Surgical treatment of hernia

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2023 update international guidelines groin hernia management surgery HerniaSurge

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"Hernia, Inguinal"[MeSH Terms] AND surgery

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https://pubmed.ncbi.nlm.nih.gov/37862616

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Surgical treatment of hernia

Surgery is the definitive treatment for most symptomatic hernias. The aim is to return the herniated contents to the abdomen, deal with the sac, and reinforce the weakened abdominal wall, usually with mesh.

When surgery is needed

Urgent or emergency repair is required if there is:

Irreducibility with severe or increasing pain
Vomiting, abdominal distension, or inability to pass stool/flatus
Skin redness, tenderness, fever, or systemic illness
Suspected intestinal obstruction or strangulation

A strangulated hernia can compromise bowel blood supply and may require bowel resection.

Elective repair is generally offered for:

Symptomatic inguinal, femoral, umbilical, incisional, or ventral hernias
Enlargement or interference with work/daily activity
Femoral hernias, because their strangulation risk is relatively high

In selected men with a minimally symptomatic, reducible inguinal hernia, watchful waiting can be reasonable, with advice to seek review if symptoms progress.

Main operations

Hernia	Usual surgical approaches
Inguinal	Open mesh repair (Lichtenstein) or laparoscopic/endoscopic repair (TEP or TAPP)
Femoral	Open or laparoscopic mesh repair, often promptly after diagnosis
Umbilical/epigastric	Primary suture repair for very small defects in selected patients; mesh repair for larger defects or higher recurrence risk
Incisional/ventral	Mesh repair, open, laparoscopic, or robotic; complex defects may need abdominal-wall reconstruction
Recurrent inguinal	Usually repair through the opposite tissue plane: laparoscopic after prior open repair, or open after prior posterior/laparoscopic repair
Pediatric inguinal	Herniotomy: high ligation of the sac, generally without mesh

1. Open mesh repair

The common operation for an adult inguinal hernia is Lichtenstein tension-free mesh repair.

Basic steps:

Incision in the groin.
Identification and reduction of the hernia sac.
Inspection of contents for viability if incarcerated.
Placement of flat synthetic mesh to reinforce the posterior wall of the inguinal canal.
Closure of layers.

Advantages:

Can be done under local, regional, or general anesthesia
Widely available and reliable
Appropriate for many primary unilateral hernias

2. Laparoscopic/endoscopic mesh repair

The two principal methods are:

TEP: totally extraperitoneal repair, outside the peritoneal cavity
TAPP: transabdominal preperitoneal repair, entering the peritoneal cavity then placing mesh in the preperitoneal plane

Advantages:

Often less early postoperative pain
Earlier return to normal activity in suitable patients
Particularly useful for bilateral inguinal hernias and recurrence after an open anterior repair

Limitations:

Requires general anesthesia, equipment, and experienced surgeons
Has a learning curve
Risks include visceral, vascular, bladder, and port-site injury, although uncommon in experienced hands

International groin-hernia guidance supports mesh-based repair for most adults, with laparoscopic/endoscopic approaches favored when expertise and resources are available, particularly for bilateral or recurrent cases. The 2023 HerniaSurge update is a key current reference.

3. Tissue repair without mesh

Examples include Shouldice and Bassini repairs. These approximate native tissues rather than implanting mesh.

They may be considered when:

Mesh is contraindicated or declined
There is gross contamination or infection
The patient is a child
An expert tissue-repair surgeon is available

However, in most adult elective groin repairs, mesh lowers recurrence compared with older tension repairs.

Mesh considerations

Mesh is commonly polypropylene or another synthetic material. It provides tension-free reinforcement and reduces recurrence. Choice of mesh and placement plane depends on hernia type, defect size, contamination, previous repairs, and surgeon expertise.

Mesh may be avoided or its use reconsidered in a contaminated operative field, especially if bowel perforation or active infection is present. The decision is individualized.

Anaesthesia and postoperative care

Many open groin repairs are day-case procedures.
Walking is encouraged shortly after surgery.
Analgesia usually includes paracetamol/acetaminophen and an NSAID if safe; stronger analgesia may be needed briefly.
Wound care and activity advice are individualized. Heavy lifting is usually limited initially based on pain and surgeon instructions, rather than prolonged strict immobility.
Return to desk work may be within days to 1-2 weeks; heavy physical work can take longer.

Complications

Potential complications include:

Seroma or hematoma
Wound infection
Urinary retention
Recurrence
Chronic groin pain or numbness after inguinal repair
Mesh infection, which is uncommon but serious
Testicular or cord-related complications in groin surgery
Bowel injury or ischemia in emergency/strangulated hernia surgery

A recent systematic review suggests laparo-endoscopic inguinal repair may reduce chronic postoperative groin pain versus Lichtenstein repair in appropriate settings, though technique and surgeon experience remain major determinants (2024 review).

Practical rule: a painful, irreducible hernia with vomiting or abdominal distension is a surgical emergency and needs immediate hospital assessment.“Surgical treatment of hernia” differs by site and whether it is elective or an emergency.

Groin hernias: inguinal and femoral
- Open mesh repair, usually Lichtenstein
- Laparoscopic/endoscopic mesh repair: TEP or TAPP
- Emergency operation if strangulated or obstructed
Primary ventral hernias: umbilical and epigastric
- Suture repair for selected very small defects
- Mesh repair for larger defects or recurrence risk
Incisional hernias
- Open or minimally invasive repair with mesh, commonly in a retromuscular position
- Complex abdominal-wall reconstruction for large defects
Special hernias: recurrent, parastomal, hiatal, pediatric
- Each needs a different operative plan
Complications and postoperative care
- Seroma, wound infection, recurrence, chronic groin pain, mesh-related issues, return to activity

In adults with symptomatic groin hernia, repair is generally recommended. Modern guideline-based care usually favors a mesh-based repair. Open anterior repair is widely applicable, while laparo-endoscopic repair can offer faster recovery and less chronic pain in appropriately selected patients when experienced surgeons and resources are available. Femoral hernias, particularly in women, merit timely repair because incarceration and strangulation are relatively more frequent. A painful irreducible hernia with vomiting, abdominal distension, fever, or skin redness is a surgical emergency. The 2023 HerniaSurge update is a key current guideline source.

Which area would you like in detail: inguinal hernia, ventral/incisional hernia, or an exam-style overview of all operations?

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