To whom should I refer a patient for an inguinal hernia repair?

Referral for Inguinal Hernia Repair

Patients with inguinal hernias should be referred to a general surgeon for repair, with the specific surgical approach determined based on hernia characteristics and patient factors. 1, 2

Types of Surgeons for Inguinal Hernia Repair

• General surgeons are the primary specialists who perform inguinal hernia repairs 1, 3
• For complex cases (recurrent hernias, bilateral hernias, or complicated presentations), referral to surgeons with advanced laparoscopic skills may be beneficial 4

Surgical Approach Considerations

Open vs. Laparoscopic Repair

• Mesh repair is the standard approach for non-complicated inguinal hernias due to lower recurrence rates compared to tissue repair 1, 2
• Laparoscopic approaches (transabdominal preperitoneal [TAPP] or totally extraperitoneal [TEP]) offer advantages including:
  • Reduced postoperative pain 5
  • Lower wound infection rates 2
  • Faster return to normal activities 5
  • Ability to assess the contralateral side for occult hernias 1, 5

Emergency Repair Considerations

• For incarcerated/strangulated hernias, immediate surgical referral is mandatory to prevent intestinal ischemia 6, 1
• Local anesthesia can be used for emergency inguinal hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 6

Special Patient Populations

Elderly Patients

• Referral decisions for older adults (≥65 years) should consider:
  • Increased surgical risk in the elderly population 7
  • Watchful waiting may be appropriate for minimally symptomatic hernias in high-risk elderly patients 7

Patients with Comorbidities

• Patients with significant comorbidities may benefit from open repair under local anesthesia 1, 2
• For unstable patients with severe sepsis or septic shock, referral to surgeons experienced with open management techniques is recommended 1

Common Pitfalls to Avoid

• Delaying referral for strangulated hernias can lead to bowel necrosis and increased morbidity/mortality 1, 2
• Failing to recognize the need for emergency referral when intestinal strangulation is suspected 6, 1
• Not considering laparoscopic approaches for bilateral or recurrent hernias, which may offer advantages in these specific scenarios 4

Referral Timing

• Symptomatic hernias should be referred for elective repair to prevent complications 3
• Emergency referral is necessary for suspected strangulation (signs include severe pain, irreducibility, systemic inflammatory response) 6, 1
• Small, minimally symptomatic hernias may not require immediate surgical referral 3