What is the treatment for an inguinal (idil) hernia?

Treatment for Inguinal Hernia

Surgical repair is the definitive treatment for inguinal hernias, with mesh repair being the recommended standard approach for non-complicated inguinal hernias. 1, 2

Assessment and Classification

• Determine if the hernia is reducible or incarcerated/strangulated, which guides the urgency and approach of surgical intervention 2
• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, lactate levels, and D-dimer levels can help predict bowel strangulation in complicated cases 1
• Delayed diagnosis (>24 hours) is associated with significantly higher mortality rates in patients with strangulated inguinal hernias 2

Treatment Algorithm

Non-complicated Inguinal Hernias

• Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias 1, 2
• Two main surgical approaches:
  • Open repair (Lichtenstein technique is most common) 1
  • Laparoscopic repair - either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approaches 1, 2
• Laparoscopic benefits include:
  • Reduced postoperative pain medication requirements 2
  • Lower wound infection rates 2
  • Faster return to normal activities 3
  • Ability to visualize the contralateral side to identify occult hernias 1
  • Particularly beneficial for bilateral hernias 1

Complicated Hernias (Incarcerated/Strangulated)

• Emergency surgical repair is mandatory for strangulated hernias to prevent intestinal ischemia and increased morbidity/mortality 1, 2
• For clean surgical fields (no strangulation): prosthetic mesh repair is recommended 1
• For clean-contaminated fields: 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
• For small defects (<3 cm) with bowel necrosis or peritonitis: primary repair is recommended 1
• When direct suture is not feasible, a biological mesh may be used 1

Special Techniques and Considerations

• Hernioscopy (laparoscopy through hernia sac) can be used to evaluate bowel viability, avoiding unnecessary laparotomy 1, 2
• Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene 2
• General anesthesia is suggested over regional anesthesia in patients aged 65 and older as it might be associated with fewer complications 4
• Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair 4

Postoperative Care

• Patients should resume normal activities without restrictions as soon as they feel comfortable 4
• Monitor for potential complications including:
  • Wound infection 2
  • Chronic pain (occurs in 10-12% of cases) 4
  • Recurrence (significantly lower with mesh repair) 4
  • Testicular complications in males 1

Common Pitfalls to Avoid

• Delaying repair of strangulated hernias can lead to bowel necrosis and increased morbidity/mortality 2, 5
• Overlooking occult inguinal hernias - these are symptomatic hernias without a visible bulge that can cause significant pain and may lead to increased opioid use if left untreated 6
• Ignoring femoral hernias, which have a higher risk of incarceration/strangulation, especially in women 4

Special Populations

• Women with groin hernias should undergo laparoscopic repair when expertise is available to decrease chronic pain risk and avoid missing femoral hernias 4
• For recurrent hernias, the approach should be different from the initial repair (posterior approach after anterior repair and vice versa) 4