What are the types of repair for direct hernia?

Types of Repair for Direct Inguinal Hernia

Mesh repair is the definitive standard for direct inguinal hernia repair, with both open (Lichtenstein) and laparoscopic approaches (TEP/TAPP) offering superior outcomes compared to tissue-only repairs. 1, 2

Primary Repair Approaches

Mesh-Based Repair (Recommended Standard)

Prosthetic repair with synthetic mesh is strongly recommended as first-line treatment for all direct inguinal hernias in clean surgical fields, demonstrating significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 3, 1, 4

• Open anterior approach (Lichtenstein technique): The most extensively evaluated mesh repair method, utilizing flat mesh placement in the anterior inguinal space with excellent long-term outcomes 1, 2

• Laparoscopic posterior approaches: Both TEP (totally extraperitoneal) and TAPP (transabdominal preperitoneal) demonstrate comparable outcomes to open repair, with specific advantages including reduced postoperative pain, lower wound infection rates (P<0.018), and ability to identify occult contralateral hernias present in 11.2-50% of cases 1, 2

• Mesh fixation considerations: In TEP repair, mesh fixation is unnecessary in most cases; however, fixation is recommended specifically for M3 hernias (large medial defects) to reduce recurrence risk in both TEP and TAPP approaches 2

Tissue-Only Repair (Limited Role)

Tissue repair techniques like Shouldice can be offered only after appropriate patient counseling regarding higher recurrence rates, and should be reserved for specific patient preferences or contraindications to mesh. 1, 4

• Primary tissue repair is recommended only for small defects (<3 cm) in contaminated/dirty surgical fields with bowel necrosis or peritonitis where mesh is contraindicated 3, 4

Approach Selection Algorithm

For Uncomplicated Direct Hernias (Clean Field)

1. First choice: Laparoscopic repair (TEP or TAPP) if expertise available, offering faster recovery and lower chronic pain risk 1, 2

2. Alternative: Open Lichtenstein repair under local anesthesia, particularly advantageous in elderly patients and those with significant comorbidities 1, 4

3. Defect plication: For M2 and M3 (medium to large medial) direct hernias, defect plication may be performed during laparoscopic repair, though evidence shows no significant difference in seroma, pain, or recurrence rates 5

For Incarcerated Direct Hernias (Without Strangulation)

• Laparoscopic approach is appropriate when no clinical signs of strangulation or peritonitis are present, with significantly lower wound infection rates and no increase in recurrence 1

• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed 1

• Synthetic mesh remains recommended for incarcerated hernias without signs of strangulation or need for bowel resection (Grade 1A recommendation) 3, 6

For Complicated Direct Hernias (Contaminated/Dirty Fields)

• Clean-contaminated field (CDC Class II): Emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or bowel resection without gross enteric spillage, associated with significantly lower recurrence risk regardless of defect size 3, 6

• Contaminated/dirty fields (CDC Class III/IV): Primary tissue repair for small defects (<3 cm); when direct suture not feasible, biological mesh may be used with choice between cross-linked and non-cross-linked depending on defect size and contamination degree 3, 4

• Alternative if biological mesh unavailable: Polyglactin mesh repair or open wound management with delayed repair 3

Critical Technical Considerations

Mesh Selection

• Weight alone should not guide mesh selection, as so-called low-weight meshes show only slight short-term benefits without better long-term outcomes for recurrence or chronic pain 2

• Avoid plug repair techniques due to higher erosion incidence compared to flat mesh 2

Anesthesia Approach

• Local anesthesia is recommended for open repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 3, 1, 4

• General anesthesia is suggested over regional in patients aged 65 and older due to lower risk of myocardial infarction, pneumonia, and thromboembolism 2

Common Pitfalls to Avoid

• Overlooking contralateral hernias: During TAPP, the contralateral side should be inspected after patient consent, as occult hernias are present in up to 50% of cases 1, 2

• Inappropriate mesh fixation: Avoid routine fixation in TEP repair except for M3 (large medial) hernias where fixation reduces recurrence 2

• Delaying repair of strangulated hernias: Immediate surgical intervention is mandatory when intestinal strangulation is suspected, as delayed diagnosis (>24 hours) is associated with significantly higher mortality rates 1, 6