What is the recommended treatment for an adult patient with an inguinal hernia?

Surgical Repair with Mesh is the Definitive Treatment for Inguinal Hernia

All symptomatic inguinal hernias should undergo surgical repair with mesh, as this approach significantly reduces recurrence rates compared to tissue repair (0% vs 19%) without increasing infection risk. 1, 2

Initial Assessment: Determine Urgency

Signs Requiring Emergency Surgery (Operate Immediately)

• Irreducible hernia with systemic symptoms (fever, tachycardia, leukocytosis) 3
• Abdominal wall rigidity or peritoneal signs 1, 3
• Elevated lactate, CPK, or D-dimer levels suggesting bowel strangulation 2, 4
• Skin changes over hernia (erythema, warmth, discoloration) 4
• Delayed treatment beyond 24 hours dramatically increases mortality 1, 3

Time from symptom onset to surgery is the single most important prognostic factor—symptomatic periods exceeding 8 hours significantly increase morbidity. 1, 3

Reducible, Symptomatic Hernias (Elective Repair)

• Schedule repair within 1-2 weeks for adults 3
• Mesh repair is mandatory as the standard of care 2, 5

Asymptomatic or Minimally Symptomatic Hernias

• Watchful waiting is acceptable for male patients with minimal symptoms, as emergency incarceration risk is low 6, 5
• However, 35-58% will eventually require surgery 6
• Women and femoral hernias should NOT undergo watchful waiting due to higher strangulation risk 2, 5

Surgical Approach Selection

For Non-Complicated Hernias (Clean Field)

Surgeons must offer both open (Lichtenstein) and laparoscopic (TEP or TAPP) options. 7, 5

Laparoscopic repair (TEP or TAPP) is preferred when expertise is available because it provides: 2, 5

• Reduced postoperative pain and faster recovery
• Lower wound infection rates (P<0.018) 2
• Ability to identify occult contralateral hernias (present in 11-50% of cases) 2, 4
• Equivalent recurrence rates to open repair 2

Lichtenstein open mesh repair is the alternative standard when: 7, 5

• Laparoscopic expertise unavailable
• Patient has significant cardiopulmonary comorbidities
• Local anesthesia is preferred (can only be used with open approach) 1, 5

For Emergency/Incarcerated Hernias

Clean Field (Incarceration WITHOUT Strangulation or Bowel Necrosis)

Use synthetic mesh repair—this is a Grade 1A recommendation. 1, 2

• Laparoscopic approach (TEP/TAPP) is appropriate if no signs of bowel compromise 2
• Open repair under local anesthesia is acceptable if no bowel gangrene suspected 1, 4

Clean-Contaminated Field (Strangulation WITH Bowel Resection, No Gross Spillage)

Synthetic mesh can still be used and significantly reduces recurrence without increasing 30-day wound complications—this is a Grade 1A recommendation. 1, 2

• Open preperitoneal approach is preferable when bowel resection anticipated 2
• General anesthesia is required when bowel gangrene suspected 2

Contaminated/Dirty Field (Bowel Necrosis, Peritonitis, Gross Spillage)

For small defects (<3 cm): perform primary tissue repair 2 For larger defects: use biological mesh if available, or polyglactin mesh as alternative 2

Critical Technique: Hernioscopy for Uncertain Bowel Viability

When hernia spontaneously reduces or viability is uncertain, perform hernioscopy (laparoscopy through hernia sac) to assess bowel. 2, 4, 8

• Decreases hospital stay and prevents unnecessary laparotomies 2
• Can be performed by surgeons without advanced laparoscopic skills 8
• Avoids bowel resection in many cases 8

Special Populations

Femoral Hernias

• 8-fold higher risk of requiring bowel resection 2
• Laparoscopic approach strongly suggested to avoid missing diagnosis and reduce chronic pain 5

Women

• Laparoscopic repair recommended to decrease chronic pain risk and avoid missing femoral hernias 5

Bilateral Hernias

• Laparoscopic approach is superior for simultaneous repair 7, 5
• During TAPP, inspect contralateral side after patient consent 5

Postoperative Management

Pain Control

Prioritize acetaminophen and NSAIDs as first-line. 2

• For laparoscopic repair: prescribe maximum 10 tablets oxycodone 5mg or 15 tablets hydrocodone/acetaminophen 5/325mg 2
• For open repair: prescribe maximum 15 tablets 2

Activity Restrictions

Patients should resume normal activities without restrictions as soon as comfortable. 5

Antibiotic Prophylaxis

• Not recommended for average-risk patients in open repair 5
• Never recommended for laparoscopic repair 5
• 48-hour prophylaxis required for intestinal strangulation with bowel resection 2

Common Pitfalls to Avoid

• Delaying surgery in strangulated hernias—every hour counts, with 24-hour delay dramatically increasing mortality 1, 3, 4
• Missing contralateral hernias—examine both groins and consider laparoscopic approach to visualize opposite side 3, 2
• Missing femoral hernias in women—these have higher strangulation risk and are often misdiagnosed 3, 5
• Attempting manual reduction with peritoneal signs or skin changes—this is contraindicated and requires immediate surgery 4
• Using tissue repair instead of mesh—recurrence rates are unacceptably high (19% vs 0%) 1, 2