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Overview of treatment for inguinal and femoral hernia in adults

Overview of treatment for inguinal and femoral hernia in adults
Author:
David C Brooks, MD
Section Editor:
Michael Rosen, MD
Deputy Editor:
Wenliang Chen, MD, PhD
Literature review current through: Jan 2024.
This topic last updated: Apr 25, 2023.

INTRODUCTION — The definitive treatment for all hernias, regardless of origin or type, is surgical repair [1]. Groin hernia repair is one of the most commonly performed operations. Over 20 million inguinal or femoral hernias are repaired every year worldwide [2], including over 700,000 in the United States [3].

An inguinal or femoral hernia repair is performed urgently in patients who develop complications such as acute incarceration or strangulation. Thus, there are no contraindications to the urgent repair when one of these complications arises. For patients without complications, the optimal timing of repair (watchful waiting versus early repair) and the optimal surgical technique (open versus minimally invasive approach) are controversial and are the focus of this topic.

Inguinal or femoral hernia repair can be performed with minimal morbidity and mortality in almost all patients, including those who are older and/or have medical comorbidities (eg, advanced liver disease [4,5]); most patients enjoy a rapid recovery to presurgical health shortly after surgery.

The clinical features and diagnosis of an inguinal or femoral hernia, the technical details of performing an inguinal or femoral hernia repair, the complications of hernia repair, and the treatment of recurrent hernias are discussed separately in other topics:

(See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

(See "Open surgical repair of inguinal and femoral hernia in adults".)

(See "Laparoscopic inguinal and femoral hernia repair in adults".)

(See "Robotic groin hernia repair".)

(See "Complications of inguinal and femoral hernia repair".)

(See "Recurrent inguinal and femoral hernia".)

TREATMENT OPTIONS — There was a time when the mere presence of a groin hernia was a sufficient indication for surgical repair. Contemporary practice, however, triages patients to surgery versus watchful waiting according to the severity of symptoms, patient sex, and the type of hernia (inguinal versus femoral).

Watchful waiting — Males with asymptomatic or minimally symptomatic inguinal hernias and pregnant patients with uncomplicated inguinal hernias can be observed. All other patients should be considered for surgical repair (algorithm 1).

Males with asymptomatic inguinal hernia — Male patients with asymptomatic or minimally symptomatic inguinal hernias can be managed with watchful waiting. The hernias can be reducible or chronically incarcerated [6]. Such patients should be counseled about modifiable risk factors, including smoking cessation, medical optimization (eg, diabetes), and weight loss. They should be told that there is no evidence that physical activity will result in a hernia incarceration or clinical worsening of an existing hernia [7]. Thus, there is no compelling reason for such patients to curtail beneficial physical activities (eg, cardiovascular or aerobic exercises) out of concern for exacerbating the hernia. Patients who opt for watchful waiting should seek prompt surgical evaluation if they experience new-onset pain or discomfort with certain physical activities or if their hernia becomes acutely incarcerated (for those whose hernias were reducible).

Historically, inguinal hernias were repaired once detected, under the assumption that complications from unrepaired hernias were common and could increase operative morbidity. However, a number of randomized trials have compared watchful waiting with surgical repair of inguinal hernias [6,8,9] and demonstrated that delaying surgical repair in asymptomatic patients was safe, as acute complications rarely occurred (1.8 emergency operations/1000 patient-years) and the pain scores experienced at one or two years with watchful waiting were not worse than those achieved with surgical repair. However, for 38 percent of patients at three years [9] and about 70 percent of patients at 7 to 10 years [10,11], surgical repair was required eventually because symptoms (usually pain) gradually increased over time. This information is particularly important when counselling young patients. The surgical outcomes of delayed repairs were not compromised compared with upfront surgery.

The only nonsurgical therapy for groin hernia in males is a truss. A truss is a strap similar to an athletic supporter with a metal or hard plastic plug positioned to lie over the hernia defect. When applied appropriately, the hard disc or plug exerts pressure to keep the hernia contents in the abdomen. Although the use of a truss may be helpful in certain situations, we generally discourage their use because there is insufficient evidence to prove their efficacy [12,13]. In addition, inappropriate use of a truss may harm abdominal contents in a hernia sac or complicate subsequent surgical repair [14].

