Hernia Management
Definitive Treatment Approach
Surgical repair with tension-free mesh reinforcement is the definitive treatment for hernias, with mesh repair demonstrating significantly lower recurrence rates (0-4%) compared to tissue repair (10-35%) without increasing infection risk in clean surgical fields. 1, 2
Emergency vs. Elective Repair Decision Algorithm
Immediate Emergency Surgery Required When:
- Strangulation suspected - based on systemic inflammatory response syndrome (SIRS) criteria, elevated lactate, CPK, or D-dimer levels, or contrast-enhanced CT showing bowel wall ischemia 1, 2
- Incarceration with peritoneal signs - obvious peritonitis mandates immediate intervention 1
- Femoral hernia presentation - carries 8-fold higher risk of bowel resection and should not be observed 1
- Delayed diagnosis beyond 24 hours - associated with significantly higher mortality rates 1
Elective Repair Appropriate For:
- All symptomatic inguinal hernias - to prevent future incarceration/strangulation 1, 3
- Asymptomatic male inguinal hernias - can be managed with watchful waiting after discussing risks, though majority eventually require surgery 1, 3
- Asymptomatic direct hernias - only if not enlarging; otherwise repair indicated 4
Surgical Approach Selection
Laparoscopic Repair (TEP or TAPP) - Preferred When:
- Hemodynamically stable patient without significant comorbidities 2
- Bilateral hernias - allows simultaneous repair and identification of occult contralateral hernias (present in 11-50% of cases) 1, 5
- Recurrent hernia after anterior repair - posterior laparoscopic approach recommended 1, 3
- Female patients - reduces chronic pain risk and avoids missing femoral hernias 1, 3
- Incarcerated hernia without strangulation - when no suspicion of bowel necrosis 1
Benefits: Significantly lower wound infection rates (P<0.018), faster recovery, lower chronic pain rates, and cost-effectiveness with minimal disposables 6, 1, 3
Open Repair - Indicated When:
- Strangulation suspected or bowel resection anticipated - open preperitoneal approach preferred 1
- Laparoscopic expertise/equipment unavailable 2
- Patient age ≥65 years - general anesthesia for laparoscopy may increase risk of MI, pneumonia, thromboembolism 3
- Unstable patients with severe sepsis/septic shock - prevents abdominal compartment syndrome 1, 5
- Recurrent hernia after posterior repair - anterior approach recommended 1, 3
Mesh Selection Based on Surgical Field Contamination (CDC Classification)
Clean Field (CDC Class I) - No Bowel Compromise:
- Synthetic mesh strongly recommended (Grade 1A) - standard approach with 0% recurrence vs. 19% with tissue repair 6, 1, 2
- Mesh must overlap defect edges by at least 5 cm to prevent recurrence 2
Clean-Contaminated Field (CDC Class II) - Bowel Resection Without Gross Spillage:
- Synthetic mesh can still be safely used - significantly lower recurrence risk without increased infection 1, 2
Contaminated/Dirty Fields (CDC Class III-IV) - Bowel Necrosis or Peritonitis:
- Primary tissue repair for defects <3 cm 1, 5
- Biological mesh when direct closure not feasible - choice between cross-linked vs. non-cross-linked depends on defect size and contamination degree 1, 5
- Polyglactin mesh or open wound management with delayed repair - if biological mesh unavailable 1
- Never use synthetic mesh - risks mesh infection requiring removal 2
Anesthesia Selection
Local Anesthesia Recommended For:
- Emergency inguinal hernia repair without bowel gangrene - provides effective anesthesia with fewer postoperative complications, shorter hospital stays, lower costs, and faster recovery 1, 2, 5
- Open repair in experienced hands - many advantages over general anesthesia 1, 3
General Anesthesia Required For:
- Suspected bowel gangrene 1, 2
- Intestinal resection needed 1, 2
- Peritonitis present 1, 2
- All laparoscopic repairs 1
Special Techniques for Emergency Cases
Hernioscopy (Laparoscopy Through Hernia Sac):
- Assess bowel viability after spontaneous reduction - prevents unnecessary laparotomy 6, 1
- Decreases hospital stay (28 hours vs. 34 hours) and major complications 6
- Particularly valuable in high-risk patients - contributes to decreased morbidity and mortality 6
Mesh Fixation in Laparoscopic Repair:
- TEP: Fixation unnecessary in almost all cases 3
- TAPP and TEP: Fix mesh only in M3 hernias (large medial) - reduces recurrence risk 3
Postoperative Management
Pain Control:
- Primary: Acetaminophen and NSAIDs 1
- Opioid prescribing limits: 15 tablets hydrocodone/acetaminophen 5/325mg or 10 tablets oxycodone 5mg for laparoscopic repair; 15 tablets for open repair 1
- Perioperative field blocks and subfascial/subcutaneous infiltrations recommended in all open repairs 3
Activity Restrictions:
Antimicrobial Prophylaxis:
- Not recommended for average-risk patients in low-risk environments for open surgery 3
- Never recommended for laparoscopic repair 3
- 48-hour prophylaxis for intestinal strangulation/bowel resection (CDC Class II-III) 1
- Full antimicrobial therapy for peritonitis (CDC Class IV) 1
Common Complications and Monitoring
Chronic Postoperative Inguinal Pain (CPIP):
- Incidence: 10-12% overall; debilitating pain affecting daily activities: 0.5-6% 3
- Risk factors: Young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, open repair 3
- Prevention: Nerve recognition in open surgery; consider prophylactic pragmatic nerve resection in selected cases 3
- Management: Multidisciplinary team approach with pharmacological/interventional measures; if unsuccessful, consider (triple) neurectomy and mesh removal in selected cases 3
Recurrence:
- Overall rate: 2-4% with mesh repair 1, 7
- Higher with primary repair: 19% vs. 0% with mesh 6
- Management: Posterior repair after anterior recurrence; anterior repair after posterior recurrence; specialist referral after both approaches fail 1, 3
Other Complications:
- Wound infection, wound dehiscence, testicular complications (males), post-operative collections 1, 7
Critical Pitfalls to Avoid
- Insufficient mesh overlap (<5 cm) - leads to recurrence through host-prosthesis interface failure 2
- Using synthetic mesh in contaminated fields - risks mesh infection and removal 2
- Delaying repair of strangulated hernias - leads to bowel necrosis, increased morbidity/mortality 1, 2
- Inadequate bowel viability assessment in incarcerated hernias - results in missed necrosis and perforation 2
- Overlooking contralateral hernias - examine opposite side laparoscopically during TAPP (present in up to 50% of cases) 1
- Using plug repair techniques - higher erosion incidence compared to flat mesh 3