What is the recommended approach for hernioplasty?

Recommended Approach for Hernioplasty

Mesh repair is the recommended approach for hernioplasty as it significantly reduces recurrence rates compared to non-mesh techniques, with synthetic mesh being appropriate for clean and clean-contaminated surgical fields. 1, 2

Mesh Selection Based on Surgical Field Classification

Clean Surgical Field (CDC Class I)

• Prosthetic repair with synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 2
• Mesh repair significantly reduces recurrence rates compared to tissue repair without increasing wound infection rates 3
• Synthetic mesh should be used even for small defects, as this provides superior long-term outcomes 1, 4

Clean-Contaminated Surgical Field (CDC Class II)

• For patients with intestinal strangulation and/or bowel resection without gross enteric spillage, synthetic mesh can still be safely used 2
• No significant increase in 30-day wound-related morbidity has been observed with mesh use in these cases 1
• Mesh repair is associated with a significantly lower risk of recurrence regardless of hernia defect size 2

Contaminated/Dirty Surgical Field (CDC Classes III and IV)

• For small defects (<3 cm) with bowel necrosis and/or gross enteric spillage, primary repair without mesh is recommended 2, 1
• For larger defects (≥3 cm), biological mesh is the preferred option when available 2, 1
• If biological mesh is unavailable, polyglactin mesh or open wound management with delayed repair may be viable alternatives 2, 1
• The choice between cross-linked and non-cross-linked biological mesh should depend on defect size and degree of contamination 2

Surgical Approaches

Open Mesh Repair

• Traditional open mesh repair (hernioplasty) is effective with low recurrence rates (3%) 5
• Advantages include familiarity, lower cost, and applicability to most patient populations 3
• May be associated with longer recovery time compared to laparoscopic approaches 5, 3

Laparoscopic Mesh Repair

• Laparoscopic approaches include Transabdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) repairs 4, 5
• Advantages include:
  • Lower wound infection rates compared to open repair 2, 5
  • Shorter hospital stays (approximately 0.6 days shorter) 3
  • Quicker return to normal activities (approximately 2.87 days sooner) 5, 3
  • Ability to evaluate hernia content viability and repair occult contralateral hernias 2
• Particularly beneficial for bilateral and recurrent hernias 6
• Operating time may be longer initially but decreases with surgeon experience 5

Special Considerations

Age-Related Factors

• In young adults (18-25 years), herniotomy (repair without mesh) may be considered as an alternative with recurrence rates as low as 0% 7
• For patients over 30 years, mesh repair is strongly recommended due to increasing recurrence rates with non-mesh techniques 3, 7

Complex Hernias

• Laparoscopic approaches are particularly valuable for diagnosing and repairing complex hernias 8
• 14% of primary and 27% of recurrent hernias have complex elements that may be better visualized laparoscopically 8

Complications and Outcomes

Mesh-Related Complications

• Seromas occur more frequently with mesh repair (RR 1.63) 3
• Wound swelling is more common with mesh repair 3
• Testicular complications show nearly equivocal results between mesh and non-mesh approaches 3

Non-Mesh Related Complications

• Neurovascular and visceral injuries are more common in non-mesh repairs 3
• Mesh repair reduces the risk of postoperative urinary retention 3
• High infection rates (up to 21%) have been reported after emergency hernia repairs with polypropylene mesh in contaminated fields 2

Practical Algorithm for Hernioplasty Approach

1. Assess surgical field classification:

   • Clean/Clean-contaminated → Use synthetic mesh 2, 1
   • Contaminated/Dirty → Assess defect size 2, 1
     • <3 cm → Primary repair 2, 1
     • ≥3 cm → Biological mesh (if available) or alternatives 2, 1

2. Consider patient factors:

   • Age <25 years → Consider herniotomy as an option 7
   • Age >30 years → Strongly prefer mesh repair 3, 7
   • Bilateral/recurrent hernias → Consider laparoscopic approach 6, 8

3. Select surgical technique based on surgeon experience and available resources:

   • Open mesh repair → Standard approach with good outcomes 5, 3
   • Laparoscopic repair → Faster recovery, better visualization 2, 5, 8