Pregnancy — A new-onset groin lump in a pregnant patient is likely caused by round ligament varicosity rather than a hernia, which can be confirmed by Doppler ultrasound, followed expectantly, and will likely spontaneously resolve after delivery [15]. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults", section on 'Differential diagnosis'.)

The prevalence of inguinal hernias during pregnancy is low and estimated to be 1:2000 [16]. Elective repair of a groin hernia during pregnancy is generally contraindicated. Instead, we suggest a watchful waiting approach [17].

Expectant management during the peripartum period has been associated with few serious hernia-related complications. In one study, seven women with groin hernias were managed nonoperatively, and each had their hernias repaired after delivery [17]. Although combined cesarean delivery and hernia repair have been reported [16,18], elective hernia repair should generally be deferred for at least four weeks postpartum to allow the lax abdominal wall to return to its baseline. Plus, some groin hernias in pregnancy may be caused by the increased laxity in ligaments during pregnancy, and the hernia may not be apparent after pregnancy.

Urgent hernia repair during pregnancy may be required if the patient develops severe discomfort or one of the complications, such as acute incarceration, strangulation, or bowel obstruction. In one study, such complications were rare and only accounted for <5 percent of intestinal obstructions observed during pregnancy [19].

Surgical repair — If surgical repair of a groin hernia is required, it can be performed using open or minimally invasive techniques, which are described in other topics. (See "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults" and "Robotic groin hernia repair".)

Open repair — Open techniques approach the hernia defect anteriorly and include tension-free mesh repairs as well as primary tissue approximation nonmesh repairs.

Open tension-free mesh repairs — Successful hernia repair depends upon a tension-free closure, which is typically achieved with placement of a mesh. Multiple studies have demonstrated that tension-free mesh repair of inguinal hernias reduces postoperative groin pain, expedites recovery, and reduces recurrence rate [1,2,20-24]. Thus, the tension-free mesh techniques are most widely used and endorsed by various hernia societies [1,25,26]. Tension-free repairs that use mesh include Lichtenstein, plug and patch, and preperitoneal (eg, Kugel or Rives-Stoppa) repair. (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Mesh repairs'.)

Open primary tissue approximation nonmesh repairs — Shouldice, Bassini, and McVay repairs are open techniques that achieve primary tissue approximation without the use of mesh [22,27-31]. Although the Shouldice repair does not incorporate mesh, some regard it as a tension-free technique. Nonmesh repair techniques are primarily used when mesh placement is contraindicated, such as when there is active infection or contamination of the groin or when the use of a mesh is cost prohibitive (eg, in resource-limited settings). (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Hernia repair techniques'.)

Minimally invasive repair — Laparoscopic or robotic repairs approach the hernia defect posteriorly. The two main techniques are totally extraperitoneal (TEP) repair and transabdominal preperitoneal patch (TAPP) repair, both of which require the use of mesh and are considered tension-free repairs [32]. The mesh employed for these repairs must be of sufficient size to cover the entire preperitoneal groin space in order to prevent recurrences. (See "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Choice of laparoscopic repair' and "Robotic groin hernia repair".)

Various minimally invasive techniques have been compared with one another. In general, there is no difference in outcomes between TEP and TAPP repair [33], and robotic repair does not have any clinical benefits over laparoscopic repair [34,35]. (See "Robotic groin hernia repair", section on 'Outcomes' and "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Special cases'.)

INGUINAL HERNIA — Techniques of repair for inguinal hernia (open versus minimally invasive) should be based on several conditions, including surgeon experience, patient comorbidities, and characteristics of the hernia. Contemporary meta-analyses suggest advantages to laparoscopic over open repairs, thus the recommendation to use the laparoscopic approach where feasible (algorithm 1). Patients who have previous lower abdominal surgery, irreducible or large inguinoscrotal hernia, ascites, or intolerance to general anesthesia should undergo open repair. The robotic approach is not included in this suggestion, due to limited evidence comparing it to the other two approaches. (See "Robotic groin hernia repair", section on 'Outcomes'.)

Candidates for laparoscopic repair — For appropriate candidates, laparoscopic repair of inguinal hernia offers less pain, faster recovery, and equally low recurrence rates compared with open repair. The evidence for laparoscopic repair is presented in the following sections for each patient population (unilateral hernia, bilateral hernia, females).

