Contemporary inguinal hernia management (2024)

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An inguinal hernia is a very common condition, with 27 per cent of men and 3 per cent of women undergoing repair during their lifetime1. Thus, inguinal hernias have a high societal cost. Historically, hernia surgery was frequently performed by the most inexperienced surgeons, but is now considered a highly specialized field with substantial research activity, specialist societies, and national clinical hernia databases. A variety of operative techniques have been described that aim to improve operative outcomes and recovery. The routine use of mesh and minimally invasive surgery have arguably had the greatest impact on hernia surgery outcomes to date. However, despite these improvements, chronic pain and recurrence still occur with a consequent negative impact on patient quality of life and increased cost to society. Inguinal hernias are difficult to prevent, and the only curative treatment is surgery. Numerous repair methods have been described in in adults, but the most common ones worldwide are Lichtenstein repair and laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs1 (Fig. 1). This Young BJS article discusses some of the surgical controversies in contemporary inguinal hernia surgery.

Mesh versus sutured repairs

Mesh and sutured repairs have comparable chronic pain rates, but the international guideline from 20181 recommended mesh repair owing to lower recurrence rates. Nevertheless, a sutured repair may be necessary in acute contaminated surgery (Fig. 1) and in patients who refuse a mesh. Even though the Shouldice technique has excellent results in expert hands1, the technique has a long learning curve and most surgeons rarely perform sutured repairs. For most general surgeons, it is probably more straightforward to use other techniques such as the Bassini and McVay repairs, depending on local expertise, but recurrence rates for these techniques are usually higher than those for mesh repair1.

Lichtenstein versus TAPP/TEP repair

Proven benefits of a Lichtenstein repair over a laparoscopic repair are a shorter learning curve1, shorter operating time2, and the possibility of performing the repair under local anaesthesia1^,3. Benefits of laparoscopic repair compared with the Lichtenstein repair are a faster recovery, reduced haematoma and wound infection rates, and less acute and chronic pain1^,2. Comparable parameters are the total long-term cost, rates of perioperative complications requiring reoperation1, seroma, and recurrence2. Taking these factors into consideration, all three types of repair have evidence-based merit. However, arguably a laparoscopic repair should be the procedure of choice in suitable patients because of the faster recovery and pain reduction, and a laparoscopic repair is also the preferred repair for groin hernias in women and for bilateral hernias. Nevertheless, to achieve excellent results with any technique, it is important to have a detailed knowledge of inguinal anatomy and to have experience in the repair method and/or supervision from an experienced surgeon.

TAPP versus TEP repair

If choosing a laparoscopic repair, the outcomes after TEP and TAPP procedures are comparable1. With TAPP repair, there is better immediate visualization of the anatomy and of both groins. With TEP repair, there is no need to open and close the peritoneum. Owing to the abdominal access, there is a risk of visceral injury (mainly TAPP) and vascular injury (mainly TEP), but the risk is extremely low and no higher than reported with a Lichtenstein repair1^,2.

Mesh choice and fixation

There is no universal consensus on mesh classification, and they are often just termed lightweight or heavyweight in daily clinical practice. However, this nomenclature is unsatisfactory because mesh properties also depend on type and amount of material as well as pore size. Data are lacking on how different meshes affect complication rates, but the trend in Lichtenstein repair is to use a flat monofilament polypropylene lightweight mesh because of the possible reduction in chronic pain4. In laparoscopic repairs, mediumweight and heavyweight meshes do not seem to increase postoperative pain1 and they are technically easier to use.

It is considered mandatory to fixate the mesh in Lichtenstein repairs. Permanent sutures are the most widely employed, and can be used for all hernia types and sizes. Self-fixating mesh or glue fixation are alternative options and may reduce short-term pain without increasing the risk of recurrence. It should be noted that the data on improvements in short-term pain are conflicting1^,5^,6, but there does not seem to be any reduction in long-term chronic pain rates7^,8.

Mesh fixation is often unnecessary in TEP repairs whereas the mesh is fixed in TAPP repairs, except when using special anatomically shaped meshes. In laparoscopic repairs, tacks (permanent or absorbable), glue, and self-fixating meshes have comparable recurrence rates1. Atraumatic mesh fixation possibly has some advantages regarding acute1^,9 and chronic9 pain.

Surgical development and education

Before widespread implementation of laparoscopic repair, most general surgeons learned to perform Lichtenstein repair as an index training procedure during the early stage of their career. The trend towards increased use of laparoscopic repairs in many hospitals has resulted in a decline in learning opportunities for younger surgeons regarding the Lichtenstein repair. This is something that surgical communities need to be aware of and plan for because there are several situations where a Lichtenstein repair is preferable (Fig. 1). The solution in hospitals that mainly perform laparoscopic repairs may be to have a limited number of surgeons with expertise in Lichtenstein and sutured repairs to treat patients for whom laparoscopic repair is not advisable.

Anaesthesia

The most recent international guideline1 on inguinal hernia management recommends using local anaesthesia when repairing reducible inguinal hernias with a Lichtenstein technique. This is based on the advantages of local anaesthesia compared with general or regional anaesthesia during open repair, such as faster mobilization, less urinary retention, and lower total healthcare cost1. The only disadvantage is the higher risk of recurrence after repairs undertaken by surgeons inexperienced in the infiltration technique. However, this guideline1 also suggests repairing a primary inguinal hernia with a laparoscopic technique. It is possible in the not-too-distant future that Lichtenstein repair under local anaesthesia will become unfeasible owing to a lack of surgeons experienced in the infiltration technique. If Lichtenstein repair is reserved for a few surgeons who become experts in open repair techniques, these surgeons can use local anaesthesia for suitable selected patients.

Future developments

Chronic pain is reported heterogeneously in the literature to date; this complicates comparison of repair methods. Inguinal hernia-specific patient-reported outcome measures show promise but require validation10. Therefore, international consensus on how to assess and report chronic pain for future meta-analyses is needed. Studies of genetic and molecular factors are under way and will possibly rationalize personalized medicine in the field of hernia surgery.

Conclusion

Mesh repairs, as opposed to sutured repairs, are generally recommended as they have lower recurrence rates without an increased risk of chronic pain. Lichtenstein, TAPP, and TEP repairs are all recommended mesh techniques, but the reduction in pain associated with laparoscopic repair suggests that TAP/TEP repair should be the default procedure of choice. If an open repair is necessary, lightweight meshes are preferred to lower the risk of chronic pain, whereas heavyweight meshes can be used for laparoscopic repair11.

Disclosure. The authors declare no conflict of interest.

References

© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com

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