Approach

The treatment of inguinal hernia in adults remains largely surgical as this offers the only potential for cure. Surgery is also important for preventing strangulation of hernias, and for treating hernias that are painful and difficult to reduce.

Watchful waiting is a reasonable option in adults with minimally symptomatic or asymptomatic inguinal hernia, especially if they are frail, elderly, or high risk for any kind of surgical procedure.

Watchful waiting

Whether all hernias should be repaired or not is controversial. Watchful waiting is considered a safe strategy in adults with minimally symptomatic or asymptomatic inguinal hernia, and this is reflected in guideline recommendations.[2][25][54]

Over time, many patients with initially asymptomatic hernias will develop symptoms and undergo elective repair.[9][54][55][56][57][58] A study of 720 men (≥18 years of age) with minimally symptomatic or asymptomatic inguinal hernia found that 23% who were randomly assigned to watchful waiting crossed over to surgery at 2 years due to the development of symptoms, usually discomfort.[54] Incarceration developed in 2 patients assigned to watchful waiting. By 7.5 years post-randomization, 72% of the watchful waiting group (46% follow-up) had undergone operative repair.[56]

One UK study of 160 older men (≥55 years of age) randomly assigned to surgery or watchful waiting found that 29% had crossed over from watchful waiting to surgery after 1 year.[58] There were 3 serious hernia-related adverse events in those who crossed over, and one of these resulted in death (postoperative myocardial infarction) following significant deterioration of comorbid cardiovascular disease during observation. At 10 years post-randomization (71% follow-up), 68% of the watchful waiting group had crossed over to surgical repair.[57]

In one study in the Netherlands (496 male patients; >50 years of age), 2-year postoperative complication and recurrence rates did not differ significantly between 99 (37.7%) of 262 patients randomized to watchful waiting and who subsequently underwent surgical repair, and patients who were originally assigned to elective repair (8.1% vs. 15.0%, P = 0.106; 7.1% vs. 8.9%, P = 0.668, respectively).[59]

Acute hernia complications, such as bowel obstruction and incarceration/strangulation, occur rarely with a watchful waiting strategy. One review recommended informing patients that the surgical emergency rate during watchful waiting is 1.8 per 1000 person-years.[60] Patients should be advised to seek medical attention immediately if they develop signs and symptoms of serious complication (e.g., abdominal pain, nausea, vomiting, and constipation).[54]

Surgery

Primary-tissue (non-mesh) repair (e.g., using Bassini, Cooper ligament or Shouldice technique) was the mainstay of surgical treatment of inguinal hernia prior to 1990; however, these techniques have mostly been superseded by open-mesh repair using the Lichtenstein technique or by minimally invasive laparo-endoscopic repair.[61] All three approaches seem to be equally efficacious.[62][63]

Open surgical repair

The Lichtenstein technique involves placing a tension-free polypropylene mesh prosthesis (approximately 5 cm x 12 cm in size) over the posterior wall of the inguinal floor and internal oblique from the pubis to the iliac spine, encircling the cord structures through a keyhole.[61] The mesh must be secured to the pubis, shelving edge of inguinal ligament, and internal oblique fascia. Inguinal numbness, which may gradually abate over time, is the most common side effect of this procedure.

Open preperitoneal mesh repair, in which the preperitoneal space is opened for mesh placement through a small suprapubic or inguinal incision, is a safe and efficacious alternative to Lichtenstein mesh repair.[64][65]

The plug-and-patch system is a less desirable open-mesh repair technique. This procedure involves inserting a cone-shaped plug of polypropylene mesh into the defect, secured to the internal ring in the case of indirect hernia, or the neck of the defect in direct hernia, which can be covered by an additional flat mesh prosthesis. This technique is not performed as often as the Lichtenstein technique due to higher rates of complications, including migration of the plug, with erosion into bowel or bladder.[66][67]

