What is the treatment for an inguinal hernia?

Management of Inguinal Hernia

Surgical repair with mesh is the definitive treatment for inguinal hernias, with emergency intervention required immediately when intestinal strangulation is suspected. 1, 2

Assessment and Classification

• Determine if the hernia is reducible or incarcerated/strangulated, which guides the urgency and approach of surgical intervention 2, 3
• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1
• The European Hernia Society classification system is recommended to stratify patients for tailored treatment, research, and audit 3, 4

Treatment Algorithm

Emergency Repair (Strangulated/Incarcerated Hernias)

• Immediate surgical intervention is mandatory when intestinal strangulation is suspected to prevent bowel necrosis 1, 2
• Delayed diagnosis (>24 hours) is associated with significantly higher mortality rates 1, 2
• Risk factors for bowel resection include lack of health insurance, obvious peritonitis, and femoral hernia 1
• Hernioscopy (laparoscopy through hernia sac) can be used to evaluate bowel viability, avoiding unnecessary laparotomy 1, 3

Non-Emergency Repair

• Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias 3, 4
• Two main approaches are available:
  • Open mesh repair (Lichtenstein technique is the standard) 3, 4
  • Laparoscopic approaches (TAPP or TEP), which offer advantages including reduced postoperative pain and faster return to normal activities 2, 3

Surgical Field Classification and Mesh Use

• Clean surgical field (CDC wound class I): Prosthetic repair with synthetic mesh is recommended for patients with intestinal incarceration but no signs of strangulation or concurrent bowel resection 1, 3
• Clean-contaminated field (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 1, 3
• Contaminated/dirty field: For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair is recommended; when direct suture is not feasible, biological mesh may be used 3

Special Considerations

• Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene 2, 3
• General anesthesia is suggested over regional anesthesia in patients aged 65 and older as it might be associated with fewer complications 4
• For women with groin hernias, laparoscopic repair is suggested to decrease chronic pain risk and avoid missing a femoral hernia 4
• Femoral hernias should be repaired with a laparoscopic approach when expertise is available, due to higher risk of strangulation 2, 4

Postoperative Care

• Patients should resume normal activities without restrictions as soon as they feel comfortable 4
• Monitor for potential complications including wound infection, chronic pain (occurs in 10-12% of cases), and recurrence 3, 4
• Antimicrobial prophylaxis is recommended for 48 hours in cases of intestinal strangulation and/or concurrent bowel resection 2, 3

Management of Recurrent Hernias

• For recurrent hernia after anterior repair, posterior repair is recommended 4
• If recurrence occurs after a posterior repair, an anterior repair is recommended 4
• After failed anterior and posterior approaches, management by a specialist hernia surgeon is recommended 4

Common Pitfalls to Avoid

• Delaying repair of strangulated hernias can lead to increased morbidity and mortality 1, 2
• Overlooking contralateral hernias, which can be identified with laparoscopic approaches 2, 3
• Underestimating the importance of surgical expertise - approximately 100 supervised laparoscopic repairs are needed to achieve results comparable to open mesh surgery 4