What are the management options for inguinal hernia?

Management of Inguinal Hernia

Primary Recommendation

Surgical repair with mesh is the definitive treatment for inguinal hernias, with laparoscopic approaches (TEP or TAPP) and open Lichtenstein repair being the recommended techniques based on surgeon expertise and clinical context. 1, 2

---

Initial Assessment and Urgency Stratification

Determine Clinical Presentation

Reducible hernia:

• Elective repair is standard, though watchful waiting may be considered in truly asymptomatic or minimally symptomatic cases 3
• However, surgical repair is generally advised due to risk of incarceration and strangulation, particularly with femoral hernias 4

Incarcerated hernia (irreducible but no vascular compromise):

• Requires urgent surgical intervention within 1-2 weeks 2
• Assess for signs including irreducibility, tenderness, erythema 5

Strangulated hernia (vascular compromise):

• Emergency repair is mandatory to prevent bowel necrosis and mortality 1, 2
• Predictive markers include SIRS, elevated lactate, CPK, D-dimer, and contrast-enhanced CT findings 1, 2
• Delayed diagnosis beyond 24 hours significantly increases mortality 1, 2

---

Surgical Approach Selection

For Elective/Uncomplicated Hernias

Mesh repair is strongly recommended over tissue repair due to significantly lower recurrence rates (0% vs 19%) without increased infection risk 1

Choose between:

Laparoscopic repair (TEP or TAPP):

• Preferred when expertise is available 2, 6
• Advantages include reduced postoperative pain, lower analgesic requirements, lower wound infection rates (P<0.018), and faster return to normal activities 1, 2
• Particularly beneficial for bilateral hernias, as it allows visualization of contralateral side to identify occult hernias (present in 11.2-50% of cases) 1, 2
• TEP and TAPP demonstrate comparable outcomes with low complication rates 1
• TAPP may be easier in recurrent cases or when TEP proves technically difficult 1
• Requires general anesthesia 1

Open Lichtenstein repair:

• Excellent option when laparoscopic expertise is unavailable 2
• Preferred in patients with significant comorbidities 1, 2
• Can be performed under local anesthesia, which is suitable and economic for day-case setting 7
• Standard polypropylene mesh remains the choice 7

---

Emergency/Complicated Hernia Management

Incarcerated Hernia Without Strangulation

Surgical field classification guides mesh selection:

Clean surgical field (CDC Class I):

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

Strangulated Hernia or Suspected Bowel Compromise

Immediate surgical intervention is mandatory 1, 2

Approach selection:

• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed 1
• General anesthesia is required when bowel gangrene is suspected or peritonitis is present 1

Mesh use in contaminated fields:

Clean-contaminated field (CDC Class II-III):

• Emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or bowel resection without gross enteric spillage 1
• Associated with significantly lower recurrence risk regardless of defect size 1
• 48-hour antimicrobial prophylaxis recommended 1, 2

Contaminated field with bowel necrosis or peritonitis:

• For small defects (<3 cm): primary repair is recommended 1
• When direct suture not feasible: biological mesh may be used 1
• If biological mesh unavailable: polyglactin mesh repair or open wound management with delayed repair are alternatives 1
• Full antimicrobial therapy required for peritonitis (CDC Class IV) 1, 2

---

Role of Hernioscopy (Diagnostic Laparoscopy)

Hernioscopy through the hernia sac can assess bowel viability after spontaneous reduction of strangulated hernias or when concern exists about bowel compromise 1, 2

Advantages:

• Avoids unnecessary laparotomy 1, 2
• Decreases hospital stay and complications compared to non-laparoscopic approaches 1
• Can be performed by surgeons with less advanced laparoscopic skills 8
• Allows visualization during entire procedure, potentially reducing need for bowel resection 8

---

Special Populations

Infants and Children

All inguinal hernias in infants require surgical repair to prevent bowel incarceration and gonadal infarction/atrophy 2, 5

Timing considerations:

• Urgent surgical referral for repair within 1-2 weeks of diagnosis 5
• Preterm infants have higher surgical complication rates but also higher incarceration risk; repair should occur soon after diagnosis 5
• Postoperative apnea risk is elevated in preterm infants under 46 weeks corrected gestational age, requiring 12-hour postoperative monitoring 5

Bilateral considerations:

• Contralateral patent processus vaginalis occurs in 64% of infants younger than 2 months 5
• Bilateral exploration is commonly performed given high rate of contralateral involvement 5

---

Postoperative Management and Monitoring

Monitor for complications:

• Wound infection 1, 2, 5
• Chronic pain (occurs in 10-12% of patients) 6
• Recurrence (11% of all patients) 1, 2, 6
• Testicular complications in males (atrophy, vas deferens injury) 1, 5

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

Delaying repair of strangulated hernias leads to bowel necrosis, increased morbidity, and significantly higher mortality 1, 2

Failing to examine the contralateral side during laparoscopic repair can result in overlooking occult hernias present in 11.2-50% of cases 1, 2

Missing femoral hernias, which have higher risk of strangulation than inguinal hernias 5, 4

Using mesh in grossly contaminated fields (CDC Class IV with peritonitis) without considering biological mesh or delayed repair options 1

Inadequate patient selection for watchful waiting - while this may be acceptable for truly asymptomatic hernias, patients must understand risks including potential for acute incarceration 3