Open-mesh repair is associated with a much lower recurrence rate than primary-tissue repair or other non-mesh repair techniques.[9][68][69] [ Cochrane Clinical Answers logo ] [Evidence A] It is also a low-risk procedure that can be done under spinal, general, or local anesthesia with mild sedation. If feasible, local anesthesia may be preferred to spinal anesthesia.[70] Otherwise, spinal or general anesthesia are equally good choices.[71]

Minimally invasive (laparoscopic) surgical repair

Minimally invasive laparoscopic mesh repair is an alternative to open-mesh repair. Laparoscopic mesh repair requires general anesthesia, and is technically more challenging and has a longer learning curve for the surgeon than open-mesh repair. It involves placing a large (approximately 12 cm diameter) mesh prosthesis in the preperitoneal space, extending from pubis to iliac spine and overlying the iliac vessels.[72][73]

Advantages of laparoscopic mesh repair compared with open-mesh repair include:[2][9][74][75][76][77][78]

  • less postoperative pain

  • earlier return to physical activity

  • better cosmetic appearance.

Recurrence and complication rates are similar to open-mesh repair, although patients undergoing laparoscopic procedures may experience less chronic inguinal pain than those who have a Lichtenstein procedure.[2][79][80] Risk of serious injury to bowel, bladder, and vascular structure is higher with laparoscopic procedures.[81] 

There are two laparoscopic approaches: totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP). The TEP procedure involves opening the preperitoneal space, usually with a balloon device, to create a space in which a large contoured mesh patch covering the inguinal area from below is placed. The TAPP procedure involves placing the laparoscope into the peritoneal cavity and incising the peritoneum under the inguinal canal to open the preperitoneal space for a mesh placement, after which the peritoneal incision is closed over the mesh. Each approach has its advocates, but there is no clear superiority of one approach over the other for repair of primary unilateral inguinal hernia, or for recurrent inguinal hernia repair following previous open primary repair.[81][82] Choice of technique may be influenced by the surgeon’s skills and experience.[2]

Choice of repair

The decision to offer the patient an open or laparoscopic repair depends on the anatomy of the hernia, whether the hernia is primary or recurrent, the experience of the surgeon, and the wishes of the patient.[74][81][83][84][85] Risks and complications vary between the two approaches.[76][81] Open surgery is the most common, accounting for the majority of inguinal hernia repairs.[72][83] An open approach may be preferable to a laparoscopic approach for a unilateral primary hernia, although a laparoscopic approach may be appropriate for some patients, pending availability of sufficient resources and surgical expertise.[2]

Laparoscopic repair may be preferable for patients with recurrence after open repair, or for those with bilateral hernias that can be repaired at the same time.[2][72][74][83][85][86]

Two recent brief reviews offer treatment decision algorithms.[9][60] The most recent meta-analysis found all three most common repairs to be comparable.[62]

Mesh prosthesis

Polypropylene mesh is the most popular prosthetic material used in hernia repair. It is important to use a large enough prosthesis. Studies with long-term follow-up demonstrate no advantage to using newer lightweight meshes over older heavier versions.[87][88] Low-cost mosquito netting has been successfully used in low-income countries in sub-Saharan Africa, and can be used in developing countries.[89][90] However, an appropriate type of netting may no longer be readily available in developing countries.[91] If mesh becomes infected, it must usually be removed. Recurrence of hernia after removal of infected mesh is uncommon.[92]

Bioprostheses obtained from cadaveric skin or from porcine intestinal mucosa may be used in a hernia repair that is associated with contaminated surgical fields.[93][94] In this situation, the use of local tissue is associated with high recurrence rate, and standard prosthetic mesh is associated with significant risk of infection. Bioprostheses are not used routinely in elective inguinal hernia repair.

Initial concerns regarding postoperative pain attributed to mesh prostheses have been shown to be unwarranted.[95] Likewise, concerns regarding infertility have been disproven as well.[96][97]

Incarcerated or strangulated hernia

A hernia is incarcerated when the hernia content cannot be reduced into the abdominal cavity. Bowel or omentum passing through the tight hernia neck can become trapped and edematous, which can lead to further swelling and fluid sequestration in the bowel lumen. This can cause bowel obstruction, impairment of the blood supply in the bowel, and eventually strangulation.

