When is an inguinal hernia (Inguinal Hernia) repaired?

From the Guidelines

Inguinal hernias should be surgically repaired immediately when intestinal strangulation is suspected, as the benefits of emergency surgery outweigh the risks in these cases. This is based on the strongest and most recent evidence, including the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1. The guidelines recommend emergency hernia repair for patients with suspected intestinal strangulation, as well as those with systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, and elevated lactate, CPK, and D-dimer levels, which are predictive of bowel strangulation.

Some key points to consider when deciding on the timing of inguinal hernia repair include:

• The risk of incarceration and strangulation, which is higher in certain patient populations, such as infants and older adults
• The presence of symptoms, such as pain, discomfort, or a bulge, which can affect daily activities
• The patient's overall health status and medical comorbidities, which can influence the risks and benefits of surgery
• The use of mesh reinforcement, which can reduce recurrence rates and improve outcomes

The surgical approach can be either open or laparoscopic, and the choice of approach depends on the individual patient's needs and circumstances. Local anesthesia can be used for emergency inguinal hernia repair in the absence of bowel gangrene, and has been shown to be effective with less postoperative complications 1. However, general anesthesia may be preferred in cases where bowel gangrene is suspected or intestinal resection is required.

In terms of specific patient populations, the guidelines recommend:

• Emergency hernia repair for patients with complicated hernias and intestinal strangulation or concomitant need of bowel resection without gross enteric spillage (clean-contaminated surgical field, CDC wound class II) 1
• Primary repair for stable patients with strangulated hernia and bowel necrosis or gross enteric spillage during intestinal resection (contaminated or dirty surgical field), when the size of the defect is small (< 3 cm) 1
• Open management for unstable patients experiencing severe sepsis or septic shock, to prevent abdominal compartment syndrome 1

Overall, the decision to repair an inguinal hernia should be individualized based on the patient's symptoms, risk factors, overall health status, and personal preferences, after discussion with a surgeon.

From the Research

Inguinal Hernia Repair

• Inguinal hernias are typically repaired when they are symptomatic, with symptoms such as groin pain, burning, gurgling, or aching sensation in the groin, and a heavy or dragging sensation that worsens toward the end of the day and after prolonged activity 2.
• Surgical intervention is not always necessary, such as with a small, minimally symptomatic hernia 2.
• The decision to repair an inguinal hernia depends on the severity of symptoms, the size of the hernia, and the patient's overall health 3.
• Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias, but not recommended in patients with symptomatic hernias or in nonpregnant women 3.

Surgical Techniques

• Mesh repair is recommended for elective operations, and the Lichtenstein technique is the standard in open inguinal hernia repair 4.
• Laparoscopic repair offers significant advantages over open techniques with regard to recurrence risk, pain, and recovery, especially for patients with recurrent inguinal hernia, or bilateral inguinal hernia, or for women 5.
• Transabdominal preperitoneal and totally extraperitoneal approaches have comparable outcomes and clear advantages, including minimal invasiveness 4.
• Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair 3, 6.

Special Considerations

• In cases of strangulation, mesh repair is recommended, but only in clean and clean-contaminated operations 4.
• If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy, or laparotomy, is recommended 4.
• Hernioscopy is a simple and safe procedure that uses the hernia sac for insertion of a port following insufflation and diagnostic examination, and can be performed even by surgeons who lack sufficient experience with laparoscopy 4.