What is the recommended treatment for an inguinal hernia?

Recommended Treatment for Inguinal Hernia

Surgical repair with mesh is the definitive treatment for inguinal hernias, with laparoscopic approaches (TEP or TAPP) preferred when expertise is available due to superior outcomes in pain, recovery, and infection rates, while open Lichtenstein repair remains excellent when laparoscopic expertise is unavailable. 1, 2

Urgency Stratification

Determine clinical presentation immediately to guide timing:

• Reducible hernia: Elective repair is appropriate, though delaying surgery offers minimal advantage as most patients ultimately require operation with poorer quality of life during the waiting period 3
• Incarcerated hernia (irreducible but viable bowel): Urgent surgical intervention required 1, 2
• Strangulated hernia (compromised bowel viability): Emergency repair mandatory to prevent bowel necrosis and mortality—delayed diagnosis beyond 24 hours significantly increases mortality 1, 2

Predictors of bowel strangulation include: SIRS criteria, contrast-enhanced CT findings, elevated lactate, serum CPK, and D-dimer levels 1, 2

Surgical Approach Selection Algorithm

For Uncomplicated/Reducible Hernias

Laparoscopic repair (TEP or TAPP) is the preferred approach when:

• Surgical expertise in laparoscopy is available 1, 2, 4
• Patient can tolerate general anesthesia 1
• Bilateral hernias are present (allows simultaneous repair) 1, 4

Advantages of laparoscopic approach:

• Significantly reduced postoperative pain and analgesic requirements 1, 5
• Lower wound infection rates (P<0.018) 1, 5
• Faster recovery: median 6 vs 10 days to normal activity, 14 vs 21 days return to work, 24 vs 36 days to athletic activities 5
• Lower recurrence rates (3% vs 6% at 2 years) 5
• Ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 2, 4

TEP vs TAPP selection:

• Both demonstrate comparable outcomes with low complication rates 1, 6
• TEP shows marginally lower recurrence rates and postoperative pain in meta-analysis 6
• TAPP may be easier in recurrent cases or when TEP proves technically difficult 1
• TAPP requires entering peritoneal cavity but permits direct visualization of contralateral side 1

Open Lichtenstein repair is appropriate when:

• Laparoscopic expertise unavailable 2
• Patient has significant comorbidities limiting general anesthesia tolerance 1, 2
• Local anesthesia preferred (particularly in emergency settings without bowel gangrene) 1, 2, 4

For Emergency/Complicated Hernias

Incarcerated without strangulation:

• Laparoscopic approach (TAPP or TEP) appropriate when no suspicion of bowel necrosis 1
• Prosthetic repair with synthetic mesh strongly recommended (Grade 1A) in clean surgical field 1, 4
• Local anesthesia can be used for open repair if no bowel gangrene suspected 1, 2, 4

Strangulated or suspected bowel compromise:

• Open preperitoneal approach preferable when bowel resection may be needed 1
• General anesthesia required when bowel gangrene suspected or peritonitis present 1
• Hernioscopy (laparoscopy through hernia sac) can assess bowel viability after spontaneous reduction, avoiding unnecessary laparotomy and decreasing hospital stay 1, 2

Mesh Selection Based on Surgical Field

Clean field (CDC Class I):

• Synthetic mesh is standard—associated with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk 1, 4

Clean-contaminated field (CDC Class II):

• Synthetic mesh can be used even with intestinal strangulation and/or bowel resection without gross enteric spillage 1

Contaminated field with bowel necrosis:

• Small defects (<3 cm): Primary tissue repair recommended 1, 4
• Larger defects: Biological mesh may be used when direct suture not feasible 1, 4
• If biological mesh unavailable: Polyglactin mesh or open wound management with delayed repair 1

Severe sepsis/septic shock:

• Open management recommended to prevent abdominal compartment syndrome 1, 4

Special Populations

Infants:

• All inguinal hernias should be repaired to avoid incarceration and gonadal infarction 2

Bilateral hernias:

• Treat both hernias simultaneously when one is symptomatic (after patient consent) 3
• Laparoscopic approach particularly advantageous 1, 2

Postoperative Antimicrobial Prophylaxis

• 48-hour prophylaxis: For intestinal strangulation and/or concurrent bowel resection (CDC Classes II-III) 1, 2
• Full antimicrobial therapy: For peritonitis (CDC Class IV) 1, 2

Critical Pitfalls to Avoid

• Never delay repair of strangulated hernias—leads to bowel necrosis, increased morbidity, and significantly higher mortality 1, 2
• During TAPP, always inspect contralateral side (after patient consent) to detect occult hernias present in up to 50% of cases 1, 2
• Avoid tissue-only repairs in clean fields—mesh repair has dramatically lower recurrence rates 1, 4

Postoperative Monitoring

Monitor for complications including:

• Wound infection 1, 2
• Chronic pain 1, 2
• Recurrence 1, 2
• Testicular complications (atrophy, vas deferens injury) in males 1, 2