What is the current practice of inguinal hernia surgery?

Current Practice of Inguinal Hernia Surgery

Mesh repair is the definitive standard of care for inguinal hernia surgery, with both open (Lichtenstein) and laparoscopic approaches (TEP/TAPP) recommended as equally valid options that surgeons should be able to offer based on patient-specific factors. 1

Surgical Approach Selection

Standard Elective Repair

• Mesh repair is strongly recommended over tissue repair due to significantly lower recurrence rates (0% vs 19%) without increased infection risk in clean surgical fields 1
• Surgeons should master both an anterior open approach (Lichtenstein) and a posterior laparoscopic approach (TEP or TAPP) to provide tailored treatment 2
• The Lichtenstein technique remains the gold standard for open repair, offering universal applicability, cost-effectiveness, ease of training, and excellent outcomes 3

Laparoscopic vs Open Decision Framework

Laparoscopic repair (TEP or TAPP) is particularly advantageous for:

• Bilateral hernias - allows simultaneous repair of both sides 1
• Recurrent hernias after previous open repair 1
• Patients requiring rapid return to physical activity - associated with reduced postoperative pain and faster recovery 1
• Detection of occult contralateral hernias (present in 11.2-50% of cases) 1

Open repair is preferred when:

• Significant comorbidities preclude general anesthesia - local anesthesia is an option 1
• Limited laparoscopic expertise is available 1
• Patient preference after informed consent regarding both approaches 4

Technical Specifications

• TEP and TAPP demonstrate comparable outcomes with low complication rates 1
• TAPP may be technically easier in recurrent cases or when TEP proves difficult 1
• Mesh should overlap the defect edge by 1.5-2.5 cm for adequate coverage 1
• Laparoscopic approaches show significantly lower wound infection rates (P<0.018) with no increase in recurrence rates (P<0.815) compared to open repair 1

Emergency/Incarcerated Hernia Management

Immediate Assessment

Determine urgency based on clinical presentation:

• SIRS criteria, elevated lactate, CPK, D-dimer levels, and contrast-enhanced CT findings predict bowel strangulation and mandate immediate surgery 1
• Delayed diagnosis beyond 24 hours significantly increases mortality in strangulated hernias 1
• Femoral hernias carry an 8-fold higher risk of requiring bowel resection 1

Surgical Approach Algorithm for Emergency Cases

For incarcerated hernias WITHOUT strangulation:

• Prosthetic mesh repair with synthetic mesh is strongly recommended (Grade 1A) 1
• Laparoscopic approach (TEP or TAPP) is appropriate when no clinical signs of strangulation or peritonitis are present 1
• Local anesthesia can be used for open repair in the absence of bowel gangrene 1

For strangulated hernias or suspected bowel compromise:

• Open preperitoneal approach is preferable when bowel resection may be needed 1
• General anesthesia is required when bowel gangrene is suspected or peritonitis is present 1
• Hernioscopy (laparoscopy through hernia sac) can assess bowel viability, avoiding unnecessary laparotomy and decreasing hospital stay 1

Mesh Use in Contaminated Fields

Clean surgical field (CDC class I):

• Synthetic mesh is standard for incarcerated hernias without strangulation or bowel resection 1

Clean-contaminated field (CDC class II):

• Synthetic mesh can be used even with intestinal strangulation and/or bowel resection without gross enteric spillage, associated with significantly lower recurrence risk 1

Contaminated/dirty fields (CDC class III-IV):

• For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair is recommended 1
• Biological mesh may be used when direct suture is not feasible 1
• If biological mesh is unavailable, polyglactin mesh repair or open wound management with delayed repair are alternatives 1

Pediatric Considerations

All inguinal hernias in newborns and infants require surgical repair within 2-4 weeks of diagnosis to prevent life-threatening complications including incarceration, bowel strangulation, and gonadal infarction 5, 6

Key Differences from Adult Repair

• Herniotomy (high ligation of hernia sac) is the procedure of choice - NOT mesh repair 5
• Mesh repair is contraindicated in primary newborn hernia repair due to high complication risk 5, 6
• Pediatric inguinal hernias are indirect hernias from patent processus vaginalis requiring only sac ligation 5
• Complication rate is 1-8% with recurrence rates around 1% 6

Contralateral Evaluation in Pediatrics

• Consider laparoscopic evaluation of the contralateral side, particularly in high-risk patients (age <4 years, left-sided initial hernia) 5
• Contralateral patent processus vaginalis occurs in 64% of infants younger than 2 months and 33-50% of children younger than 1 year 5
• Prophylactic closure reduces metachronous contralateral hernia risk by 5.7% and eliminates need for second anesthesia exposure 5, 6

Postoperative Pain Management

Prioritize non-opioid analgesia:

• Acetaminophen and NSAIDs should be the primary form of pain control 1
• For laparoscopic repair: limit opioids to 15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg 1
• For open repair: limit to 15 tablets of hydrocodone/acetaminophen 5/325mg 1

Common Pitfalls to Avoid

• Never delay repair of strangulated hernias - leads to bowel necrosis and increased morbidity/mortality 1
• Do not overlook contralateral hernias - consider laparoscopic approach to identify occult hernias present in up to 50% of cases 1
• In pediatric cases, do not delay repair until school age - this is not evidence-based and exposes the child to unnecessary incarceration risk 5, 6
• Do not use mesh in primary newborn hernia repair - herniotomy is the appropriate technique 5, 6
• Do not simply observe reducible hernias in infants - all require surgical correction 5
• Chronic pain and quality of life metrics now supersede recurrence as the primary clinical outcome, making informed consent about approach selection critical 3, 4