What are the principles of hernia repair in an adult patient with a history of medical conditions, presenting with an inguinal hernia?

Principles of Hernia Repair in Adults with Inguinal Hernia

Core Surgical Principle: Mesh-Based Repair is Standard

Mesh repair is the definitive standard approach for inguinal hernia repair, offering significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk in clean surgical fields. 1, 2

Fundamental Principles of Hernia Repair

1. Tension-Free Repair with Prosthetic Mesh

• Synthetic mesh is strongly recommended as the standard approach for all non-complicated inguinal hernias, based on superior outcomes compared to tissue repair 1
• Primary tissue repair should only be considered for small defects (<3 cm) in contaminated fields with bowel necrosis or peritonitis 1
• The mesh should overlap the defect edge by 1.5-2.5 cm to ensure adequate coverage 3

2. Surgical Approach Selection Algorithm

For Non-Complicated Hernias:

• Bilateral hernias or hernias in women: Laparoscopic approach (TEP or TAPP) is preferable, offering reduced postoperative pain, lower wound infection rates, and ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 4
• Unilateral hernias in men: Either open (Lichtenstein) or laparoscopic approach is acceptable, though laparoscopic results in less chronic pain 1, 5
• Recurrent hernias: Laparoscopic approach is preferred, with recurrence rates of 0.5-5% compared to up to 36% with open anterior approach 6

For Complicated/Incarcerated Hernias:

• Without strangulation signs: Prosthetic repair with synthetic mesh is recommended (Grade 1A), using either laparoscopic or open approach 1, 2
• With suspected strangulation or bowel compromise: Open preperitoneal approach is preferable when bowel resection may be needed 1, 4
• Emergency setting without bowel gangrene: Local anesthesia can be used for open repair, associated with fewer postoperative complications 1, 2

3. Assessment of Hernia Urgency

Immediate surgical intervention is mandatory when:

• Systemic inflammatory response syndrome (SIRS) is present 2, 4
• Contrast-enhanced CT shows bowel wall ischemia 2
• Elevated lactate, CPK, or D-dimer levels suggest strangulation 1, 2
• Delayed diagnosis beyond 24 hours significantly increases mortality 4

4. Intraoperative Principles

Bowel Viability Assessment:

• Hernioscopy (laparoscopy through hernia sac) can evaluate bowel viability, avoiding unnecessary laparotomy and decreasing hospital stay 1, 2
• Risk factors requiring bowel resection include obvious peritonitis, femoral hernia (8-fold higher risk), and lack of health insurance 1, 4

Mesh Selection Based on Contamination:

• Clean field (CDC Class I): Synthetic mesh is standard 1, 2
• Clean-contaminated field (CDC Class II): Synthetic mesh can still be used even with intestinal strangulation and/or bowel resection without gross spillage 1, 2
• Contaminated/dirty fields (CDC Class III-IV): Biological or biosynthetic meshes are preferred due to lower displacement risk and higher resistance to infections 3, 1

5. Technical Execution Principles

Primary Defect Closure:

• Primary repair with non-absorbable sutures (2-0 or 1-0 monofilament or braided) should be attempted when possible, classically in two layers using interrupted mattress sutures 3
• For defects >3 cm, primary closure creates excessive tension and results in 42% recurrence rate—mesh reinforcement is mandatory 3

Mesh Fixation:

• Mesh can be fixed using tackers or transfascial sutures 3
• Avoid tackers near the pericardium due to risk of cardiac complications 3
• For defects >8 cm or >20 cm² area, mesh interposition is required 3

6. Laparoscopic Technique Selection

TEP (Totally Extraperitoneal) vs TAPP (Transabdominal Preperitoneal):

• Both demonstrate comparable outcomes with low complication rates 1
• TAPP may be easier in recurrent cases or when TEP proves technically difficult 1
• TAPP permits identification of occult contralateral hernias 1
• TEP avoids entering the peritoneal cavity, potentially reducing adhesion risk 5, 7

7. Special Considerations

Contraindications to Laparoscopic Approach:

• Anticipated bowel resection 1
• Active strangulation with bowel compromise 1
• Inability to tolerate general anesthesia 1
• Severe peritonitis requiring open management 1

Patients with Cirrhosis:

• Control ascites before elective herniorrhaphy, as uncontrolled ascites increases recurrence and complication rates 4
• Laparoscopic approaches are recommended when surgery is necessary 4

8. Antimicrobial Prophylaxis Protocol

• Short-term prophylaxis: For intestinal incarceration without ischemia 2
• 48-hour prophylaxis: For intestinal strangulation and/or concurrent bowel resection (CDC Class II-III) 1, 4
• Full antimicrobial therapy: For patients with peritonitis (CDC Class IV) 1

9. Postoperative Pain Management

• Acetaminophen and NSAIDs should be the primary form of pain control 1
• 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 1

Critical Pitfalls to Avoid

• Delaying repair of strangulated hernias leads to bowel necrosis and significantly increased morbidity/mortality 1, 4
• Overlooking contralateral hernias occurs in up to 50% of cases—laparoscopic approach allows bilateral assessment 1
• Using tissue repair instead of mesh results in 19% recurrence rate versus 0% with mesh in clean fields 1
• Attempting primary closure of defects >3 cm creates excessive tension and 42% recurrence rate 3
• Forcing manual reduction when skin changes, peritoneal signs, or firm irreducible mass are present risks bowel perforation 4