Unilateral hernia — For male patients with a unilateral primary inguinal hernia, we suggest a laparoscopic repair (totally extraperitoneal [TEP] or transabdominal preperitoneal patch [TAPP]) rather than an open repair, provided that the surgeon has sufficient experience with the minimally invasive techniques. Our suggestion is based on the fact that patients undergoing laparoscopic repair have a faster recovery and decreased pain. Although earlier studies associated laparoscopic inguinal hernia repair with higher complication and recurrence rates compared with open repair [25,26,36], contemporary studies showed comparable outcomes for surgeons who have ascended the learning curve by performing 250 laparoscopic groin hernia repairs [7,23,37]. Our suggestion is consistent with the latest (2018) international guidelines from the HerniaSurge group [38].

Open and laparoscopic inguinal hernia repairs have been directly compared in a number of randomized trials [39-41] and large cohort studies [42,43]. In a 2022 review of 21 systematic reviews and meta-analyses comparing open and laparoscopic inguinal hernia repair, laparoscopic repair was associated with a lower risk of chronic groin pain compared with open repair (range 26 to 46 percent) [44]. Most reviews showed no difference in recurrence rates between laparoscopic and open repairs, regardless of the types of repair or the types of hernia that were studied, but most reviews had wide confidence intervals, and four reviews containing fewer studies found an advantage for open repair.

As an example, in a 2021 network meta-analysis of 35 randomized trials, laparoscopic repair (TEP/TAPP) was associated with:

Reduced early postoperative pain

TAPP versus Lichtenstein: risk ratio (RR) 0.36; 95% CI 0.15-0.81

TEP versus Lichtenstein: RR 0.36, 95% CI 0.21-0.54

Earlier return to work/activities

TAPP versus Lichtenstein: weighted mean difference (WMD) -3.3 days; 95% CI -4.9 to -1.8

TEP versus Lichtenstein: WMD -3.6 days; 95% CI -4.9 to -2.4

Additionally, laparoscopic repair is also associated with lower rates of chronic pain, hematoma, and wound infection compared with the open (Lichtenstein) repair. Hernia recurrence, seroma, and hospital length of stay were similar across treatments [33].

As another example, a 2019 meta-analysis of 58 randomized trials reported that laparoscopic hernia repair was associated with significantly less postoperative pain in three intervals: from two weeks to within six months after surgery (RR 0.74, 95% CI 0.62-0.88), six months to one year (RR 0.74, 95% CI 0.59-0.93), and one year onward (RR 0.62, 95% CI 0.47-0.82). Paraesthesia (RR 0.27, 95% CI 0.18-0.40) and patient-reported satisfaction (RR 0.91, 95% CI 0.85-0.98) were also significantly better in the laparoscopic repair group [45].

The literature has generally credited open inguinal hernia repair with the advantages of a shorter operative time and a shorter learning curve compared with laparoscopic repair, as well as the feasibility to be performed without general anesthesia, which is not possible for laparoscopic repair [46]. Additionally, studies have generally found an overall cost benefit for open, as opposed to laparoscopic or robotic, hernia repair [47-51]. In one analysis, for example, laparoscopic repair reduced value by 3 percent and robotic repair reduced value by 69 percent when compared with open repair [52]. Factors considered in such studies included the cost of operating room time and equipment (especially single-use items), length of hospital stay, and cost of treating potential complications. Variations in one or more of these factors (eg, by using reusable equipment or shortening operative time) could make laparoscopic or robotic surgery more cost effective [47].

Although the popularity of laparoscopic repair for unilateral primary inguinal hernias is growing, not all surgeons perform laparoscopic repairs routinely. Because clinical outcomes are as much a function of surgeon experience as other factors, surgeons should choose the approach with which they are most comfortable and most experienced. Ultimately, a well-performed open inguinal hernia repair is perfectly acceptable, and the learning curve for laparoscopic groin hernia repair is real and can result in serious complications. Patients are best served by seeking consultation from well-respected surgeons who perform high-volume hernia surgery and going with their recommendations.

Finally, while open repair of a primary hernia is feasible in almost all patients, laparoscopic repair cannot be safely performed in certain patients, due to anatomic or technical reasons (eg, prior surgery, ascites, inability to tolerate a general anesthetic). (See 'Choice of anesthesia' below.)

Bilateral hernias — For all patients with bilateral inguinal hernias, we suggest repairing bilateral inguinal hernias laparoscopically rather than open. This is because:

Both hernias can be repaired through the same incisions, which improves cosmesis.

A laparoscopic approach permits exploration of the contralateral groin in patients with symptoms suggestive but not diagnostic of a contralateral hernia [53].

