What is the recommended surgical approach for an otherwise healthy adult with an uncomplicated inguinal hernia?

Principles of Uncomplicated Inguinal Hernia Surgery

For an otherwise healthy adult with an uncomplicated inguinal hernia, tension-free mesh repair is the definitive surgical approach, with both open (Lichtenstein) and laparoscopic techniques (TEP/TAPP) offering excellent outcomes—the choice depends on surgeon expertise, with laparoscopic approaches providing advantages of reduced chronic pain, faster recovery, and lower wound infection rates. 1, 2, 3

Fundamental Surgical Principle

• Mesh repair is mandatory as the standard of care for all uncomplicated inguinal hernias, demonstrating significantly lower recurrence rates (0-3%) compared to tissue repair (10-35%) without increasing infection risk in clean surgical fields 1, 2, 3
• Tension-free closure using prosthetic mesh reinforcement forms the cornerstone of modern hernia surgery 2
• The mesh must overlap the defect edges by at least 5 cm (or 1.5-2.5 cm minimum) to prevent recurrence through failure of the host-prosthesis interface 1, 2

Surgical Approach Selection

Open Mesh Repair (Lichtenstein Technique)

• The Lichtenstein repair remains the most common open mesh-based repair performed, with proven efficacy and low complication rates 4, 3
• Local anesthesia is recommended for open repair, providing effective anesthesia with fewer cardiac and respiratory complications, shorter hospital stays, lower costs, and faster recovery compared to general anesthesia 5, 2, 3
• Perioperative field blocks and/or subfascial/subcutaneous infiltrations should be used in all open repair cases 3
• Standard polypropylene mesh remains the preferred choice, though lightweight meshes may offer slight short-term benefits in postoperative pain without improving long-term outcomes 6, 3

Laparoscopic Repair (TEP/TAPP)

• Laparoscopic approaches (TEP or TAPP) are recommended when expertise is available, offering comparable recurrence rates to open repair with significant advantages 1, 7, 3
• Key benefits include: reduced chronic postoperative pain and numbness, faster return to normal activities, decreased wound infection rates (P<0.018), and lower hematoma incidence 1, 7, 3
• Both TEP and TAPP demonstrate comparable outcomes with low complication rates; TAPP may be easier in recurrent cases or when TEP proves technically difficult 1
• TAPP allows identification of occult contralateral hernias (present in 11.2-50% of cases), and after patient consent, the contralateral side should be inspected during TAPP 1, 3
• Mesh fixation in TEP is unnecessary in most cases; however, fixation is recommended for large medial hernias (M3) in both TEP and TAPP to reduce recurrence risk 3
• General anesthesia is required for laparoscopic approaches 5, 2

Mesh Selection and Placement

• Synthetic mesh is the standard in clean surgical fields (CDC Class I), providing durable reinforcement 1, 2
• Mesh selection should not be based on weight alone; so-called low-weight meshes may reduce short-term postoperative pain but are not associated with better long-term outcomes regarding recurrence or chronic pain 3
• Plug repair techniques are not recommended due to higher erosion incidence compared to flat mesh 3
• Surgeons must be aware of the intrinsic characteristics of the meshes they use 3

Antimicrobial Prophylaxis

• Antibiotic prophylaxis is NOT recommended for average-risk patients in low-risk environments undergoing open surgery 3
• Antibiotic prophylaxis is never recommended for laparoscopic repair 3
• Prophylactic antibiotics should only be used in centers with high rates of wound infection 6

Anesthesia Considerations

• Local anesthesia is strongly recommended for open repair provided the surgeon is experienced in this technique, offering multiple advantages 5, 2, 3
• For patients aged 65 and older, general anesthesia is suggested over regional anesthesia as it may be associated with fewer complications including myocardial infarction, pneumonia, and thromboembolism 3
• General anesthesia is mandatory for laparoscopic approaches 5, 2

Perioperative Management

• Day surgery is recommended for the majority of groin hernia repairs provided aftercare is organized 3
• Patients should resume normal activities without restrictions as soon as they feel comfortable 3
• Pain control should prioritize acetaminophen and NSAIDs as primary agents 1
• For laparoscopic repair: limit opioid prescribing to 10 tablets of oxycodone 5mg or 15 tablets of hydrocodone/acetaminophen 5/325mg 1
• For open repair: limit to 15 tablets of hydrocodone/acetaminophen 5/325mg 1

Surgeon Expertise and Learning Curves

• Approximately 100 supervised laparoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein 3
• Surgeon case load is more important than center volume for optimal outcomes 3
• Surgical treatment should be tailored to surgeon expertise, with services ideally providing both anterior and posterior approach options 3

Common Pitfalls to Avoid

• Insufficient mesh overlap (<5 cm) leads to recurrence through failure of the host-prosthesis interface 1, 2
• Performing tissue repair instead of mesh repair results in unacceptably high recurrence rates (10-35% vs 0-3%) 2, 3
• Using plug techniques increases erosion risk and should be avoided 3
• Overlooking contralateral hernias during unilateral repair—laparoscopic TAPP allows visualization to identify occult hernias present in up to 50% of cases 1
• Failing to use local anesthesia for open repair when appropriate, missing opportunities for reduced complications and costs 5, 2

Expected Outcomes

• Overall clinically significant chronic pain incidence is 10-12%, decreasing over time 3
• Debilitating chronic pain affecting normal daily activities or work ranges from 0.5-6% 3
• Recurrence rates with proper mesh repair are 0-3% regardless of technique when performed by experienced surgeons 2, 3
• All repair techniques report similar and low rates of 30-day complications when performed appropriately 4