From the Guidelines
Patients with suspected intestinal strangulation should undergo emergency hernia repair immediately, as recommended by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. The management of hernias depends on various factors, including the type of hernia, size, and patient condition.
Key Considerations
- For patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection, prosthetic repair with a synthetic mesh is recommended, as it is associated with a lower recurrence rate and no increase in wound infection rate 1.
- In cases of complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage, emergent prosthetic repair with synthetic mesh can be performed, with a significant lower risk of recurrence 1.
- For stable patients with strangulated hernia with bowel necrosis and/or gross enteric spillage, primary repair is recommended when the size of the defect is small, and a biological mesh may be used for repair when direct suture is not feasible 1.
Post-Operative Care
- Patients should avoid heavy lifting and gradually increase activity as tolerated, with prescribed pain medications like acetaminophen or NSAIDs as needed.
- Surgical site care involves keeping the area clean and dry, watching for signs of infection, and following up with the surgeon as scheduled.
Additional Recommendations
- 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.
- For unstable patients, open management is recommended to prevent abdominal compartment syndrome, and intra-abdominal pressure may be measured intraoperatively 1.
From the Research
Hernia Management Overview
- Hernia management involves various approaches, treatment indications, and techniques for groin hernia repair, warranting guidelines to standardize care, minimize complications, and improve results 2.
- The main goal of hernia management guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair 2.
Diagnosis and Treatment
- Inguinal hernia diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms, with ultrasound, dynamic MRI, or CT scan rarely needed 2.
- Symptomatic groin hernias should be treated surgically, while asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low 2, 3, 4.
- Mesh repair is recommended as the first choice, either by an open procedure or a laparo-endoscopic repair technique, with Lichtenstein and laparo-endoscopic repair being the best-evaluated techniques 2, 5, 6.
Surgical Techniques and Considerations
- Surgeons should provide both anterior and posterior approach options, with the choice of procedure tailored to the surgeon's expertise, patient- and hernia-related characteristics, and local/national resources 2, 6.
- Laparo-endoscopic techniques have faster recovery times, lower chronic pain risk, and are cost-effective, but require expertise and resources 2, 5, 4.
- The use of low-weight mesh may have slight short-term benefits, but is not associated with better longer-term outcomes, and mesh selection should not be based on weight alone 2.
Postoperative Care and Complications
- Patients should resume normal activities without restrictions as soon as they feel comfortable, and perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair 2.
- Chronic postoperative inguinal pain (CPIP) is a significant complication, with risk factors including young age, female gender, high preoperative pain, and open repair, and should be managed by multi-disciplinary teams using a combination of pharmacological and interventional measures 2.