Inguinal Hernia Treatment and Management
Definitive Treatment Recommendation
All symptomatic inguinal hernias should undergo surgical repair with mesh, as this approach reduces recurrence rates to 0% compared to 19% with tissue repair, without increasing infection risk 1, 2.
Emergency vs. Elective Management Algorithm
Immediate Emergency Surgery Required When:
- Irreducible hernia with systemic symptoms (fever, tachycardia, leukocytosis) 2
- Abdominal wall rigidity or peritoneal signs 2
- Skin changes over hernia (erythema, warmth, discoloration) 2
- Elevated biomarkers suggesting strangulation (lactate, CPK, D-dimer) 2, 3
- SIRS criteria or contrast-enhanced CT findings indicating bowel ischemia 1, 3
Time is critical: Delayed diagnosis beyond 24 hours dramatically increases mortality 2, 3, and symptomatic periods exceeding 8 hours significantly increase morbidity 2. Every hour counts in strangulated hernias 4.
Elective Repair Appropriate When:
- Reducible hernia without signs of strangulation 1
- Symptomatic hernia causing discomfort but no emergency features 2
Surgical Approach Selection
For Non-Complicated Hernias:
Laparoscopic repair (TEP or TAPP) is recommended when expertise is available, offering 1, 2:
- Reduced chronic postoperative pain and numbness 1
- Faster return to normal activities 1
- Lower wound infection rates (P<0.018) 1
- Ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1
- No increase in recurrence rates compared to open repair 1
Open Lichtenstein repair remains the standard alternative, particularly when 1, 5:
- Laparoscopic expertise unavailable 5
- Patient has significant comorbidities 1
- Local anesthesia preferred (offers fewer cardiac/respiratory complications, shorter hospital stays, lower costs) 1
Both approaches demonstrate comparable recurrence rates when performed correctly 1, 5.
For Incarcerated/Strangulated Hernias:
Clean surgical field (no strangulation, no bowel resection needed):
- Prosthetic mesh repair with synthetic mesh is strongly recommended (Grade 1A) 1, 2
- Laparoscopic approach (TEP/TAPP) appropriate when no clinical signs of strangulation or peritonitis 1
- Local anesthesia can be used for open repair in absence of bowel gangrene 1, 3
Clean-contaminated field (strangulation with bowel resection but no gross spillage):
- Synthetic mesh can still be used safely 1
- Open preperitoneal approach preferable when bowel resection anticipated 1, 2
- General anesthesia required when bowel gangrene suspected 1
Contaminated/dirty field (bowel necrosis or peritonitis):
- For defects <3 cm: primary repair recommended 1
- For larger defects: biological mesh preferred, or polyglactin mesh if biological unavailable 1, 2
- Open wound management with delayed repair is alternative 1
Hernioscopy Technique for Bowel Viability Assessment
Hernioscopy (laparoscopy through hernia sac) should be used to evaluate bowel viability, particularly after spontaneous reduction of strangulated hernias 1, 3. This technique:
- Prevents unnecessary laparotomy 1, 6
- Decreases hospital stay 1
- Reduces major complications in high-risk patients 1
- Can be performed by surgeons with limited laparoscopic experience 6
Special Population Considerations
Women with Inguinal Hernias:
Laparoscopic repair is strongly recommended to avoid missing femoral hernias (which carry 8-fold higher risk of bowel resection) and decrease chronic pain risk 2.
Bilateral Hernias:
Laparoscopic approach is particularly beneficial, allowing simultaneous repair and identification of occult contralateral hernias 1.
Patients with Cirrhosis and Ascites:
- Control ascites before elective herniorrhaphy, as uncontrolled ascites increases recurrence and complication rates 3
- Laparoscopic approaches recommended when surgery necessary 3
Mesh Selection and Technical Principles
Mesh must overlap defect edge by 1.5-2.5 cm 1. Mesh reinforcement is mandatory for defects >3 cm to avoid 42% recurrence rate 1.
Synthetic mesh is standard in clean fields, with significantly lower recurrence rates (0% vs 19% tissue repair) without increased infection risk 1, 2, 4.
For defects >8 cm or >20 cm² area, mesh interposition required 1.
Anesthesia Selection
For open repair: local anesthesia strongly recommended when surgeon experienced, providing 1:
General anesthesia required for:
Antibiotic Prophylaxis
- Not recommended for average-risk patients in open repair 2
- 48-hour prophylaxis required for intestinal strangulation with bowel resection (CDC classes II-III) 1, 2
- Full antimicrobial therapy for peritonitis (CDC class IV) 1
Postoperative Pain Management
Prioritize acetaminophen and NSAIDs as first-line pain control 1, 2. When opioids necessary 1:
- Laparoscopic repair: 15 tablets hydrocodone/acetaminophen 5/325mg OR 10 tablets oxycodone 5mg
- Open repair: 15 tablets hydrocodone/acetaminophen 5/325mg
Critical Pitfalls to Avoid
Never delay surgery in strangulated hernias - mortality increases dramatically with each hour of delay 2, 3, 4. Time from symptom onset to surgery is the single most important prognostic factor 2.
Never attempt manual reduction when:
- Skin changes present (erythema, warmth, discoloration) 3
- Peritoneal signs on examination 3
- Firm, tender, irreducible mass 3
Never use tissue repair instead of mesh - this results in unacceptably high recurrence rates (19% vs 0%) 2.
Never overlook contralateral hernias - examine both groins and consider laparoscopic approach to visualize opposite side (occult hernias present in up to 50% of cases) 1, 2.
Never miss femoral hernias in women - careful examination and consideration of laparoscopic approach essential 2.
Postoperative Monitoring
Monitor for complications including 1: