What is the initial approach to managing an inguinal hernia?

Initial Management of Inguinal Hernia

The initial approach to managing an inguinal hernia should be determined by whether the hernia is reducible (asymptomatic/minimally symptomatic) or incarcerated/strangulated, with surgical repair being the definitive treatment in most cases. 1

Assessment and Classification

• Determine if the hernia is reducible or incarcerated/strangulated, as this guides the urgency of intervention 1
• Evaluate for signs of strangulation including systemic inflammatory response syndrome (SIRS), elevated lactate, serum creatinine phosphokinase (CPK), and D-dimer levels 1
• Contrast-enhanced CT may help predict bowel strangulation in uncertain cases 1

Management Algorithm

For Asymptomatic or Minimally Symptomatic Reducible Hernias:

• Watchful waiting is an acceptable initial approach for truly asymptomatic or minimally symptomatic inguinal hernias 2
• Be aware that 35-58% of patients managed with watchful waiting will eventually require surgery due to developing symptoms 2
• The risk of strangulation in watchful waiting is relatively low (0.27% at 2 years, 0.55% at 4 years) 3
• Patients should be counseled about warning signs requiring urgent evaluation (increasing pain, irreducibility) 1

For Symptomatic Reducible Hernias:

• Elective surgical repair is recommended using mesh techniques 1
• Options include:
  • Open anterior approach (Lichtenstein repair) - most commonly used 4
  • Laparoscopic approaches (TAPP or TEP) - particularly beneficial for bilateral hernias 1
• Local anesthesia can be used for open repairs, offering economic advantages in day-case settings 5

For Incarcerated/Strangulated Hernias:

• Emergency surgical intervention is mandatory when intestinal strangulation is suspected 1
• Early intervention (<6 hours from symptom onset) is associated with lower incidence of bowel resection 6
• In the absence of bowel gangrene, local anesthesia can be used to decrease the risk of aerosol spreading in emergency settings 7
• Hernioscopy (laparoscopy through hernia sac) can be used to evaluate bowel viability and avoid unnecessary laparotomy 1

Surgical Approach Selection

• Mesh repair is strongly recommended for non-complicated inguinal hernias due to lower recurrence rates 1
• For clean surgical fields (CDC wound class I): Prosthetic repair with synthetic mesh is recommended 1
• For clean-contaminated fields (CDC wound class II): Emergent prosthetic repair with synthetic mesh can still 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

Laparoscopic vs. Open Approach:

• Laparoscopic repairs (TAPP/TEP) offer advantages including:
  • Reduced postoperative pain medication requirements 1
  • Lower wound infection rates 1
  • Ability to visualize the contralateral side to identify occult hernias (present in 11.2-50% of cases) 1
  • Shorter hospital length of stay compared to open repairs 6
  • Lower recurrence rates (OR 0.75) 6
• TAPP approach allows better assessment of bowel viability in emergency settings 8
• Open repair may be preferred in patients with significant comorbidities 1

Common Pitfalls to Avoid

• Delaying repair of strangulated hernias can lead to bowel necrosis and increased morbidity/mortality 1
• Delayed diagnosis (>24 hours) is associated with significantly higher mortality rates in patients with strangulated inguinal hernias 1
• Overlooking contralateral hernias, which can be avoided by considering a laparoscopic approach 1
• Underestimating the risk of chronic postoperative pain, which should be discussed during preoperative counseling 2