What is the recommended management for a patient presenting with an inguinal hernia?

Management of Inguinal Hernia

Immediate Assessment: Determine Urgency

The first critical decision is whether the hernia is reducible or incarcerated/strangulated, as this determines whether emergency surgery is needed immediately or elective repair can be planned. 1, 2

Emergency Indicators Requiring Immediate Surgery:

• Strangulated hernias demand immediate surgical intervention to prevent bowel necrosis and death 3
• Predictive markers of strangulation include systemic inflammatory response syndrome (SIRS), elevated lactate, serum creatinine phosphokinase (CPK), D-dimer levels, and contrast-enhanced CT findings showing bowel wall ischemia 1, 3
• Delayed diagnosis beyond 24 hours significantly increases mortality rates 1, 3
• Incarcerated hernias require urgent (though not necessarily emergent) repair 3

Contraindications to Manual Reduction:

• Skin changes over the hernia (erythema, warmth, discoloration) 1
• Firm, tender, irreducible mass 1
• Peritoneal signs on examination 1
• Even if manual reduction is successful, same-admission surgery is indicated to prevent recurrent incarceration, and diagnostic laparoscopy should be considered to evaluate bowel viability and rule out occult ischemia 1, 3

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Elective Management of Non-Complicated Hernias

Surgical vs. Watchful Waiting:

• Symptomatic groin hernias should be treated surgically 1, 4
• Asymptomatic or minimally symptomatic male inguinal hernia patients may be managed with watchful waiting since their risk of hernia-related emergencies is low 4, 5
• However, 35-58% of watchful waiting patients will eventually require surgery 5
• Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities 4

Standard Surgical Approach:

Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias, with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk in clean surgical fields 1, 2, 3, 4

Choice Between Open and Laparoscopic:

• Laparoscopic approaches (TAPP or TEP) offer comparable outcomes to open repair with advantages including reduced postoperative pain medication requirements, lower wound infection rates, and faster return to normal activities 1, 2, 4
• Laparoscopic repair is particularly beneficial for bilateral hernias and allows identification of occult contralateral hernias (present in 11.2-50% of cases) 1, 2, 3
• The Lichtenstein technique is the standard for open inguinal hernia repair 4, 6
• Open repair can be performed under local anesthesia, which has many advantages in appropriate patients 4
• For women with groin hernias, laparoscopic repair is suggested to decrease the risk of chronic pain and avoid missing a femoral hernia 4

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Emergency Management of Incarcerated/Strangulated Hernias

Surgical Field Classification and Mesh Selection:

Clean surgical field (CDC wound class I):

• Prosthetic repair with synthetic mesh is recommended for intestinal incarceration without signs of strangulation or need for bowel resection 1, 2, 3

Clean-contaminated field (CDC wound class II):

• Emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or concomitant bowel resection without gross enteric spillage, with significantly lower recurrence risk 2, 3

Contaminated/dirty field (CDC wound class III-IV):

• For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair is recommended 2
• When direct suture is not feasible, biological mesh may be used 2
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 2

Laparoscopic vs. Open Approach in Emergencies:

Laparoscopic approach is appropriate when:

• Incarcerated hernia without strangulation and no suspicion of bowel necrosis 2
• Benefits include significantly lower wound infection rates and ability to assess bowel viability throughout the procedure 2, 6

Open preperitoneal approach is preferable when:

• Strangulation is suspected or bowel resection may be needed 2
• Local anesthesia can be used for incarcerated inguinal hernias without bowel gangrene 1, 2, 4

Contraindications to laparoscopic approach:

• Bowel resection is anticipated 2
• Active strangulation with bowel compromise 2
• Inability to tolerate general anesthesia 2

Hernioscopy for Bowel Viability Assessment:

Hernioscopy (laparoscopy through the hernia sac) can be used to evaluate bowel viability, avoiding unnecessary laparotomy and decreasing hospital stay, particularly after spontaneous reduction of a previously incarcerated hernia 1, 2, 3, 6

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Special Populations

Patients with Cirrhosis and Ascites:

• Control ascites before elective herniorrhaphy, as uncontrolled ascites increases recurrence and complication rates 1
• Laparoscopic approaches are recommended for hernia repair when surgery is necessary 1
• Immediate surgical repair is mandatory in cases of hemodynamic instability 1

Femoral Hernias:

• Timely mesh repair by laparoscopic approach is suggested provided expertise is available 4
• Femoral hernias carry an 8-fold higher risk of requiring bowel resection 3

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Perioperative Management

Anesthesia:

• Local anesthesia is recommended for emergency inguinal hernia repair in the absence of bowel gangrene 1, 2
• General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications 4
• Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair 4

Antimicrobial Prophylaxis:

• Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery 4
• In laparoscopic repair, antibiotic prophylaxis is never recommended 4
• 48-hour antimicrobial prophylaxis is recommended for intestinal strangulation and/or concurrent bowel resection (CDC classes II and III) 1, 2, 3
• Full antimicrobial therapy is recommended for patients with peritonitis (CDC class IV) 2, 3

Postoperative Care:

• Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable 4
• Encourage acetaminophen and NSAIDs as primary pain control 2
• Opioid prescribing should be limited: 15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg for laparoscopic repair; 15 tablets for open repair 2
• Day surgery is recommended for the majority of groin hernia repairs provided aftercare is organized 4

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Management of Recurrent Hernias

For recurrent hernia after anterior repair, posterior repair is recommended; if recurrence occurs after posterior repair, an anterior repair is recommended 4

After failed anterior and posterior approaches, management by a specialist hernia surgeon is recommended 4

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Critical Pitfalls to Avoid

• Never delay surgery for imaging when strangulation is clinically suspected—imaging only delays definitive management and worsens outcomes 3
• Do not assume spontaneous reduction excludes bowel ischemia—the bowel may have been compromised during incarceration and reduced while still ischemic 3
• Delaying repair of strangulated hernias can lead to bowel necrosis and increased morbidity/mortality 1, 2, 3
• Overlooking contralateral hernias occurs in up to 50% of cases—laparoscopic approach allows bilateral assessment 1, 2, 3
• Elapsed time from symptom onset to surgery is the most important prognostic factor 3

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Complications and Chronic Pain

• Overall incidence of clinically significant chronic pain is 10-12%, with debilitating pain affecting normal activities ranging from 0.5-6% 4
• Risk factors for chronic postoperative inguinal pain include young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, and open repair 4
• Focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection 4
• Chronic pain management should be performed by multidisciplinary teams using a combination of pharmacological and interventional measures, followed by (triple) neurectomy and mesh removal in selected cases if unsuccessful 4