What is the recommended surgical procedure for hernia repair and what are the key considerations for preoperative and postoperative care?

Recommended Surgical Procedures for Hernia Repair

Prosthetic mesh repair is strongly recommended as the first-choice procedure for hernia repair due to significantly lower recurrence rates compared to tissue repair, with both open and laparoscopic approaches being viable options depending on the clinical scenario. 1, 2

Surgical Approach Selection

• Laparoscopic repair (TEP or TAPP) is preferred when expertise is available, offering lower wound infection rates, shorter hospital stays, and reduced chronic pain risk compared to open procedures 1, 2
• For emergency repairs of strangulated hernias, immediate surgical intervention is mandatory to prevent bowel necrosis and increased mortality 2, 3
• For clean surgical fields (no intestinal strangulation), synthetic mesh repair is strongly recommended (grade 1A recommendation) 1
• For clean-contaminated fields (with intestinal strangulation and/or bowel resection without gross spillage), synthetic mesh can still be safely used with no increase in 30-day wound-related morbidity 1, 2

Specific Repair Techniques

• Total extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) approaches are recommended laparoscopic techniques with good outcomes 1, 4
• Lichtenstein technique is the preferred open approach with well-established long-term results 5, 4
• Hernioscopy (mixed laparoscopic-open technique) can be valuable for evaluating hernia content viability in cases of spontaneous reduction 1
• Onlay mesh technique shows lower recurrence rates (5.8%) compared to inlay technique (10.9%) when using prolen mesh 6

Mesh Selection and Fixation

• Synthetic mesh is recommended for most hernia repairs to reduce recurrence rates 1, 2
• Mesh fixation in TEP is generally unnecessary except for large medial (M3) hernias 5
• In TAPP repairs, mesh fixation is recommended for large medial hernias to reduce recurrence risk 5
• Plug repair techniques should be avoided due to higher erosion rates 5

Preoperative Considerations

• Risk factors for hernia incarceration/strangulation include female gender, femoral hernia, and history of hospitalization related to groin hernia 5
• CT scan is the gold standard for diagnosing complicated hernias, though most can be diagnosed clinically 2
• Early detection and repair is crucial as delayed treatment significantly increases mortality rates 2, 3
• Systemic inflammatory response syndrome, elevated lactate, and other biomarkers can predict bowel strangulation and should guide urgency of intervention 3

Anesthesia Selection

• Local anesthesia is recommended for open repair when expertise is available, providing effective pain control with fewer cardiac and respiratory complications 2, 7
• General anesthesia is preferred when bowel gangrene is suspected, intestinal resection is needed, or in cases of peritonitis 3, 7
• General anesthesia is suggested over regional anesthesia in patients aged 65 and older to reduce complications like myocardial infarction, pneumonia, and thromboembolism 5

Postoperative Care

• Short-term antimicrobial prophylaxis is recommended for clean surgical fields 2, 3
• 48-hour antimicrobial prophylaxis is recommended for cases with intestinal strangulation and/or concurrent bowel resection 2, 3
• Full antimicrobial therapy is recommended for patients with peritonitis 2, 3
• Patients should resume normal activities without restrictions as soon as they feel comfortable 5
• Day surgery is recommended for the majority of groin hernia repairs provided aftercare is organized 5

Management of Recurrent Hernias

• For recurrent hernia after anterior repair, posterior repair is recommended 5
• If recurrence occurs after a posterior repair, an anterior repair is recommended 5
• Laparoscopic repair of recurrent inguinal hernias shows good outcomes with acceptable recurrence rates (4.7%) 8
• After failed anterior and posterior approaches, management by a specialist hernia surgeon is recommended 5

Special Considerations

• For femoral hernias, timely mesh repair by a laparoscopic approach is suggested when expertise is available 2
• Women with groin hernias should undergo laparoscopic repair to decrease chronic pain risk and avoid missing a femoral hernia 5
• In unstable patients with severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 2, 7
• The incidence of clinically significant chronic postoperative inguinal pain is 10-12%, decreasing over time 5

Common Pitfalls and Caveats

• Delay in diagnosis and treatment significantly increases morbidity and mortality 2, 3
• Inadequate mesh size is associated with higher recurrence rates; proper mesh size is crucial 4
• Surgical inexperience is a risk factor for recurrence; approximately 100 supervised laparoscopic repairs are needed to achieve proficiency 5
• Chronic pain risk factors include young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, and open repair 5