What is the assessment and plan for an inguinal hernia?

Assessment and Plan for Inguinal Hernia

Initial Assessment

Immediately determine if the hernia is reducible, incarcerated, or strangulated, as this dictates urgency of surgical intervention and directly impacts morbidity and mortality. 1

Clinical Evaluation

• Reducible hernia: Presents as groin swelling with pain or dragging sensation that can be manually reduced 2
• Incarcerated hernia: Non-reducible hernia requiring urgent surgical intervention 1, 3
• Strangulated hernia: Emergency requiring immediate repair to prevent bowel necrosis and death 1, 3

Predictors of Strangulation

• Systemic inflammatory response syndrome (SIRS) 1, 3
• Contrast-enhanced CT findings 1, 3
• Elevated lactate, serum creatinine phosphokinase (CPK), and D-dimer levels 1, 3
• Delayed diagnosis beyond 24 hours significantly increases mortality 1, 3

Risk Factors for Bowel Resection

• Lack of health insurance 1
• Obvious peritonitis 1
• Femoral hernia 1

Treatment Plan

Emergency/Urgent Situations (Incarcerated or Strangulated)

For strangulated hernias, immediate surgical intervention is mandatory to prevent bowel necrosis and death. 1, 3

Surgical Approach Selection:

• Early intervention (<6 hours from symptom onset) significantly reduces bowel resection rates (OR 0.1) 4
• Laparoscopic approach is preferred when bowel viability is uncertain, as it allows continuous assessment during the procedure and results in lower bowel resection rates compared to open surgery 5, 4
• Hernioscopy (laparoscopy through hernia sac) can assess bowel viability after spontaneous reduction, avoiding unnecessary laparotomy and decreasing hospital stay 1, 5
• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection is anticipated 1

Mesh Use in Emergency Settings:

• Clean surgical field (CDC class I): Use prosthetic synthetic mesh 1
• Clean-contaminated field (CDC class II-III): Synthetic mesh can be used even with intestinal strangulation and/or bowel resection without gross enteric spillage, with significantly lower recurrence rates (OR 0.34) 1, 4
• Contaminated field with bowel necrosis or peritonitis: For small defects (<3 cm), perform primary repair; for larger defects, consider biological mesh if available 1

Anesthesia Considerations:

• Local anesthesia can be used for incarcerated inguinal hernias without bowel gangrene 1, 3
• General anesthesia is required when bowel gangrene is suspected or peritonitis is present 1

Antibiotic Prophylaxis:

• 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection (CDC classes II-III) 1, 3
• Full antimicrobial therapy for peritonitis (CDC class IV) 1, 3

Elective Repair (Reducible Hernias)

Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias due to significantly lower recurrence rates (0% vs 19% with tissue repair). 1

Surgical Technique Selection:

Laparoscopic repair (TEP or TAPP) is preferred when expertise is available, offering:

• Reduced postoperative pain and lower analgesic requirements 1, 3
• Significantly lower wound infection rates (p<0.018) 1
• No increase in recurrence rates (p<0.815) 1, 4
• Faster return to normal activities 3
• Ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 3

Open Lichtenstein repair remains excellent when:

• Laparoscopic expertise is unavailable 3
• Patient has significant comorbidities 1, 3
• Local anesthesia is preferred 1, 3

Bilateral Hernias:

• Laparoscopic approach is particularly beneficial for bilateral hernias 1
• TAPP and TEP demonstrate comparable outcomes with low complication rates 1
• TAPP may be easier in recurrent cases or when TEP proves technically difficult 1

Special Population: Newborns and Infants

All inguinal hernias in infants require surgical repair to prevent incarceration, bowel strangulation, and gonadal infarction. 3, 6

• Herniotomy (high ligation of hernia sac) is the recommended procedure, NOT mesh repair 6
• Semi-urgent repair within 2-4 weeks of diagnosis minimizes incarceration risk 6
• Consider laparoscopic evaluation of contralateral side, particularly in high-risk patients (age <4 years, left-sided initial hernia) 6
• Laparoscopic evaluation with prophylactic closure reduces metachronous contralateral hernia risk by 5.7% 6

Postoperative Monitoring

Monitor for:

• Wound infection 1, 3
• Chronic pain 1, 3
• Recurrence 1, 3
• Testicular complications (atrophy, vas deferens injury) in males 1, 3

Critical Pitfalls to Avoid

• Never delay repair of strangulated hernias—this leads to bowel necrosis, increased morbidity, and significantly higher mortality 1, 3
• Do not overlook contralateral hernias—examine the opposite side laparoscopically when performing TAPP, as occult hernias are present in up to 50% of cases 1, 3
• Do not use mesh in primary newborn hernia repair—herniotomy is the appropriate technique 6
• Do not simply observe reducible hernias in infants—all require surgical correction 6
• Do not delay infant repair until school age—this exposes the child to unnecessary morbidity risk 6