What is the recommended treatment for a hernia?

Treatment of Hernias

Immediate Management Based on Clinical Presentation

For uncomplicated hernias in stable patients, mesh repair using either open (Lichtenstein) or laparoscopic approach is the recommended treatment, while patients with suspected intestinal strangulation require immediate emergency surgical intervention. 1, 2

Emergency vs. Elective Repair Decision Algorithm

Immediate surgical intervention is mandatory when:

• Intestinal strangulation is suspected based on clinical examination 1, 2
• Systemic inflammatory response syndrome (SIRS) is present 1, 2
• Elevated lactate, serum creatinine phosphokinase (CPK), or D-dimer levels suggest bowel compromise 1, 2
• Symptoms of incarceration with obstruction (severe pain, nausea, vomiting, inability to reduce) 1

Delayed diagnosis beyond 24 hours significantly increases mortality rates in complicated hernias, making early detection critical. 1, 2

Surgical Approach Selection

For stable patients with uncomplicated hernias:

• Laparoscopic repair is preferred when expertise and resources are available, offering faster recovery and lower chronic pain risk 2, 3
• Open mesh repair (Lichtenstein technique) remains highly effective and is recommended when laparoscopic expertise is unavailable 3
• Both anterior and posterior approach options should be available within surgical services 3

For unstable patients or confirmed strangulation:

• Open laparotomy approach is mandatory to allow rapid assessment and management of compromised bowel 2
• Damage control surgery principles apply in critically unstable patients 1

Mesh Selection and Placement Strategy

Mesh reinforcement is strongly recommended for all defects larger than 3 cm due to recurrence rates up to 42% with primary repair alone. 2

Mesh Type Based on Surgical Field Contamination

Clean fields (CDC Class I):

• Synthetic mesh is the standard recommendation 2, 4
• Provides lowest recurrence rates without increased infection risk 4

Clean-contaminated fields (CDC Class II):

• Synthetic mesh can still be used safely 4

Contaminated or dirty fields (CDC Class III-IV):

• Biological or biosynthetic meshes are preferred due to superior infection resistance 1, 2, 4
• For small defects (<3 cm), primary tissue repair without mesh is recommended 4

Technical specifications:

• Mesh should overlap defect edges by 1.5-2.5 cm for defects larger than 8 cm or area >20 cm² 2
• In laparoscopic TEP repair, mesh fixation is unnecessary in most cases 3
• Mesh fixation is recommended in large medial hernias (M3) during both TEP and TAPP to reduce recurrence 3
• Avoid tackers near the pericardium due to cardiac complication risk 1, 2

Primary Repair Technique

Primary repair with non-absorbable sutures should be attempted when defects can be closed without tension. 1, 2

• The Shouldice technique is the first-choice tissue repair method when mesh cannot be used 3
• This approach requires patient counseling about higher recurrence rates compared to mesh repair 3

Specific Hernia Type Considerations

Femoral Hernias

Timely mesh repair by laparoscopic approach is recommended when expertise is available, as femoral hernias carry higher strangulation risk. 2, 3

Spigelian Hernias

Prosthetic repair is the treatment of choice, with laparoscopic approach preferred in stable patients without strangulation. 4

Hiatal/Paraesophageal Hernias

Surgery is recommended for complicated non-traumatic diaphragmatic hernias, with approach selection based on patient stability. 1

• Unstable patients require laparotomy 1
• Stable patients can undergo minimally invasive repair 1
• Primary repair with non-absorbable sutures should be attempted when possible 1

Anesthesia Selection

Local anesthesia is recommended for open inguinal hernia repair when surgeon expertise exists, offering multiple advantages. 3

• General anesthesia is suggested over regional for patients ≥65 years old due to lower risk of myocardial infarction, pneumonia, and thromboembolism 3
• Perioperative field blocks and subfascial/subcutaneous infiltrations are recommended in all open repairs 3

Antibiotic Prophylaxis

Antibiotic prophylaxis is NOT recommended for average-risk patients in open surgery in low-risk environments. 3

• Never recommended in laparoscopic repair 3
• Short-term prophylaxis recommended for intestinal incarceration without ischemia 4
• 48-hour prophylaxis for intestinal strangulation and/or concurrent bowel resection 4
• Full antimicrobial therapy for patients with peritonitis 4

Management of Recurrent Hernias

After failed anterior repair, posterior repair is recommended; after failed posterior repair, anterior repair is recommended. 3

• After both approaches fail, referral to a specialist hernia surgeon is mandatory 3

Special Population Considerations

Female Patients

Women with groin hernias should undergo laparoscopic repair when expertise is available to decrease chronic pain risk and avoid missing femoral hernias. 2

Pregnant Patients

Watchful waiting is recommended during pregnancy as groin swelling often represents self-limited round ligament varicosities. 2

• Ultrasound is the first-line imaging modality in pregnant patients 2

Critical Pitfalls to Avoid

• Never delay surgery beyond 24 hours when strangulation is suspected - mortality increases significantly with delayed intervention 1, 2
• Do not use plug repair techniques - higher erosion rates compared to flat mesh 3
• Avoid mesh fixation with tackers near the pericardium - risk of cardiac complications 1, 2
• Do not assume all hernias are equal - complex hernias require individualized surgical planning based on defect size, contamination, and patient factors 5

Postoperative Management

Patients are recommended to resume normal activities without restrictions as soon as comfortable. 3

• Day surgery is appropriate for the majority of groin hernia repairs when aftercare is organized 3