Management of Left Inguinal Hernia
Surgical Repair is the Definitive Treatment
All inguinal hernias, including left-sided hernias, should undergo surgical repair with mesh as the standard approach to prevent incarceration, bowel necrosis, and gonadal infarction while minimizing recurrence rates. 1, 2
Initial Assessment and Urgency Determination
Classify the Hernia Presentation
- Reducible hernia: Elective repair can be scheduled, though watchful waiting may be considered only in asymptomatic or minimally symptomatic adult males after thorough discussion of risks 3, 4
- Incarcerated hernia: Urgent surgical intervention is required 2
- Strangulated hernia: Emergency repair is mandatory immediately to prevent bowel necrosis and mortality 1, 2
Predictors of Strangulation
- Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, elevated lactate, serum creatinine phosphokinase (CPK), and D-dimer levels predict bowel strangulation 1
- Delayed diagnosis beyond 24 hours significantly increases mortality 1
Surgical Approach Selection
For Non-Complicated (Reducible) Hernias
Mesh repair is strongly recommended over tissue repair due to significantly lower recurrence rates. 1, 5, 4
Choose Between Open and Laparoscopic Approaches:
Laparoscopic repair (TEP or TAPP) is preferred when expertise is available due to:
- Reduced postoperative pain and lower analgesic requirements 1, 2
- Lower wound infection rates 1, 2
- Faster return to normal activities 2, 5
- Ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 5
- Comparable recurrence rates to open repair 6
Open Lichtenstein repair remains an excellent option when:
- Laparoscopic expertise is unavailable 7, 4
- Patient has significant comorbidities limiting general anesthesia tolerance 1
- Local anesthesia is preferred (can be performed under local anesthesia) 1, 5
For Emergency/Complicated Hernias
Incarcerated Without Strangulation (Clean Field - CDC Class I):
- Prosthetic repair with synthetic mesh is recommended 8, 1
- Laparoscopic approach is appropriate if no suspicion of bowel necrosis 1
Strangulated With Bowel Resection (Clean-Contaminated - CDC Class II):
- Emergent prosthetic repair with synthetic mesh can still be performed even with intestinal strangulation and/or bowel resection without gross enteric spillage 8, 1
- This approach shows significantly lower recurrence rates regardless of defect size 1
- Open preperitoneal approach is preferable when strangulation is suspected 1
Bowel Necrosis/Peritonitis (Contaminated/Dirty - CDC Class III/IV):
- For small defects (<3 cm): Primary tissue repair is recommended 8, 1
- For larger defects when direct suture not feasible: Biological mesh may be used, with choice between cross-linked and non-cross-linked depending on defect size and contamination degree 8, 1
- If biological mesh unavailable: Polyglactin mesh repair or open wound management with delayed repair are alternatives 8, 1
Special Techniques and Considerations
Hernioscopy (Laparoscopy Through Hernia Sac)
- Can evaluate bowel viability after spontaneous reduction of strangulated hernias, avoiding unnecessary laparotomy 1, 2
- Shows decreased hospital stay and fewer complications compared to non-laparoscopic approaches 1
Anesthesia Selection
- Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 8, 1, 5
- General anesthesia is required when bowel gangrene is suspected or peritonitis is present 1
- General anesthesia may be preferred over regional in patients aged ≥65 years to reduce risk of myocardial infarction, pneumonia, and thromboembolism 4
Mesh Considerations
- Mesh fixation in TEP is unnecessary in most cases 4
- Fix mesh in large medial hernias (M3) in both TEP and TAPP to reduce recurrence 4
- Avoid plug repair techniques due to higher erosion incidence 4
Special Populations
Pediatric Patients (Infants)
- All inguinal hernias in infants should be repaired to avoid incarceration and gonadal infarction 8
- Left-sided hernias are less common than right-sided (60% occur on right) due to earlier involution of left processus vaginalis 8
- Timing considerations: Balance risk of incarceration against operative/anesthetic complications, particularly postoperative apnea in preterm infants 8
- Former preterm infants <46 weeks corrected gestational age should be observed ≥12 hours postoperatively 8
Women
- Laparoscopic repair is suggested for women to decrease chronic pain risk and avoid missing femoral hernias 4
- Pregnant women: Watchful waiting is suggested as groin swelling often represents self-limited round ligament varicosities 4
Postoperative Management
Activity Restrictions
- Patients should resume normal activities without restrictions as soon as comfortable 4
Antimicrobial Prophylaxis
- Not recommended for average-risk patients in low-risk environments for open surgery 4
- Never recommended for laparoscopic repair 4
- 48-hour prophylaxis for intestinal strangulation and/or concurrent bowel resection (CDC classes II-III) 1
- Full antimicrobial therapy for peritonitis (CDC class IV) 1
Monitor for Complications
- Wound infection 8, 2
- Chronic pain (occurs in 10-12% of patients, with debilitating pain affecting daily activities in 0.5-6%) 7, 4
- Recurrence (1-3% with mesh repair) 8
- Testicular atrophy, vas deferens injury (1-8% in infants) 8
Critical Pitfalls to Avoid
Never Delay Repair of Strangulated Hernias
- Delaying repair leads to bowel necrosis, increased morbidity, and significantly higher mortality 1, 2
- Risk factors for requiring bowel resection include lack of health insurance, obvious peritonitis, and femoral hernia 1
Don't Overlook Contralateral Hernias
- During TAPP, inspect the contralateral side after patient consent (occult hernias present in 11.2-50% of cases) 1, 5
- Not suggested during unilateral TEP repair 4