Three randomized trials have independently concluded that laparoscopic compared with open repair of bilateral inguinal hernias resulted in less postoperative pain, faster recovery, and similar rates of recurrence [54-56]. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom and the HerniaSurge group international guidelines both advocate laparoscopic repair for patients with bilateral hernias [38,57].

When laparoscopic repair is not available, the alternative for patients with bilateral hernias is bilateral open tension-free mesh repair, which can be performed as a single operation, rather than two separate procedures [58].

Female patients — Inguinal hernias are nine to 12 times more common in males than in females, whereas femoral hernias are four times more likely to be in females than in males [59-62]. Compared with men, women are more likely to have femoral hernias, complicated hernias (incarceration or strangulation), or recurrent hernias [60]. Groin hernia repairs are eight to 10 times more common in males than in females. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults", section on 'Epidemiology' and "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults", section on 'Femoral hernia'.)

For female patients with a groin hernia, we suggest surgical repair regardless of symptoms or the type of hernia (inguinal versus femoral). The rationale is that females are four times more likely to have femoral hernias than males [61]. Femoral hernias are eight times more likely to strangulate than inguinal hernias (36 to 39 versus 5 percent) [59,63], and there is no reliable way to distinguish femoral from inguinal hernia in some patients (eg, those with obesity) by clinical examination or ultrasound [64-66]. As such, 17 percent of females with groin hernias require emergency repair, compared with 5 percent of males [59,60]. Watchful waiting has never been studied in females to determine if it is as safe in females as in males and should not be used except in pregnant patients. (See 'Pregnancy' above.)

For females without any history of prior lower abdominal surgery (eg, cesarean section, hysterectomy), we further suggest a laparoscopic repair. In reoperations after a failed anterior repair, a femoral hernia is found in 40 percent of female patients, a risk of missed or occult femoral hernias at the initial repair that is 10-fold higher than in males [60,62,67-70]. The anterior approach does not permit the search for a possible femoral hernia. By contrast, a laparoscopic repair permits identification and repair of occult hernias (eg, femoral). Indeed, reoperation rates after a TEP or TAPP repair are lower than those after open/anterior repairs [62,63,68,69,71]. (See "Recurrent inguinal and femoral hernia", section on 'Occult hernias'.)

The UpToDate contributors feel that the suggestion for laparoscopic repair in female patients is based on weak evidence, and a reasonable alternative is open repair with exploration of the femoral triangle via the infrainguinal approach. For females who have had a prior surgery involving the lower preperitoneal space (eg, cesarean section or hysterectomy), an open anterior mesh repair is the best option. (See 'Patients with prior surgery involving the lower preperitoneal space' below.)

One controversy that applies to all techniques of female inguinal hernia repair is whether to divide or preserve the round ligament. With very little high-quality data, the decision is largely left to individual surgeons. Dividing the round ligament can optimize the dissection and facilitate mesh placement, especially with a posterior approach. However, dividing the round ligament can risk injuring the genital branch of the genitofemoral nerve and, in theory, predispose to uterine prolapse when done bilaterally.

In a retrospective study of 1365 female patients who underwent open (36.3 percent), laparoscopic (34.5 percent), or robotic (28.2 percent) repair of inguinal hernias, the round ligament was divided in 63.6 percent and preserved in 36.4 percent of cases [72]. There were no significant differences in overall complication, reoperation, or recurrence rates. Mean European Registry for Abdominal Wall Hernias quality-of-life summary scores were not significantly different at 30 days or 6 months. However, the mean pain-specific scores at six months in the division group were lower than those in the preservation group (3 versus 4.7, p<0.01), which persisted on multivariable analysis (p = 0.02).

Noncandidates for laparoscopic repair — Laparoscopic repair of groin hernias may not be feasible for either anatomical reasons (ie, previous lower abdominal surgery, irreducible or large inguinoscrotal hernia, or ascites) or patient intolerance of general anesthesia. In either case, an open repair is required, with the exception that some surgeons may choose the TAPP approach for irreducible or large inguinoscrotal hernia.

For patients in whom mesh placement is not contraindicated, we suggest using a mesh repair technique to achieve a tension-free repair rather than a nonmesh repair technique. (See "Hernia mesh", section on 'Mesh repair of groin hernias'.)

