Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

incarcerated or strangulated hernia

1st line – surgical repair

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ACUTE
|
incarcerated or strangulated hernia
1st line – 

surgical repair

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.

Consider – prophylactic antibiotic therapy

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ACUTE
|
incarcerated or strangulated hernia
Consider – 

prophylactic antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Adult patients undergoing open repair for acutely incarcerated/strangulated groin hernia should receive antibiotic prophylaxis.[2]

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.

Primary options

cefazolin: 1-2 g intramuscularly/intravenously as a single dose 30-60 minutes prior to procedure; consult local guidance for intraoperative and postoperative dosing requirements

OR

cefazolin: 1-2 g intramuscularly/intravenously as a single dose 30-60 minutes prior to procedure; consult local guidance for intraoperative and postoperative dosing requirements

and

vancomycin: 15 mg/kg intravenously as a single dose within 120 minutes prior to procedure

Secondary options

clindamycin: 900 mg intravenously as a single dose within 60 minutes prior to procedure; consult local guidance for intraoperative and postoperative dosing requirements

OR

vancomycin: 15 mg/kg intravenously as a single dose within 120 minutes prior to procedure

ONGOING

small, asymptomatic hernia

1st line – watchful waiting

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ONGOING
|
small, asymptomatic hernia
1st line – 

watchful waiting

Watchful waiting is considered a safe strategy in adults with minimally symptomatic or asymptomatic hernia, and this is reflected in guideline recommendations.[2][25][54]

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]

Over time, many patients with initially asymptomatic hernias will develop symptoms and undergo elective repair.[54][55][56][57][58]

large or symptomatic uncomplicated hernia

1st line – open-mesh or laparoscopic repair

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ONGOING
|
large or symptomatic uncomplicated hernia
|
surgical candidate: unilateral primary hernia
1st line – 

open-mesh or laparoscopic repair

Open-mesh repair may be preferable for patients with unilateral primary hernia.[2][72]​[74][83]​​ However, a laparoscopic approach may be appropriate for some patients with primary unilateral inguinal hernia, pending availability of sufficient resources and surgical expertise.[2]

Open-mesh repair is a low-risk procedure that is associated with a much lower recurrence rate than primary-tissue repair or other non-mesh repair techniques.[68][69] [ Cochrane Clinical Answers logo ] [Evidence A] It 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]

The Lichtenstein technique is the most commonly performed open-mesh repair. The 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]

In the laparoscopic procedure, a large (approximately 12 cm diameter) mesh is placed in the preperitoneal space, covering the internal ring and direct and femoral spaces, using either an extraperitoneal (TEP) or a transabdominal (TAPP) approach under general anesthesia.[72][73]

Consider – prophylactic antibiotic therapy

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ONGOING
|
large or symptomatic uncomplicated hernia
|
surgical candidate: unilateral primary hernia
Consider – 

prophylactic antibiotic therapy

Treatment recommended for SOME patients in selected patient group

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 suggested in a high-risk patient undergoing open-mesh repair, but not required in an average-risk patient undergoing open-mesh repair.[2][100] [ Cochrane Clinical Answers logo ]

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

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]

Primary options

cefazolin: 1-2 g intramuscularly/intravenously as a single dose 30-60 minutes prior to procedure; consult local guidance for intraoperative and postoperative dosing requirements

OR

cefazolin: 1-2 g intramuscularly/intravenously as a single dose 30-60 minutes prior to procedure; consult local guidance for intraoperative and postoperative dosing requirements

and

vancomycin: 15 mg/kg intravenously as a single dose within 120 minutes prior to procedure

Secondary options

clindamycin: 900 mg intravenously as a single dose within 60 minutes prior to procedure; consult local guidance for intraoperative and postoperative dosing requirements

OR

vancomycin: 15 mg/kg intravenously as a single dose within 120 minutes prior to procedure

1st line – laparoscopic mesh repair

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ONGOING
|
large or symptomatic uncomplicated hernia
|
surgical candidate: recurrence (after open-mesh repair) or bilateral primary hernia
1st line – 

laparoscopic mesh repair

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

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 repair compared with open-mesh repair include less postoperative pain, earlier return to physical activity, and better cosmetic appearance.[2][74][75][76][77][78] 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 types of laparoscopic approach: totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP).

In TEP, a balloon device is placed into the preperitoneal space and inflated to open the space for mesh placement. It is the most popular approach for laparoscopic mesh placement. The TAPP procedure requires the peritoneal cavity to be entered (via a peritoneal incision) for mesh placement, which may lead to increased risk of injury to organs. Each approach has its advocates, but there is no clear superiority with one approach over the other for recurrent inguinal repair following previous open primary repair.[82] Choice of technique may be influenced by the surgeon's skills and experience.[2]

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

1st line – nonsurgical treatment (e.g., truss) or observation

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ONGOING
|
large or symptomatic uncomplicated hernia
|
nonsurgical candidate, life expectancy limited, or refuses repair
1st line – 

nonsurgical treatment (e.g., truss) or observation

A truss (or a wearable device that compresses the tissues over the inguinal canal) may be used for patients in whom surgical intervention represents a very significant risk, whose life expectancy is limited, or who refuse repair.

A truss should be applied only after the hernia is reduced and when symptoms have been alleviated.

The objectives of the truss are to keep the hernia reduced and to relieve pain and discomfort. However, many patients find it cumbersome, and hernia accidents (where the hernia escapes from the truss and may become strangulated by the truss) and skin atrophy under the truss may occur.

Patients not undergoing any form of treatment (surgical or nonsurgical) should be closely monitored for complications.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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