What are the different types of hernia repair methods for a patient with a hernia, considering factors such as hernia type and size, overall health, and medical history?

Different Types of Hernia Repair

The choice of hernia repair method should be stratified primarily by wound contamination status (CDC classification) and hernia complexity, with synthetic mesh repair being the gold standard for clean fields, while biological meshes or tissue repair are reserved for contaminated/infected cases. 1

Repair Selection Based on Wound Classification

Clean Surgical Fields (CDC Class I)

• Synthetic mesh repair is strongly recommended as it provides significantly lower recurrence rates compared to tissue repair without increasing wound infection risk 1
• For groin hernias, mesh repair is the first-choice approach, with either open (Lichtenstein) or laparoscopic techniques (TEP/TAPP) being preferred 2, 3
• Non-mesh tissue repair (such as Mayo repair for umbilical hernias or Shouldice for inguinal hernias) may be considered in clean fields when mesh is contraindicated or patient preference dictates, though recurrence rates are higher 4, 2

Clean-Contaminated Fields (CDC Class II)

• Synthetic mesh can still be safely used in patients with intestinal strangulation requiring bowel resection without gross spillage 1
• This approach shows significantly lower recurrence risk without increasing 30-day wound-related morbidity, regardless of hernia defect size 1
• 48-hour antimicrobial prophylaxis is recommended in these cases 1

Contaminated Fields (CDC Class III) and Dirty Fields (CDC Class IV)

• For stable patients with small defects (<3 cm): primary tissue repair is recommended 1
• For larger defects when direct suture is not feasible: biological mesh may be used 1
• The choice between cross-linked and non-cross-linked biological mesh should depend on defect size and contamination degree 1
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are viable alternatives 1
• For unstable patients (severe sepsis/septic shock): open management is recommended to prevent abdominal compartment syndrome 1

Surgical Approach Options

Open Anterior Repair

• Lichtenstein technique is the most extensively evaluated open mesh repair and serves as the standard anterior approach 2, 3
• Local anesthesia is recommended for Lichtenstein repair when surgeon expertise permits, offering advantages including reduced postoperative complications 1, 2
• Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all open repairs 2

Laparoscopic/Endoscopic Posterior Repair

• TEP (totally extraperitoneal) and TAPP (transabdominal preperitoneal) are the recommended laparoscopic approaches 2, 3
• Laparoscopic techniques offer faster recovery, lower chronic pain risk (10-12% overall incidence vs higher with open), and cost-effectiveness when expertise and resources are available 2, 5
• TEP is preferred over TAPP due to lower complication rates 5
• Mesh fixation in TEP is generally unnecessary except for large medial hernias (M3) where fixation reduces recurrence risk 2
• Approximately 100 supervised laparoscopic repairs are needed to achieve equivalent outcomes to open mesh surgery 2

Special Considerations by Hernia Type

Femoral Hernias:

• Laparoscopic repair is suggested when expertise is available to decrease chronic pain risk 2

Recurrent Hernias:

• After failed anterior repair, posterior repair is recommended 2
• After failed posterior repair, anterior repair is recommended 2
• After both approaches fail, referral to a specialist hernia surgeon is recommended 2
• Laparoscopic repair of recurrent groin hernias shows superior results (0% recurrence) compared to conventional repair (1.5-35% recurrence) 6

Bilateral Hernias:

• During TAPP, the contralateral side should be inspected after patient consent 2
• This is not suggested during unilateral TEP repair 2

Women with Groin Hernias:

• Laparoscopic repair is suggested to decrease chronic pain risk and avoid missing femoral hernias 2

Large Midline Abdominal Wall Hernias:

• Component separation technique may be a useful and low-cost option 1
• Various minimally invasive techniques are available including eTEP, MILOS/eMILOS, and IPOM variants 7

Mesh Selection Considerations

• Surgeons should be aware of intrinsic mesh characteristics 2
• Low-weight mesh may provide slight short-term benefits (reduced postoperative pain, shorter convalescence) but shows no better long-term outcomes for recurrence or chronic pain 2
• Mesh selection based on weight alone is not recommended 2
• Plug repair techniques are not suggested due to higher erosion incidence compared to flat mesh 2

Biological Mesh Performance Data

When biological meshes are indicated (contaminated/infected fields):

• Permacol (cross-linked porcine): 13.8-29% infection rate, 5.8-18.3% recurrence at 12-24 months 1
• Strattice (non-cross-linked porcine): 4.9-29.9% infection rate, 0-43% recurrence 1
• Surgisis (non-cross-linked porcine): 41% infection rate, 61% recurrence at median 47 months 1
• Tutomesh (non-cross-linked bovine): 3% infection rate, 0% recurrence at 12 months 1

Emergency Hernia Repair

• Patients should undergo emergency repair immediately when intestinal strangulation is suspected 1
• SIRS, contrast-enhanced CT findings, lactate, CPK, and D-dimer levels are predictive of bowel strangulation 1
• Diagnostic laparoscopy may be useful for assessing bowel viability after spontaneous reduction of strangulated groin hernias 1
• Laparoscopic approach may be used for incarcerated hernias without strangulation; open preperitoneal approach is preferable when bowel resection is suspected 1

Key Contraindications

• Active local infection is an absolute contraindication to mesh placement 4
• Significant contamination contraindicates mesh placement 4
• In pregnant women, watchful waiting is suggested as groin swelling often consists of self-limited round ligament varicosities 2