Nonmesh repair techniques may be required for patients with active groin infection or contamination (eg, as a result of bowel perforation from a strangulated hernia). (See 'Complicated hernia' below.)

Recurrent hernia — For patients with a recurrent groin hernia, we suggest repairing the recurrent groin hernia with a posterior approach (TEP or TAPP) if the initial repair was open but with an open anterior approach if the initial repair was laparoscopic or robotic. The rationale is that recurrent hernia repair is optimal if performed in a previously undissected tissue plane. (See "Recurrent inguinal and femoral hernia", section on 'Surgical repair'.)

Patients with prior open repair – Many surgeons feel that recurrent hernias, particularly those that recur after an anterior mesh repair, are best addressed via a laparoscopic technique [73,74]. As with primary repairs, a laparoscopic repair of recurrent hernias was also associated with faster recovery, less postoperative pain, and fewer complications [56,73,75-77]. The NICE in the United Kingdom and the HerniaSurge group also advocate laparoscopic repair for recurrent hernias after an anterior repair [38,57].

Patients with prior laparoscopic repair – An open repair is required for patients with a recurrent hernia if they have had a previous laparoscopic hernia repair (usually with mesh placement) or other surgeries involving the preperitoneal space (eg, prostatectomy, hysterectomy, cesarean section, or laparotomy via lower midline incision). In such patients, the preperitoneal space may be difficult to access. (See 'Patients with prior surgery involving the lower preperitoneal space' below.)

Irreducible or inguinoscrotal hernia — In male patients with a large scrotal or irreducible hernia, we suggest either an open mesh repair or a transabdominal laparoscopic repair (TAPP) rather than a TEP repair. This suggestion, which is consistent with HerniaSurge consensus [38], is not based on evidence but clinical necessity. Irreducible or scrotal hernias have large, incarcerated components that are very difficult to manipulate laparoscopically, especially in the limited preperitoneal space when approached with TEP.

Patients with prior surgery involving the lower preperitoneal space — For patients who have had one or more previous surgeries involving the preperitoneal space (eg, prostatectomy, hysterectomy, cesarean section, or laparotomy via lower midline incision), we suggest an anterior open repair rather than a laparoscopic posterior repair. Although laparoscopic repair is feasible in such patients (especially with the TAPP technique), it is technically challenging, requires a longer operative time, and is associated with more complications than open surgery in such patients [78,79].

Laparoscopic repair, especially with the TEP technique, requires the development and maintenance of the preperitoneal space. Adhesions formed after previous surgery, incision, or mesh placement could render that space inaccessible. In a meta-analysis of seven comparative cohort studies, TEP repair in patients with prior low abdominal surgery was associated with higher intraoperative morbidities (OR 2.85) and postoperative morbidities (multiport subgroup; OR 2.14) compared with in those without prior lower abdominal surgery [80].

Patients with ascites — In patients with ascites, we suggest an open rather than laparoscopic repair. In particular, the TAPP approach (which is transperitoneal) should be avoided as entry into the peritoneal space may result in persistent leakage of ascites or even fistula formation at the trocar sites.

Prior to surgery, ascites should be minimized as much as possible with medical treatment. At the time of surgery, the hernia sac should be left intact to avoid complications such as persistent leakage of ascitic fluid. (See "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".)

FEMORAL HERNIA — For all patients with femoral hernia, we suggest surgical repair, rather than watchful waiting, regardless of the patient's sex or symptoms.

Femoral hernias are associated with a higher risk of developing complications than inguinal hernias [12,81-83]. In one study, the rates of strangulation were 22 and 45 percent at 3 and 21 months, respectively, for femoral hernias, compared with 2.8 and 4.5 percent for inguinal hernias [84].

Thus, early elective repair is advised for patients with a newly diagnosed femoral hernia to avoid complications that may necessitate urgent surgery. Urgent surgery for complicated hernias is more likely to involve bowel resection, which is associated with a higher mortality rate. In one study, for example, bowel resection was required in 23 percent of urgent compared with 0.6 percent of elective femoral hernia repairs, and urgent femoral hernia repairs were associated with a 10-fold increase in mortality [59].

