What are the steps for inguinal hernia surgery, including preoperative and postoperative management?

Inguinal Hernia Surgery: Surgical Steps and Perioperative Management

Preoperative Assessment and Preparation

Determine immediately whether the hernia is reducible, incarcerated, or strangulated, as this dictates the urgency of surgical intervention. 1, 2

Emergency vs. Elective Classification

• Strangulated hernias require immediate emergency repair to prevent bowel necrosis and mortality, with delayed diagnosis beyond 24 hours significantly increasing mortality rates 1, 2, 3
• Predictive markers of bowel strangulation include systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, elevated lactate, serum creatinine phosphokinase (CPK), and D-dimer levels 1, 3
• Incarcerated hernias without strangulation require urgent but not emergent surgical intervention 2, 3
• Reducible hernias can be scheduled for elective repair 2

Preoperative Workup

• Assess patient comorbidities and ability to tolerate general anesthesia, as this influences surgical approach selection 1
• Risk factors for bowel resection include lack of health insurance, obvious peritonitis, and femoral hernia type 2
• Obtain informed consent that includes discussion of examining the contralateral side, as occult contralateral hernias are present in 11.2-50% of cases 1, 3

Antibiotic Prophylaxis

• Administer a single dose of 1g intravenous cefazolin preoperatively for clean cases (CDC class I) 4, 5
• For intestinal strangulation and/or concurrent bowel resection (CDC classes II-III), provide 48-hour antimicrobial prophylaxis 1, 3
• Full antimicrobial therapy is required for patients with peritonitis (CDC class IV) 1, 3

Surgical Approach Selection

Mesh repair is the standard approach for all non-complicated inguinal hernias, with significantly lower recurrence rates (0% vs 19% with tissue repair) compared to tissue repair alone. 1, 2, 3

Laparoscopic vs. Open Approach Decision Algorithm

Choose Laparoscopic (TAPP or TEP) when:

• Bilateral hernias are present 1
• Patient desires reduced postoperative pain and faster return to activities 2, 3
• Incarcerated hernia without strangulation or bowel compromise 1
• Recurrent hernia (TAPP may be easier than TEP in these cases) 1
• Surgeon has laparoscopic expertise available 3

Choose Open Repair when:

• Strangulated hernia with suspected bowel compromise or need for bowel resection 1
• Patient has significant comorbidities or cannot tolerate general anesthesia 1, 3
• Local anesthesia is preferred or required 1, 2
• Laparoscopic expertise is unavailable 3
• Bowel gangrene is suspected 1

Detailed Surgical Steps

For Open Mesh Repair (Lichtenstein Technique)

Patient Positioning and Anesthesia

• Position patient supine 6
• Local anesthesia can be used for incarcerated inguinal hernias without bowel gangrene, providing effective anesthesia with fewer postoperative complications 1, 3
• General anesthesia is required when bowel gangrene is suspected or peritonitis is present 1

Incision and Exposure

• Make an incision parallel to the inguinal ligament, exposing the external oblique aponeurosis 7
• Use electrocautery for dissection, avoiding injury to tissue between vessels to prevent lymphocele formation 7
• Identify and protect the ilioinguinal nerve, iliohypogastric nerve, and genital branch of the genitofemoral nerve 3

Hernia Sac Management

• Identify and isolate the hernia sac 3
• For indirect hernias, dissect the sac from the cord structures 3
• Reduce the sac contents or resect the sac if large 3
• If bowel viability is questionable after reduction, consider hernioscopy (laparoscopy through hernia sac) to assess bowel viability and avoid unnecessary laparotomy 1, 2, 3

Mesh Placement

• Place synthetic mesh in clean surgical fields (CDC class I), as it is associated with significantly lower recurrence rates without increased infection risk 1, 3
• For clean-contaminated fields (CDC class II) with intestinal strangulation and/or bowel resection without gross enteric spillage, synthetic mesh can still be used 1
• For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair is recommended 1
• If biological mesh is needed (contaminated fields), choose between cross-linked and non-cross-linked based on defect size and contamination degree 1

Closure

• Close the external oblique aponeurosis 3
• Close subcutaneous tissue and skin in layers 3

For Laparoscopic Repair (TAPP or TEP)

Patient Positioning and Port Placement

• Position patient supine with arms tucked 1
• Establish pneumoperitoneum (for TAPP) or preperitoneal space insufflation (for TEP) 1
• Place camera port at umbilicus and working ports in lower abdomen 1

TAPP Technique

• Enter peritoneal cavity and create peritoneal flap above the hernia defect 1
• Identify hernia defect and reduce contents 1
• Examine the contralateral side to identify occult hernias, present in 11.2-50% of cases 1, 3
• Dissect preperitoneal space and identify anatomical landmarks (inferior epigastric vessels, vas deferens, spermatic vessels) 1
• Place large mesh covering all potential hernia sites in the preperitoneal space 1
• Close peritoneal flap 1

TEP Technique

• Create preperitoneal space without entering peritoneal cavity 1
• Identify and reduce hernia defect 1
• Place mesh in preperitoneal space 1
• TEP and TAPP demonstrate comparable outcomes with low complication rates 1

Special Considerations for Emergency Cases

• For incarcerated hernias, laparoscopic approach shows significantly lower wound infection rates (P<0.018) compared to open repair 1
• Diagnostic laparoscopy can assess bowel viability after spontaneous reduction of strangulated hernias 1, 2
• If active strangulation with bowel compromise is present, convert to open preperitoneal approach for potential bowel resection 1

Postoperative Management

Immediate Postoperative Care

• Monitor vital signs and assess for complications 2
• Manage pain with appropriate analgesia (laparoscopic approach requires less postoperative pain medication) 1, 2
• Encourage early mobilization 3
• Most open repairs under local anesthesia can be performed on an ambulatory basis 4, 6

Wound Care and Follow-up Schedule

• Examine wound before discharge for signs of infection 8
• Schedule follow-up examinations at 3,5,7, and 30 days postoperatively 8
• For percutaneous venous access sites (if used), remove deep skin sutures on day 3 or 4 7

Monitoring for Complications

• Wound infection: Occurs in approximately 5-7% of cases without prophylactic antibiotics, reduced with antibiotic prophylaxis 4, 8, 5
• Chronic pain: Monitor and manage appropriately 2, 3
• Recurrence: Significantly lower with mesh repair (0%) compared to tissue repair (19%) 1, 3
• Testicular complications: Including testicular atrophy and vas deferens injury in males 1, 3
• Seroma formation: Not significantly reduced by antibiotic prophylaxis 5

Activity Restrictions

• Laparoscopic repair allows faster return to normal activities compared to open repair 2, 3
• Mesh implantation is associated with quicker resumption of normal activities 6

Critical Pitfalls to Avoid

Most Dangerous Pitfall

Delaying repair of strangulated hernias leads to bowel necrosis, increased morbidity, and significantly higher mortality—emergency repair must be performed immediately. 1, 2, 3

Other Important Pitfalls

• Failing to examine the contralateral side during laparoscopic repair, missing occult hernias present in up to 50% of cases 1, 3
• Using laparoscopic approach when bowel resection is anticipated or active strangulation is present 1
• Inadequate antibiotic prophylaxis in emergency cases with bowel compromise 1, 3
• Injury to tissue between femoral artery and vein during groin dissection, leading to lymphocele formation 7
• Nerve injury during dissection, causing chronic postoperative pain 3