What is the recommended open hernia repair method for an adult patient with a hernia?

Open Hernia Repair Methods for Adult Patients

For adult inguinal hernias in clean surgical fields, prosthetic mesh repair using the Lichtenstein technique is the recommended first-line approach, demonstrating significantly superior recurrence rates (0.2-0.9%) compared to tissue-based repairs (4.2-19%) without increased infection risk. 1, 2, 3

Primary Repair Selection Algorithm

For Uncomplicated Inguinal Hernias (Clean Field)

Mesh-based repair is mandatory - The American College of Surgeons establishes prosthetic repair with synthetic mesh as standard treatment for all direct inguinal hernias in clean surgical fields 1. This recommendation extends to most inguinal hernias given the dramatic difference in outcomes.

• Lichtenstein technique (open anterior approach) is the most extensively evaluated mesh repair method, utilizing flat mesh placement in the anterior inguinal space 1, 4
• This technique achieves recurrence rates of 0.2-0.9% versus 4.2-19% with tissue-based repairs 2, 3, 5
• Can be performed under local anesthesia in 71% of cases, making it suitable for elderly patients and those with significant comorbidities 1, 6

Alternative: Laparoscopic posterior approaches (TEP or TAPP) are recommended as first choice when expertise is available, offering faster recovery, lower chronic pain risk, reduced wound infection rates (P<0.018), and ability to identify occult contralateral hernias present in 11.2-50% of cases 1

For Contaminated/Dirty Fields (CDC Class III-IV)

The approach must be stratified by defect size and contamination level:

• Small defects (<3 cm): Primary suture repair is recommended 7
• Larger defects when direct suture not feasible: Biological mesh is the preferred option 7
  • Cross-linked biological meshes resist mechanical stress better and longer, suitable for larger defects 7
  • Non-cross-linked meshes are completely remodeling, better for moderate contamination 7
• If biological mesh unavailable: Polyglactin mesh repair or open wound management with delayed repair are viable alternatives 7

Critical Technical Considerations

Mesh Selection and Placement

• Avoid plug repair techniques due to higher erosion incidence compared to flat mesh 1
• Polypropylene mesh in contaminated fields (CDC Class III) carries 19-21% infection rates and should be avoided 7
• Modified Lichtenstein for complex hernias includes: lateral mesh fixation 20-30 degrees caudal to tubercle, running "U" suture to both Poupart's and Cooper's ligaments, and specific internal ring "locking" sutures 6

Anesthesia Approach

• Local anesthesia is recommended for open repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 1, 6
• 71% of cases can be successfully performed under local anesthesia as outpatient procedures 6

Tissue-Based Repair: Limited Role

The Shouldice technique is the best non-mesh repair option but has significant limitations:

• Recurrence rate of 4.2% versus 0.9% with Lichtenstein (RR 3.68,95% CI 2.05-6.60, p<0.001) 2
• Number needed to treat to prevent one recurrence is 30.3 patients 2
• May be considered only in highly selected patients where mesh is contraindicated 2, 3
• Recent 2024 meta-analysis confirms Lichtenstein superiority despite Shouldice being the "best" tissue repair 2

Common Pitfalls to Avoid

• Delayed intervention in strangulation: Diagnosis delay >24 hours is associated with significantly higher mortality rates; immediate surgical intervention is mandatory when intestinal strangulation is suspected 1
• Ignoring contralateral hernias: During TAPP, inspect the contralateral side after patient consent, as occult hernias are present in up to 50% of cases 1
• Using absorbable prosthesis: These inevitably lead to hernia recurrence due to complete dissolution of prosthetic support 7
• Inadequate mesh overlap in contaminated fields: Recurrence is largely due to failure of the host-prosthesis interface from improper fixation with minimal overlap 7

Expected Outcomes

• Lichtenstein technique complications: Hematoma 1.86%, seroma 0.4%, wound infection 0.4%, chronic pain 1.7%, recurrence 0.16-0.2% 6, 5
• Chronic pain rates are comparable between Lichtenstein and laparoscopic techniques in long-term follow-up 4
• Hospital stay: Mean 2.5 hours for day surgery or 1.6 days for inpatient procedures 6