Treatment of Right Inguinal Hernia
Surgical repair with mesh is the definitive treatment for your right inguinal hernia, with laparoscopic approaches (TAPP or TEP) offering advantages over open repair including reduced postoperative pain, lower wound infection rates, and faster recovery. 1, 2
Initial Assessment Priority
First, determine if the hernia is reducible or incarcerated/strangulated, as this dictates urgency:
- Reducible hernia: Schedule elective mesh repair 1, 2
- Incarcerated/strangulated hernia: Emergency surgical intervention is mandatory within 6 hours to prevent bowel necrosis and mortality 3
- Use SIRS criteria, contrast-enhanced CT, lactate, CPK, and D-dimer levels to predict bowel strangulation 1, 4
- Delayed diagnosis beyond 24 hours significantly increases mortality 1, 2
Surgical Approach for Uncomplicated Hernias
Mesh repair is strongly recommended as the standard approach (Grade 1A evidence), showing 0% recurrence versus 19% with tissue repair: 1
Laparoscopic vs Open Repair
Choose laparoscopic repair (TAPP or TEP) as first-line because: 1, 3
- Significantly lower wound infection rates (p<0.018) 1
- No increase in recurrence rates (p<0.815) 1
- Reduced postoperative pain medication requirements 1, 2
- Shorter hospital length of stay (mean difference -3.00 days) 3
- Allows visualization of contralateral side (occult hernias present in 11.2-50% of cases) 1, 2
TAPP versus TEP: Both demonstrate comparable outcomes with low complication rates; TAPP may be easier in recurrent cases or when TEP proves technically difficult 1
Open repair (Lichtenstein technique) is preferred when: 1
- Patient has significant comorbidities limiting general anesthesia tolerance
- Local anesthesia is needed for high-risk patients
- Laparoscopic expertise is unavailable
Emergency Management of Incarcerated/Strangulated Hernias
Timing
Operate within 6 hours of symptom onset - early intervention reduces bowel resection risk (OR 0.1, p<0.0001) 3
Surgical Approach Selection
For incarcerated hernias WITHOUT strangulation: 1, 4
- Laparoscopic approach is appropriate when no bowel necrosis suspected
- Use hernioscopy (laparoscopy through hernia sac) to assess bowel viability, avoiding unnecessary laparotomy and decreasing hospital stay 1, 2
For strangulated hernias or suspected bowel compromise: 1
- Open preperitoneal approach is preferable when bowel resection may be needed
- General anesthesia is required when bowel gangrene suspected or peritonitis present 1, 4
- Local anesthesia can be used for incarcerated hernias without bowel gangrene 1, 4
Mesh Use in Emergency Settings
Clean surgical field (CDC Class I): Prosthetic repair with synthetic mesh is strongly recommended (Grade 1A) 1, 4
Clean-contaminated field (CDC Class II): Emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or bowel resection without gross enteric spillage - significantly lower recurrence risk regardless of defect size 1, 4, 3
Contaminated/dirty fields (CDC Class III-IV): 1
- Small defects (<3 cm) with bowel necrosis or peritonitis: primary tissue repair
- Larger defects: biological mesh (choice between cross-linked and non-cross-linked depends on defect size and contamination degree)
- If biological mesh unavailable: polyglactin mesh repair or open wound management with delayed repair
Antimicrobial Prophylaxis
- Intestinal incarceration without ischemia: Short-term prophylaxis 4
- Intestinal strangulation and/or bowel resection (CDC Class II-III): 48-hour antimicrobial prophylaxis 1, 2
- Peritonitis (CDC Class IV): Full antimicrobial therapy 1
Critical Pitfalls to Avoid
Delaying repair of strangulated hernias leads to bowel necrosis, increased morbidity, and 10-fold increase in mortality 1, 2, 5
Overlooking contralateral hernias - laparoscopic approach identifies occult contralateral hernias in up to 50% of cases 1, 2
Using laparoscopic approach when contraindicated: 1
- Active strangulation with bowel compromise
- Anticipated bowel resection
- Inability to tolerate general anesthesia