Surgical Repair for Symptomatic Hernias in Adults
Surgery is the definitive treatment for symptomatic hernias, with mesh repair being the gold standard—laparoscopic approach is preferred in stable patients due to superior outcomes including lower morbidity (6% vs 18% open), faster recovery, and reduced chronic pain risk. 1, 2
Immediate vs. Elective Repair Decision
Timing of surgery directly impacts mortality and morbidity—emergency repair is mandatory when intestinal strangulation is suspected, as delays beyond 24 hours significantly increase mortality. 3, 2
Emergency Repair Indications:
- Suspected intestinal strangulation or bowel compromise 2
- Signs of systemic inflammatory response syndrome (SIRS) including fever, tachycardia, leukocytosis 3
- Abdominal wall rigidity or peritonitis 3
- Elevated white blood cell count with fibrinogen elevation (independently predictive of strangulation) 2
- Symptomatic period lasting longer than 8 hours increases morbidity risk 3
Elective Repair Considerations:
- Asymptomatic or minimally symptomatic inguinal hernias in males may be managed with watchful waiting, as the risk of hernia-related emergencies is low 4, 5
- However, 30-57.8% of patients on watchful waiting eventually require surgery 6, 5
- Patients should be informed that chronic pain after repair occurs in 5-12% at one year, particularly relevant for asymptomatic hernias 7, 8
Surgical Approach Selection
Laparoscopic repair is strongly recommended as the gold standard for stable patients, offering an excellent safety profile with in-hospital mortality of only 0.14%. 3, 1
Laparoscopic Advantages:
- Faster recovery times and shorter hospital stays 4
- Lower chronic pain risk compared to open repair 4, 7
- Cost-effective when performed as day surgery with minimal disposables 4
- Lower morbidity rate (6%) versus open approach (18%) 3
Open Approach Indications:
- Unstable patients with severe sepsis or septic shock (to prevent abdominal compartment syndrome) 2
- When bowel gangrene is suspected or intestinal resection is needed 2
- Recurrent hernia after previous laparoscopic repair (anterior approach recommended after posterior failure) 4
Key Operative Principles
Primary Repair Technique:
- Primary crural closure using interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers is the first-line approach 1, 9
- Mesh reinforcement is mandatory for defects >3 cm or when primary closure creates excessive tension 1, 9
- Primary repair alone has an unacceptably high recurrence rate of 42%—mesh reinforcement significantly reduces this risk 1, 2
Mesh Selection and Placement:
- Biosynthetic, biologic, or composite meshes are preferred over synthetic due to lower recurrence rates, higher infection resistance, and lower displacement risk 1, 9
- Mesh should overlap defect edges by 1.5-2.5 cm 3, 1
- In laparoscopic TEP repair, mesh fixation is unnecessary in most cases 4
- Mesh fixation is recommended in large medial hernias (M3) to reduce recurrence risk 4
- Synthetic mesh can be safely used even with intestinal strangulation/bowel resection without gross enteric spillage 2
Critical Pitfall to Avoid:
Never use mesh in dirty fields with unstable patients—this leads to catastrophic complications. 2 In contaminated fields, biologic or biosynthetic meshes can be safely used 3
Anesthesia Selection
Local anesthesia is recommended for open repair in stable patients, providing fewer cardiac and respiratory complications, shorter hospital stays, lower costs, and faster recovery compared to general anesthesia. 2, 7
Local Anesthesia Benefits:
- Eliminates urinary retention risk 7
- Higher patient satisfaction than other techniques 7
- Conversion rate to general anesthesia is <1% 7
- Facilitates faster mobilization and earlier discharge 7
General Anesthesia Indications:
- Mandatory when bowel gangrene is suspected, intestinal resection needed, or peritonitis present 2
- Suggested over regional anesthesia in patients aged ≥65 years (fewer complications including myocardial infarction, pneumonia, thromboembolism) 4
Perioperative Pain Management:
- Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all open repairs 4
- Postoperative pain is best treated with combination of local analgesia and peripherally acting agents (paracetamol, NSAIDs) 7
- Avoid opioids due to side effects (nausea, sedation) 7
Special Populations
Women with Groin Hernias:
- Laparoscopic repair is suggested to decrease chronic pain risk and avoid missing a femoral hernia 4
- Femoral hernias should undergo timely mesh repair by laparoscopic approach when expertise is available 4
Pregnant Women:
- Watchful waiting is suggested, as groin swelling most often consists of self-limited round ligament varicosities 4
High-Risk Elderly Patients:
- Percutaneous endoscopic gastrostomy (PEG) or gastrostomy is suggested for patients unsuitable for definitive surgical repair 1
Postoperative Management
Activity Resumption:
- Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable 4
- No documentation supports that prolonged convalescence reduces recurrence risk 7
- Mean duration of convalescence with short convalescence recommendations is 6-8 days 7
Day Surgery:
- Day surgery is recommended for the majority of groin hernia repairs, provided aftercare is organized 4
- No medical or surgical contraindications exist for day-case surgery, including recurrent hernias 7
Management of Complications
Chronic Postoperative Inguinal Pain (CPIP):
- Defined as bothersome moderate pain impacting daily activities lasting ≥3 months postoperatively 4
- Overall incidence of clinically significant chronic pain is 10-12%, with debilitating pain affecting work in 0.5-6% 4
- Risk factors include young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, and open repair 4
- Management should be performed by multidisciplinary teams using combination of pharmacological and interventional measures 4
- In selected cases after failed conservative management, (triple) neurectomy and mesh removal may be considered 4