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected to prevent bowel necrosis and increased morbidity/mortality 4, 1
- Early intervention (<6 hours from symptom onset) is associated with a significantly lower incidence of bowel resection 5
Surgical Approach for Non-complicated Hernias
- Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias 1
- Three main surgical options are available:
- Laparoscopic approaches offer several advantages:
- Reduced postoperative pain medication requirements 1
- Lower wound infection rates 1
- Ability to visualize the contralateral side to identify occult hernias (present in 11.2-50% of cases) 1
- Faster return to normal activities, though at higher cost and requiring general anesthesia 7
- Decreased recurrence rates (OR, 0.75) and shorter hospital length of stay compared to open repairs 5
Management of Complicated Hernias (Incarcerated/Strangulated)
- Emergency surgical repair is mandatory for strangulated hernias to prevent intestinal ischemia 4, 1
- Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 4
- Delayed diagnosis (>24 hours) is associated with higher mortality rates 4
- Surgical options for complicated hernias:
- Prosthetic repair with synthetic mesh is recommended for intestinal incarceration without signs of strangulation or need for bowel resection 1
- Mesh repair can be performed even with intestinal strangulation and/or concomitant bowel resection without gross enteric spillage 1, 5
- For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair is recommended 1
- When direct suture is not feasible, 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
- The Shouldice method is regarded as the best non-mesh repair technique when mesh cannot be used 6
Special Techniques and Considerations
- Hernioscopy (laparoscopy through hernia sac) can be used to evaluate bowel viability, avoiding unnecessary laparotomy 1, 6
- Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene 1
- For unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 1
- Risk factors for bowel resection include lack of health insurance, obvious peritonitis, and femoral hernia 4
Postoperative Care and Complications
- Monitor for potential complications including:
- Antimicrobial prophylaxis is recommended:
Common Pitfalls to Avoid
- Delaying repair of strangulated hernias can lead to bowel necrosis and increased morbidity/mortality 4, 1
- Overlooking contralateral hernias, which can be avoided by considering a laparoscopic approach 1
- Underestimating the risk of chronic postoperative pain, which should be discussed with patients preoperatively 2