Emergent surgical repair is indicated for acute incarcerated hernia.[2] The optimal surgical approach is not known,[2] but a laparoscopic approach may be considered in the absence of strangulation.[98] An incarcerated hernia may be reduced with the patient sedated, but care should be taken to avoid pushing a nonviable loop of the bowel from the hernia sac back into the peritoneal cavity (hernia en masse). Mesh repair is indicated if the bowel is viable, but non-mesh repair is indicated if the bowel is nonviable or if viability is in doubt.

Patients should undergo emergent open surgical repair for suspected strangulated inguinal hernia because the bowel may necrose if the underlying obstruction is not relieved promptly.[2][98] Adequate fluid resuscitation, nasogastric intubation, and urethral catheterization are often required. In the absence of necrosis or contamination, the bowel can be reduced and the hernia repaired with a mesh.[2][98][99] If nonviable bowel (gangrenous) or contamination is found during surgery, bowel resection is usually required, and a non-mesh primary tissue repair of the hernia performed.[2][98] Mesh repair should be avoided in this situation due to the risk of mesh infection.

Prophylactic antibiotic therapy

Use of antibiotic prophylaxis during uncomplicated hernia repair is controversial, particularly as the rate of surgical site infection is low.

In a low-risk environment (≤5% incidence of wound infection), antibiotic prophylaxis is:[2][100] [ Cochrane Clinical Answers logo ]

  • suggested in a high-risk patient undergoing open-mesh repair

  • not required in an average-risk patient undergoing open-mesh repair.

In a high-risk environment (>5% incidence of wound infection), antibiotic prophylaxis is recommended for any patient undergoing open-mesh repair.[2]

Antibiotic prophylaxis for laparoscopic repair is not recommended.[2][101][100]

Adult patients with acutely incarcerated/strangulated inguinal hernias should receive antibiotic prophylaxis.[2] Nevertheless, antibiotic use is common in the US.

Choice of antibiotic regimen depends on local guidance. A single dose of a cephalosporin (e.g., cefazolin) has been recommended. For patients known to have MRSA, vancomycin can be added. Clindamycin or vancomycin may be used as an alternative to cefazolin in patients who are allergic to beta-lactam antibiotics.[102] A meta-analysis found that beta‐lactam/beta‐lactamase inhibitors and first‐generation cephalosporins appear to be the most effective antibiotics for adult patients undergoing inguinal hernia repair.[103] In the absence of definitive evidence, single-dose antimicrobial prophylaxis with a first-generation cephalosporin is an acceptable approach for open-mesh repair. 

Recurrence following surgery

Prior to the introduction of mesh repairs, recurrence rates following primary inguinal hernia repair were estimated to be between 10% and 30%.[104] Recurrence rates after mesh repairs, either open or laparoscopic, are much lower at less than 2%.[104][105][106] One systematic review and meta-analysis found that one hernia recurrence could be prevented for every 46 mesh repairs rather than non-mesh repairs.[68] The risk of developing a new hernia on the contralateral side after repair on one side has been estimated to be 7% to 11% over ten years.[107]

Truss

A truss (or a wearable device that compresses the tissues over the inguinal canal) is a traditional nonsurgical treatment for inguinal hernia. If used, it should be applied after the hernia is reduced and when symptoms have been alleviated. A truss should keep the hernia reduced so that pain and discomfort are minimized. However, many patients find them cumbersome to use. Furthermore, hernia accidents (where the hernia escapes from the truss and may become strangulated by the truss) and atrophy of the skin under the truss can occur. A truss is not a cure. Long-term use should be reserved for patients in whom surgery is not appropriate, whose life expectancy is limited, or who refuse surgical repair.

Use of this content is subject to our disclaimer