Hernioplasty: Recommended Treatment for Adult Hernia
Primary Recommendation
For an adult patient with a diagnosed hernia and no significant medical conditions, prosthetic repair with synthetic mesh is the definitive treatment, with laparoscopic approaches (TEP or TAPP) preferred as first-line due to lower chronic pain rates, reduced wound infections, and faster recovery compared to open repair. 1, 2, 3
Surgical Approach Selection
Laparoscopic Repair (Preferred)
- Laparoscopic techniques (TEP or TAPP) should be the first choice for uncomplicated hernias when surgical expertise is available 3, 4
- Laparoscopic repair demonstrates significantly lower wound infection rates (P<0.018) without higher recurrence rates (P<0.815) compared to open approaches 1
- Patients develop chronic pain less frequently with laparoscopic repair than with open surgery 3, 4
- Additional advantages include the ability to evaluate for occult contralateral hernias (present in 11.2-50% of cases) and repair them simultaneously 1, 3
- Recovery is faster with earlier resumption of activities of daily living 5
Open Lichtenstein Repair (Alternative)
- Open anterior mesh repair (Lichtenstein technique) is an acceptable alternative, particularly when laparoscopic expertise is unavailable 3
- This approach can be performed under local anesthesia, making it advantageous for elderly patients or those with significant comorbidities 3
Mesh vs. Tissue Repair
Mesh repair is mandatory over tissue repair to prevent recurrence 1, 2, 3:
- Synthetic mesh in clean surgical fields shows 0% recurrence versus 19% with tissue repair (P<0.05) 1, 3
- Mesh repair does not increase wound infection rates compared to tissue repair 1
- The pathogenesis of hernias involves abnormalities of the extracellular matrix, making mesh reinforcement physiologically rational 4
Technical Considerations
Mesh Placement
- Flat mesh placement is recommended; avoid plug repair techniques due to higher erosion incidence 3
- Mesh should be transfixed to anatomic landmarks with sutures or staples 6
- The peritoneum should be closed to separate mesh from abdominal contents 6
Anesthesia Options
- Local anesthesia is effective for open repair in uncomplicated cases 3
- General anesthesia is typically used for laparoscopic approaches 7
Special Clinical Scenarios
Bilateral Hernias
- Laparoscopic or endoscopic procedures are preferable to open approaches for all bilateral hernias 4
Female Patients
- All inguinal hernias in women should be operated on (watchful waiting is not recommended) 4, 5
- Laparoscopic approaches are preferred 4
Asymptomatic Male Patients
- Watchful waiting is a reasonable and safe option for men with asymptomatic or minimally symptomatic inguinal hernias 5
- However, surgery remains the definitive treatment when symptoms develop 5
Recurrent Hernias
- Laparoscopic repair is particularly advantageous for recurrent hernias, with recurrence rates of 0.5-5% compared to up to 36% with open anterior approaches 8
- The laparoscopic approach avoids already weakened tissues and distorted anatomy from previous repairs 8
Expected Outcomes
Recovery Timeline
- 90% of patients are discharged from perioperative care immediately 6
- 77% return to normal activity within 4 weeks, with 35% returning to vigorous activity 8
- Mean postoperative hospital stay is 1.4 days (range 0-4 days) 8
Recurrence Rates
- Laparoscopic mesh repair shows recurrence rates of 0-5% with proper technique 1, 8, 6
- Most recurrences are due to technical errors rather than method failure 7
Patient Satisfaction
- 92% of patients report complete symptom relief 8
- 86% prefer laparoscopic repair over conventional approaches 8
- 95% would recommend laparoscopic hernia surgery to family and friends 8
Critical Pitfalls to Avoid
Diagnostic Errors
- 14% of primary and 27% of recurrent hernias are complex, a surprisingly high incidence that may be overlooked without laparoscopic visualization 7
- In women, ultrasonography is often needed for diagnosis as physical examination is less reliable 5
- Always inspect the contralateral side during TAPP (after patient consent) due to high occult hernia rates 3
Technical Errors
- All documented recurrences in high-quality series were due to technical errors, not method failure 7
- Ensure adequate mesh overlap and proper fixation to anatomic landmarks 6
- Avoid plug repair techniques 3
Patient Selection Errors
- Do not offer watchful waiting to symptomatic patients or women 4, 5
- Surgeons must master both open and laparoscopic techniques to provide guideline-concordant care 4