What is the best course of treatment for a patient presenting with a hernia?

Treatment of Hernia

Critical Initial Assessment

The optimal treatment for hernia depends fundamentally on the hernia type and clinical presentation—surgical repair with mesh is the standard of care for most hernias, with technique selection based on hernia location, patient stability, and available expertise. 1, 2

Inguinal Hernia Management

Indications for Surgery

• All symptomatic inguinal hernias require surgical repair to prevent life-threatening complications including incarceration and strangulation 3, 2
• All inguinal hernias in women should be operated on regardless of symptoms, due to higher risk of femoral hernia and complications 2, 4
• Asymptomatic or minimally symptomatic male patients may be managed with watchful waiting, though the majority will eventually require surgery 2, 4

Surgical Approach Selection

• Mesh repair is recommended as first choice over tissue repair, given the pathogenesis involves abnormal collagen metabolism and extracellular matrix abnormalities 2, 4
• Laparoscopic/endoscopic repair is preferred for:
  • All bilateral hernias 2, 4
  • All hernias in women 2
  • Recurrent hernias after anterior repair 2
• Open repair (Lichtenstein technique) is appropriate for:
  • Primary unilateral hernias in men 2, 4
  • Recurrent hernias after posterior repair 2
• Laparoscopic techniques result in faster recovery, lower chronic pain rates (10-12% vs higher with open), and are cost-effective when expertise is available 2, 4

Technical Considerations

• Surgeons must master both open and laparoscopic techniques to provide optimal individualized care 4
• Approximately 100 supervised laparoscopic repairs are needed to achieve equivalent outcomes to open mesh surgery 2
• Day surgery is recommended for the majority of repairs 2

Diaphragmatic Hernia Management

Traumatic Diaphragmatic Hernia

• Surgery is strongly recommended in hemodynamically stable patients, preferably with laparoscopic approach to reduce postoperative complications and facilitate early diagnosis 5, 1
• Open laparotomy is indicated for hemodynamically unstable patients 5, 1
• Damage control surgery is strongly recommended for patients with intraoperative instability, hypothermia, coagulopathy, or significant acidosis 5, 1

Repair Technique

• Primary repair with non-absorbable sutures (2-0 or 1-0 monofilament/braided) in two layers should be attempted first when defects can be closed without tension 5, 1
• Mesh reinforcement is mandatory for defects >3 cm, >8 cm, or >20 cm² area due to 42% recurrence rate with primary repair alone 5, 1
• Biosynthetic, biologic, or composite meshes are preferred over synthetic due to lower recurrence rates, higher infection resistance, and lower displacement risk 5, 1

Adjunctive Procedures

• PEG, gastrostomy, or jejunostomy should be considered in patients with oral intake difficulties, particularly high-risk elderly patients 1
• Preemptive anti-reflux surgery is NOT recommended in emergency traumatic or complicated hernia settings 5, 1

Ventral/Abdominal Wall Hernia

Complex Ventral Hernias

• Retrorectus placement of macroporous polypropylene mesh with extensive suture fixation (up to 45 points) achieves superior outcomes compared to wide meshes with minimal fixation 6
• This approach demonstrates zero recurrence rates and low surgical site occurrence rates (7.9%) across all Ventral Hernia Working Group grades 6

Spigelian Hernia

• Urgent surgical approach with mesh repair is required when presenting with small bowel obstruction 7
• Minilaparotomy with preperitoneal mesh positioning is effective for large defects 7

Anesthesia Considerations

• Local anesthesia is recommended for open inguinal hernia repair when surgeon expertise is available, offering multiple advantages 2
• General anesthesia is preferred over regional in patients ≥65 years due to lower risk of myocardial infarction, pneumonia, and thromboembolism 2
• Perioperative field blocks and subfascial/subcutaneous infiltrations are recommended in all open repairs 2

Postoperative Management

• Patients should resume normal activities without restrictions as soon as comfortable 2
• Antibiotic prophylaxis is NOT recommended in average-risk patients in low-risk environments for open surgery, and never for laparoscopic repair 2

Common Pitfalls

• Missing femoral hernias in women—laparoscopic approach allows visualization and treatment 2
• Inadequate mesh fixation in large medial (M3) hernias during TEP/TAPP—fixation reduces recurrence risk 2
• Using plug repair techniques—associated with higher erosion rates compared to flat mesh 2
• Delayed diagnosis of diaphragmatic hernia—33-66% are missed in acute trauma due to associated injuries 5