What is the recommended treatment for an adult patient with an inguinal hernia?

Treatment of Inguinal Hernia

Surgical repair with mesh is the definitive treatment for inguinal hernias, with laparoscopic approaches (TEP or TAPP) offering comparable outcomes to open Lichtenstein repair while providing advantages of reduced chronic pain, faster recovery, and lower wound infection rates. 1, 2

Emergency vs. Elective Decision

Immediate Surgery Required (Strangulated Hernia)

• Strangulated hernias demand immediate surgical intervention within hours to prevent bowel necrosis and death. 3, 4
• Predictive markers of strangulation include SIRS criteria (fever, tachycardia), elevated lactate, CPK, D-dimer levels, and contrast-enhanced CT findings showing bowel wall ischemia. 1, 3
• Delayed diagnosis beyond 24 hours significantly increases mortality rates—elapsed time from symptom onset to surgery is the single most important prognostic factor. 5, 3
• Early intervention (<6 hours from symptom onset) reduces bowel resection incidence by 90% (OR 0.1). 4

Urgent Surgery Required (Incarcerated Hernia)

• Incarcerated hernias require urgent (not emergent) repair, typically within 24 hours. 1, 6
• Risk factors predicting need for bowel resection include femoral hernia (8-fold higher risk), obvious peritonitis, and lack of health insurance. 5, 1
• Even after successful manual reduction, same-admission surgery is indicated to prevent recurrent incarceration. 3

Elective Surgery (Reducible Hernia)

• Symptomatic groin hernias should be treated surgically. 2
• Asymptomatic or minimally symptomatic male patients may be managed with watchful waiting since risk of hernia-related emergencies is low, though majority will eventually require surgery. 2

Surgical Approach Selection

For Non-Complicated Hernias

• Mesh repair is strongly recommended (Grade 1A) as the standard approach due to significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 1, 2
• Laparoscopic approaches (TEP or TAPP) are preferred when expertise is available, offering reduced postoperative pain, lower chronic pain rates (10-12% overall vs higher with open), faster return to activities, and lower wound infection rates. 1, 2
• Open Lichtenstein repair remains the standard open technique when laparoscopic expertise is unavailable. 7, 2
• 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

For Complicated Hernias (Incarcerated/Strangulated)

Clean Surgical Field (CDC Class I - No Strangulation):

• Prosthetic synthetic mesh repair is strongly recommended (Grade 1A) for incarcerated hernias without signs of strangulation or need for bowel resection. 1, 6
• Laparoscopic approach (TEP or TAPP) is appropriate when no clinical signs of strangulation or peritonitis are present. 1, 4

Clean-Contaminated Field (CDC Class II - Strangulation Without Gross Spillage):

• Emergent prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and/or bowel resection without gross enteric spillage, associated with significantly lower recurrence risk. 1
• Open preperitoneal approach is preferable when strangulation is suspected or bowel resection may be needed. 1, 6

Contaminated/Dirty Field (CDC Class III-IV - Bowel Necrosis/Peritonitis):

• For small defects (<3 cm) with bowel necrosis or peritonitis, primary repair with non-absorbable sutures is recommended. 1
• For defects >3 cm, biological mesh may be used; choice between cross-linked and non-cross-linked depends on defect size and contamination degree. 1
• If biological mesh unavailable, polyglactin mesh repair or open wound management with delayed repair are alternatives. 1

Anesthesia Selection

• Local anesthesia is strongly recommended for open repair in emergency settings without bowel gangrene, providing effective anesthesia with fewer cardiac/respiratory complications, shorter hospital stays, lower costs, and faster recovery. 1, 6
• General anesthesia is required for laparoscopic approaches and mandatory when bowel gangrene is suspected or peritonitis is present. 1, 6
• General anesthesia is suggested over regional in patients aged ≥65 years as it may be associated with fewer complications like myocardial infarction, pneumonia, and thromboembolism. 2

Special Techniques and Considerations

Hernioscopy (Diagnostic Laparoscopy Through Hernia Sac)

• Hernioscopy is specifically recommended when bowel viability is uncertain, particularly after spontaneous reduction of a previously incarcerated hernia. 3, 6
• This technique decreases hospital stay, prevents unnecessary laparotomies, and reduces major complications in high-risk patients. 1, 7
• Requires less advanced laparoscopic skills than emergency laparoscopic hernia repair and can be performed by surgeons lacking extensive laparoscopic experience. 7

Bilateral Hernia Assessment

• During TAPP, the contralateral side should be inspected after patient consent, as occult contralateral hernias are present in 11.2-50% of cases. 1, 3
• This is not suggested during unilateral TEP repair. 2

Mesh Fixation

• In TEP, mesh fixation is unnecessary in almost all cases. 2
• In both TEP and TAPP, mesh fixation is recommended for M3 hernias (large medial) to reduce recurrence risk. 2
• Mesh should overlap defect edge by 1.5-2.5 cm to ensure adequate coverage. 1

Antimicrobial Management

• Antibiotic prophylaxis is not recommended in average-risk patients in low-risk environments for open surgery. 2
• In laparoscopic repair, antibiotic prophylaxis is never recommended. 2
• 48-hour antimicrobial prophylaxis is recommended for intestinal strangulation and/or concurrent bowel resection (CDC Class II-III). 1, 3
• Full antimicrobial therapy is recommended for patients with peritonitis (CDC Class IV). 1, 3

Postoperative Care

• Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. 2
• Encourage acetaminophen and NSAIDs as primary pain control; opioid prescribing should be limited to 15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg for laparoscopic repair; 15 tablets for open repair. 1
• Monitor for complications including wound infection, chronic pain (10-12% incidence overall, 0.5-6% debilitating), recurrence, and testicular complications. 1, 2

Critical Pitfalls to Avoid

• Never delay surgery for imaging when strangulation is clinically suspected—imaging only delays definitive management and worsens outcomes. 3
• Do not assume spontaneous reduction excludes bowel ischemia—the bowel may have been compromised during incarceration and reduced while still ischemic. 3
• Delaying repair of strangulated hernias beyond 24 hours leads to bowel necrosis and significantly increased morbidity/mortality. 5, 3
• Overlooking contralateral hernias occurs in up to 50% of cases—laparoscopic approach allows bilateral assessment. 3
• Avoid using plug repair techniques as incidence of erosion is higher with plug versus flat mesh. 2

Special Populations

Women

• Women with groin hernias should undergo laparoscopic repair when expertise is available to decrease chronic pain risk and avoid missing a femoral hernia. 2

Pregnant Women

• Watchful waiting is suggested as groin swelling most often consists of self-limited round ligament varicosities. 2

Patients with Cirrhosis and Ascites

• Control ascites before elective herniorrhaphy, as uncontrolled ascites increases recurrence and complication rates. 6
• Laparoscopic approaches are recommended when surgery is necessary. 6

Femoral Hernias

• Timely mesh repair by laparoscopic approach is suggested for femoral hernias provided expertise is available, given the 8-fold higher risk of requiring bowel resection. 1, 2

Recurrent Hernias

• For recurrent hernia after anterior repair, posterior repair is recommended. 2
• If recurrence occurs after posterior repair, an anterior repair is recommended. 2
• After failed anterior and posterior approaches, management by a specialist hernia surgeon is recommended. 2