A femoral hernia should be repaired posteriorly rather than anteriorly, if possible, for both technical and patient outcome reasons. Posterior repairs are mostly done laparoscopically (TEP or TAPP) as the only open posterior repair (Kugel) is rarely performed. Thus, we suggest a laparoscopic rather than open anterior repair of femoral hernia. In database studies, the recurrence and reoperation rates (0.62 versus 3.4 percent [63]) were lower after mesh, as opposed to suture, repair of femoral hernias [2,63]. In one study, open preperitoneal mesh repair was associated with better outcomes than anterior mesh plug repair [85]. Several cohort studies have reported lower recurrence rates with laparoscopic repair of femoral hernias than open anterior repair [2,59,63,69]. For example, in a Danish Hernia Database study of 5893 females, all femoral recurrences occurred after a previous open anterior operation [69].

In addition, the laparoscopic approach is also better at identifying occult hernias [86]. In one study of 250 men undergoing laparoscopic repair of presumed inguinal hernias, femoral hernias were detected in addition to (29) or in lieu of (4) inguinal hernias in 33 patients (13.2 percent) [87]. Of the 33 patients with a femoral hernia, 61 percent had undergone a previous open inguinal hernia repair, reflecting either the failure to recognize a concomitant femoral hernia during their initial open surgery or the interval development of a femoral hernia.

A posterior repair is also favored due to the ease of access. Anterior femoral hernia repairs require a breach of the inguinal canal to gain access to the femoral hernia posteriorly; posterior repairs have direct access to the femoral hernia without going through the inguinal canal.

COMPLICATED HERNIA — Patients with an acutely incarcerated inguinal hernia but without signs of strangulation (eg, skin changes, peritonitis) should be offered urgent surgical repair. However, hernia reduction can be attempted in patients who wish to delay surgery [88]. If hernia reduction is successful, the patient should follow up with their surgeon within one to two days to exclude recurrent incarceration and arrange for elective repair. Those who fail hernia reduction should proceed urgently to surgery (algorithm 2).

Patients who develop bowel strangulation or bowel obstruction due to a groin hernia should undergo urgent surgical repair after fluid resuscitation, nasogastric decompression, and antimicrobial coverage. Surgery performed within four to six hours from the onset of symptoms may prevent bowel loss due to one of these complications. (See "Management of small bowel obstruction in adults", section on 'Surgical causes of small bowel obstruction'.)

The approach to repairing incarcerated or strangulated groin hernias depends on the clinical scenario. No randomized studies, systematic reviews, or comparative cohort studies address the question.

An open approach is probably the safest and the most expedient, especially when bowel resection may be necessary. In a dirty wound, there is also the option of performing a nonmesh repair with the open, but not any of the laparoscopic, approaches. In case that the incarcerated hernia spontaneously reduces upon induction of anesthesia, some surgeons perform "hernioscopy" through the hernia defect to ensure viability of the bowel before hernia repair. One randomized study found that approach to be accurate and that it reduced complications and unnecessary laparotomies compared with no hernioscopy, although only preliminary results have been reported [89].

A primary laparoscopic approach is possible but may be difficult to perform, again depending on the hernia and the patient [90,91]. For example, one option is to start with a laparoscopic exploration and attempt to reduce the incarcerated bowel. If successful, the hernia can then be repaired using the TAPP or TEP technique. If bowel reduction is not possible, or if bowel resection is required, the procedure can then be converted to open.

It is controversial whether to use mesh and which kind of mesh should be used when repairing an acutely incarcerated or strangulated groin hernia. The general consensus is that it depends on the wound classification according to the Centers for Disease Control and Prevention (CDC) (table 1) [38].

Class 1 (clean) – For patients with bowel incarceration but not strangulation and no need for bowel resection, the wound should be classified as clean, and a synthetic mesh should be used to repair the hernia. Low-quality cohort studies and a small randomized trial did not find worse outcomes with anterior mesh repair of such hernias compared with anterior nonmesh repair [92-94].

Class 2 (clean-contaminated) – For patients with bowel strangulation and/or a concomitant bowel resection, the wound should be classified as clean-contaminated, and a synthetic, monofilament, large-pore mesh should be used to repair the hernia. A 2014 systematic review and meta-analysis of two small randomized trials and seven cohort studies concluded that, compared with nonmesh repair, mesh repair of strangulated hernias was associated with fewer wound complications (odds ratio [OR] 0.46, 95% CI 0.20-1.07) and fewer recurrences (OR 0.2, 95% CI 0.05-0.78) [95].

