What are the treatment options for a patient with a left-sided inguinal hernia?

Treatment of Left-Sided Inguinal Hernia

Surgical repair with mesh is the definitive treatment for inguinal hernias, with laparoscopic approaches (TEP or TAPP) offering superior outcomes including faster recovery, lower infection rates, and reduced recurrence compared to open repair. 1, 2

Initial Assessment

Determine whether the hernia is:

• Reducible (uncomplicated): Contents can be pushed back into the abdomen
• Incarcerated: Contents trapped but no vascular compromise
• Strangulated: Vascular compromise with risk of bowel necrosis 1, 3

Look for these red flags indicating strangulation:

• Constant pain (versus intermittent pain with reducible hernias)
• Systemic inflammatory response syndrome (SIRS) criteria
• Elevated lactate, CPK, or D-dimer levels
• Contrast-enhanced CT showing bowel wall ischemia
• Peritoneal signs on examination 1, 3

Critical pitfall: If a previously palpable hernia suddenly becomes non-palpable with new abdominal tenderness, suspect spontaneous reduction of strangulated bowel—this requires emergency diagnostic laparoscopy as ischemic bowel may now be in the abdomen. 4

Treatment Algorithm for Uncomplicated Hernias

Surgical Approach Selection

Laparoscopic repair (TEP or TAPP) is preferred when expertise is available, offering: 1

• Faster return to normal activities (6 vs 10 days) and work (14 vs 21 days)
• Lower wound infection rates (statistically significant, P<0.018)
• Reduced chronic postoperative pain and numbness
• Lower recurrence rates (3% vs 6% with open repair)
• Ability to identify occult contralateral hernias (present in 11-50% of cases) 1, 2

Open mesh repair (Lichtenstein technique) is appropriate when: 1

• Laparoscopic expertise unavailable
• Patient has significant comorbidities
• Local anesthesia preferred (offers fewer cardiac/respiratory complications, shorter hospital stay, lower costs) 1

Mesh repair is mandatory—tissue repair alone has a 19% recurrence rate versus 0% with mesh in clean fields. 1

Watchful Waiting Option

For truly asymptomatic or minimally symptomatic hernias, watchful waiting is acceptable with these caveats: 5, 6

• Conversion to surgery occurs in 35-58% of patients
• Acute incarceration risk is low but present
• Chronic pain after repair is common (consider this when deciding)
• Patient must understand risks and commit to monitoring 5

However, most symptomatic hernias warrant repair to prevent complications and improve quality of life. 6

Emergency Management for Complicated Hernias

Strangulated/Incarcerated Hernias

Immediate surgical intervention is mandatory when strangulation is suspected—delayed diagnosis beyond 24 hours significantly increases mortality. 1, 3

Surgical approach depends on clinical presentation:

• No signs of strangulation or peritonitis: Laparoscopic approach (TEP/TAPP) with synthetic mesh is appropriate 1

• Suspected strangulation or need for bowel resection: Open preperitoneal approach is preferable 1

• Hemodynamic instability: Emergency open repair 3

Hernioscopy technique (laparoscopy through hernia sac) should be used to assess bowel viability after spontaneous reduction, avoiding unnecessary laparotomy and decreasing hospital stay. 1, 4

Mesh Selection in Contaminated Fields

• Clean field (no bowel compromise): Synthetic mesh strongly recommended 1

• Clean-contaminated (strangulation with bowel resection, no gross spillage): Synthetic mesh can still be used safely 1, 4

• Contaminated/dirty fields (bowel necrosis, peritonitis):

  • Primary repair for defects <3 cm
  • Biological mesh if direct suture not feasible
  • Polyglactin mesh or delayed repair if biological mesh unavailable 1

Anesthesia Considerations

• Local anesthesia: Recommended for open repair of incarcerated hernias without bowel gangrene 1, 3

• General anesthesia: Required for laparoscopic approaches and when bowel gangrene suspected 1

Technical Principles

Mesh must overlap defect edge by 1.5-2.5 cm to ensure adequate coverage. 1

For defects >3 cm: Mesh reinforcement is mandatory—primary repair alone has 42% recurrence rate. 1

Both TEP and TAPP demonstrate comparable outcomes; TAPP may be easier in recurrent cases or when TEP proves technically difficult. 1

Postoperative Management

Pain control: Prioritize acetaminophen and NSAIDs; limit opioids to 10-15 tablets of hydrocodone/acetaminophen 5/325mg or oxycodone 5mg for laparoscopic repair. 1

Antimicrobial prophylaxis: 48-hour coverage for intestinal strangulation with bowel resection; full therapy for peritonitis. 1

Monitor for complications: Wound infection, chronic pain, recurrence, and testicular complications in males. 1

Special Populations

Patients with cirrhosis and ascites: Control ascites before elective repair; uncontrolled ascites increases recurrence and complication rates. Laparoscopic approach preferred when surgery necessary. 3