When is surgical intervention indicated for inguinal (in the groin area) hernia repair?

From the Guidelines

Surgery for inguinal hernia repair should be considered immediately when intestinal strangulation is suspected, as this represents a medical emergency. The decision to operate is based on the risk of complications, such as bowel strangulation, which can lead to significant morbidity and mortality if left untreated.

Key Considerations

• The presence of systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1.
• Early diagnosis of strangulated obstruction may be difficult, and delayed diagnosis can lead to septic complications, highlighting the need for prompt surgical intervention when strangulation is suspected.
• The use of mesh in clean surgical fields is associated with a lower recurrence rate, and prosthetic repair with a synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 1.

Surgical Approaches

• Open repair and laparoscopic repair are the two main surgical approaches, with the choice depending on patient factors, hernia characteristics, and surgeon expertise.
• Laparoscopic repair may be a useful tool for assessing bowel viability after spontaneous reduction of strangulated groin hernias, and can be performed in the absence of strangulation and suspicion of the need of bowel resection 1.

Post-Operative Care

• Most patients can return to light activities within 1-2 weeks and full activities within 4-6 weeks after surgery.
• The decision for surgery should be individualized, weighing the risks of surgical complications against the benefits of preventing hernia complications and improving quality of life. Some key points to consider when deciding on surgery for inguinal hernia repair include:
• The risk of bowel strangulation and the potential for significant morbidity and mortality if left untreated
• The presence of SIRS, CT findings, and laboratory results that are predictive of bowel strangulation
• The use of mesh in clean surgical fields and the recommendation for prosthetic repair with a synthetic mesh in certain cases
• The choice between open and laparoscopic repair, depending on patient factors and surgeon expertise
• The importance of individualizing the decision for surgery, weighing the risks and benefits of surgical intervention.

From the Research

Indications for Surgery

Surgery should be considered for inguinal hernia repair in the following situations:

• Symptomatic groin hernias should be treated surgically 2
• Asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with "watchful waiting", but the majority of these individuals will eventually require surgery 2
• Patients with significant hernia-related symptoms, such as pain or discomfort, should undergo surgical repair 3
• Patients with recurrent hernia, scrotal hernia, or previous pelvic and lower abdominal surgery may require surgical repair 4
• Patients with severe cardiac or pulmonary comorbidities may require surgical repair, but the decision should be made on a case-by-case basis 4

Watchful Waiting

Watchful waiting may be considered for:

• Asymptomatic or minimally symptomatic inguinal hernias, as the risk of hernia-related emergencies is low 5, 3, 2
• Pregnant women, as groin swelling most often consists of self-limited round ligament varicosities 2

Timing of Surgery

Surgery should be performed:

• Electively, rather than emergently, in high-risk geriatric patients, to reduce the risk of morbidity and mortality 6
• In a timely manner, for patients with symptomatic inguinal hernias, to reduce the risk of complications and improve outcomes 4, 2

Factors to Consider

When deciding on surgery, the following factors should be considered:

• Patient-related factors, such as age, sex, and comorbidities 4, 2
• Hernia-related factors, such as the size and location of the hernia, and the presence of any complications 4, 2
• Surgeon-related factors, such as expertise and experience 4, 2
• Local and national resources, such as the availability of surgical facilities and equipment 4, 2