What is the recommended treatment for hernias?

Recommended Treatment for Hernias

For uncomplicated hernias in clean surgical fields, mesh repair using synthetic mesh is the definitive treatment and should be performed via laparoscopic approach when expertise is available, as this reduces chronic pain, accelerates recovery, and lowers recurrence rates compared to open repair. 1, 2

Emergency vs. Elective Repair

Immediate surgical intervention is mandatory when intestinal strangulation is suspected 1

• Predictors of bowel strangulation requiring emergency surgery include: systemic inflammatory response syndrome (SIRS), elevated lactate, elevated serum creatinine phosphokinase (CPK), elevated D-dimer levels, and contrast-enhanced CT findings 1
• Delayed diagnosis beyond 24 hours significantly increases mortality rates 1, 3
• For asymptomatic or minimally symptomatic inguinal hernias in men, watchful waiting is a safe alternative, as the risk of hernia-related emergencies is low (approximately 1% per year) 2, 4, 5
• Watchful waiting is not recommended for symptomatic hernias or in non-pregnant women 2, 5

Surgical Approach Selection

Laparoscopic repair is preferred over open repair when expertise and resources are available 3, 2, 4

• Laparoscopic techniques (TEP or TAPP) offer faster recovery, earlier return to activities, reduced chronic pain risk (10-12% vs higher with open), and are cost-effective 2, 4
• Open repair (Lichtenstein technique) remains appropriate when laparoscopic expertise is unavailable or in resource-limited settings 2
• For incarcerated hernias without strangulation or suspected bowel resection, laparoscopic approach may be used; however, open preperitoneal approach is preferable if bowel resection is anticipated 1
• For unstable patients or confirmed strangulation, open surgical approach is mandatory 3

Mesh Selection Based on Contamination Level

The choice of mesh material depends critically on the CDC wound classification 1

Clean Fields (CDC Class I - No Strangulation, No Bowel Resection):

• Synthetic mesh is strongly recommended as it provides lower recurrence rates without increasing wound infection risk 1
• Mesh repair is superior to tissue repair alone, which has recurrence rates up to 42% 3, 6

Clean-Contaminated Fields (CDC Class II - Strangulation with Bowel Resection, No Gross Spillage):

• Synthetic mesh can be safely used without increased 30-day wound-related morbidity and provides significantly lower recurrence risk 1

Contaminated/Dirty Fields (CDC Class III-IV - Gross Spillage or Peritonitis):

• For defects <3 cm: primary repair without mesh 1
• For defects >3 cm: biological mesh is preferred due to higher infection resistance 1, 3, 6
• Cross-linked biological meshes have lower failure rates in contaminated fields compared to non-cross-linked 1
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1

Technical Considerations

Mesh fixation and sizing requirements 3, 6, 2

• For defects >3 cm or area >20 cm², mesh should overlap defect edges by 1.5-2.5 cm 3, 6
• In TEP repair, mesh fixation is unnecessary in most cases 2
• In both TEP and TAPP, mesh fixation is recommended for large medial hernias (M3) to reduce recurrence 2
• Avoid tacker fixation near vital structures and pericardium 3

Crural closure technique for hiatal hernias 6, 4

• Primary crural closure using interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers 6
• Mesh reinforcement indicated when defects cannot be closed without tension or are >3 cm 6, 4

Anesthesia Selection

Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene 1

• Local anesthesia provides effective anesthesia with fewer cardiac complications, respiratory complications, shorter ICU and hospital stays, lower costs, and faster recovery compared to general anesthesia 1
• General anesthesia is preferred for patients ≥65 years old as it may be associated with fewer complications like myocardial infarction, pneumonia, and thromboembolism 2
• General anesthesia is mandatory when bowel gangrene is suspected or peritonitis is present 1

Management of Unstable Patients

For patients with severe sepsis or septic shock, open management is mandatory to prevent abdominal compartment syndrome 1, 3

• Intra-abdominal pressure should be measured intraoperatively 1
• Avoid fascial closure when excessive tension would occur ("open abdomen" approach) 1
• Following stabilization, attempt early definitive closure only when risk of excessive tension or recurrent intra-abdominal hypertension is minimal 1
• If definitive fascial closure cannot be achieved, skin-only closure is viable with delayed abdominal closure and synthetic mesh repair at a later stage 1

Special Populations

Female patients 3, 2

• Laparoscopic repair is preferred to decrease chronic pain risk and avoid missing femoral hernias 3, 2
• Femoral hernias should undergo timely mesh repair via laparoscopic approach when expertise is available 3

Pregnant women 3, 2

• Watchful waiting is recommended as groin swelling often consists of self-limited round ligament varicosities 2
• Ultrasound is first-line imaging, followed by MRI if necessary 3

Recurrent Hernias

Surgical approach for recurrence depends on prior repair technique 2

• After failed anterior repair, posterior repair is recommended 2
• After failed posterior repair, anterior repair is recommended 2
• After failed anterior and posterior approaches, referral to a specialist hernia surgeon is mandatory 2

Antimicrobial Prophylaxis

Duration of antimicrobial coverage depends on CDC wound class 1

• CDC Class I (no ischemia, no bowel resection): short-term prophylaxis 1
• CDC Class II-III (strangulation and/or bowel resection): 48-hour antimicrobial prophylaxis 1
• CDC Class IV (peritonitis): full antimicrobial therapy, not just prophylaxis 1
• Antibiotic prophylaxis is not recommended for average-risk patients in low-risk environments undergoing open surgery 2
• Antibiotic prophylaxis is never recommended for laparoscopic repair 2

Common Pitfalls

• Never use plug repair techniques due to higher erosion rates compared to flat mesh 2
• Do not rely on chest X-ray alone for diagnosis, as sensitivity is only 2-60% for left-sided hernias and 17-33% for right-sided; CT scan is the gold standard with 14-82% sensitivity and 87% specificity 3, 6
• Avoid delayed diagnosis as symptomatic periods >8 hours significantly affect morbidity, and delays >24 hours increase mortality 1, 3
• Do not perform primary repair alone for defects >3 cm due to recurrence rates up to 42% 3, 6
• Recognize that approximately 100 supervised laparoscopic repairs are needed to achieve proficiency equivalent to open mesh techniques 2

Postoperative Management

Patients should resume normal activities without restrictions as soon as they feel comfortable 2

• Day surgery is recommended for the majority of groin hernia repairs provided aftercare is organized 2
• Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair 2