What is the recommended surgical technique for inguinal hernia repair?

Recommended Surgical Technique for Inguinal Hernia Repair

For most inguinal hernia repairs, mesh-based repair techniques are strongly recommended over tissue repair due to significantly lower recurrence rates, less postoperative pain, and faster recovery.1, 2

Preferred Techniques Based on Clinical Scenario

For Uncomplicated Inguinal Hernias (Clean Surgical Field)

• Prosthetic repair using synthetic mesh is the gold standard and first choice for uncomplicated inguinal hernias 3
• Two main recommended approaches:
  • Open anterior approach: Lichtenstein tension-free mesh repair is simple, safe, and effective with extremely low recurrence rates (0.2%) 4, 5
  • Laparoscopic approach: Total extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repair with faster recovery times and lower chronic pain risk 3, 2

For Incarcerated Hernias Without Strangulation

• Mesh repair remains recommended with synthetic mesh 3
• Laparoscopic approach may be considered if expertise is available, showing lower wound infection rates 3, 6
• Hernioscopy (laparoscopy through hernia sac) is effective for evaluating bowel viability after spontaneous reduction 3, 6

For Strangulated Hernias With Bowel Compromise

• For clean-contaminated fields (no gross enteric spillage): Emergent prosthetic repair with synthetic mesh is still recommended 3
• For contaminated/dirty fields (bowel necrosis or enteric spillage): Primary tissue repair for small defects (<3cm) 3
• If direct suture not feasible for contaminated fields, biological mesh may be used 3, 7

Specific Technique Considerations

Open Mesh Techniques

• Lichtenstein technique: Mesh placed anterior to transversalis fascia 4, 5
  • Takes 7-10 minutes less to perform than Shouldice (tissue) procedures 1
  • Significantly lower recurrence rates compared to non-mesh repairs 1, 2
• Other emerging preperitoneal approaches:
  • Transinguinal preperitoneal (TIPP) and transrectus sheath preperitoneal (TREPP) techniques show promising results for reducing chronic pain 8

Laparoscopic Techniques

• TEP or TAPP approach places mesh in preperitoneal space 3, 2
• Benefits include shorter hospital stay, quicker return to usual activities, and lower chronic pain risk 6, 2
• During TAPP, contralateral side should be inspected after patient consent 2
• Mesh fixation generally unnecessary in TEP except for large medial (M3) hernias 2

Tissue Repair Techniques

• Shouldice technique is the preferred tissue repair when mesh cannot be used 2
• However, tissue repairs have higher recurrence rates and longer recovery times 5, 1

Special Considerations

Mesh Selection and Fixation

• Surgeons should be aware of intrinsic characteristics of meshes they use 2
• Low-weight mesh may provide slight short-term benefits but doesn't improve long-term outcomes 2
• Plug repair techniques are not recommended due to higher erosion rates 2
• Mesh fixation is unnecessary in most TEP repairs but recommended for large medial hernias in both TEP and TAPP 2

Anesthesia Options

• Local anesthesia for open repair has many advantages if surgeon is experienced 3, 6
• General anesthesia is suggested over regional in patients aged 65+ to reduce complications 2
• Perioperative field blocks and subfascial/subcutaneous infiltrations are recommended for all open repairs 2

Antimicrobial Prophylaxis

• Short-term prophylaxis for intestinal incarceration without ischemia 3, 6
• 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection 3, 6

Common Pitfalls and Complications

• Chronic pain occurs in 10-12% of patients, with debilitating pain in 0.5-6% 2
• Risk factors for chronic pain include young age, female gender, high preoperative pain, and open repair 2
• For recurrent hernias, use the opposite approach from the failed repair (posterior after anterior failure, anterior after posterior failure) 2
• Immediate surgical intervention is mandatory when intestinal strangulation is suspected 3, 9