Class 3 (contaminated) or class 4 (dirty-infected) – For patients with bowel perforation and/or abscess formation, the wound should be classified as contaminated or dirty-infected, in which case no mesh should be used to repair the hernia. Once source control has been achieved, the hernia can be repaired without mesh or left unrepaired, depending on the clinical condition of the patient. This is not based on data but expert opinion and common sense.

PREOPERATIVE PREPARATION — Inguinal and femoral hernias can usually be repaired with minimal morbidity and mortality. We use the following preoperative routine to optimize patient outcomes and experience.

Preoperative prophylaxis — Most inguinal and femoral hernia repairs are elective procedures performed in an outpatient setting. Thromboprophylaxis and/or prophylactic antibiotics may be required in selected patients to prevent complications such as venous thromboembolism (VTE), surgical site infection (SSI), or urinary retention.

Thromboprophylaxis — Thromboprophylaxis is administered according to the patient's risk of developing VTE perioperatively (table 2). Patients who are young (<40 years of age), otherwise healthy, and have no other risk factors for VTE do not require pharmacologic thromboprophylaxis. Mechanical thromboprophylaxis should be applied to patients undergoing general anesthesia. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

Antibiotic prophylaxis — For patients undergoing uncomplicated inguinal or femoral hernia repair with planned mesh placement, we suggest administering prophylactic antibiotics rather than no antibiotics. Patients with complicated hernias require broader antimicrobial coverage than prophylactic antibiotics. For patients undergoing uncomplicated inguinal or femoral hernia repair without planned mesh placement, prophylactic antibiotics may be omitted based upon surgeon preference.

The role of prophylactic antibiotics given prior to inguinal or femoral hernia repair remains controversial [96-101]. Uncomplicated hernia surgery is considered clean surgery, for which prophylactic antibiotics are not indicated. A 2020 Cochrane review found that prophylactic antibiotics had little or no effect on elective open groin hernia repair in preventing wound infections in low-infection-risk settings but may be beneficial in preventing superficial wound infections in high-infection-risk settings [102]. These data are consistent with the 2018 HerniaSurge group's recommendation for prophylactic antibiotics only for open groin hernia repair in high-risk settings but not for open groin hernia repair in low-risk settings or for laparoscopic groin hernia repair [38].

However, some surgeons, including us, prefer to administer antibiotics to all patients undergoing hernioplasty (ie, hernia repair with mesh) to prevent potential mesh infection [101,102]. Prophylactic antibiotics should cover the usual skin flora, including aerobic gram-positive organisms, aerobic streptococci, staphylococci, and enterococci (table 3) [103]. To be effective, prophylactic antibiotics must be administered within one hour before the time of incision [104,105]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection following gastrointestinal procedures in adults".)

Patients undergoing urgent inguinal or femoral hernia repairs should receive antibiotics according to the complication (eg, bowel perforation, bowel ischemia, or obstruction). For those patients, antibiotics are considered therapeutic rather than prophylactic, and the initial coverage should be broad (table 3). Once an intraoperative culture has been obtained, further antibiotic therapy should be guided by microbiology data and continue for about five days after source control. (See "Antimicrobial approach to intra-abdominal infections in adults".)

Urinary retention prophylaxis — For patients without a prior history of prostate surgery or voiding problems, we suggest asking the patient to empty the bladder just prior to the groin hernia repair rather than prophylactic urinary catheterization. Routine urinary catheterization is not necessary before either open or laparoscopic groin hernia repair [106]. Laparoscopic TAPP repair can be safely performed without urinary catheters [107]. A randomized trial of 491 patients (95 percent male) undergoing laparoscopic inguinal hernia repair found that routine bladder catheterization did not reduce the incidence of postoperative urinary retention (9.6 percent with catheter versus 8.5 percent without catheter). There was no bladder injury in either group [108].

Some surgeons give an alpha-1-receptor antagonist preoperatively (eg, prazosin, phenoxybenzamine hydrochloride, or tamsulosin) to prevent postoperative urinary retention. We do not routinely do this. In a meta-analysis of five trials, preoperative alpha blockade reduced the incidence of urinary retention requiring catheterization by 20 percent [109].

Choice of anesthesia — Inguinal or femoral hernia repair can be performed using general, neuraxial (spinal or epidural), or regional anesthesia (peripheral nerve block, local) [110,111]. The choice of anesthesia depends upon the type and size of the hernia, surgical approach, and patient/surgeon preferences.

Anesthesia for open repair — For patients undergoing open groin hernia repair, we suggest local anesthesia, rather than neuroaxial or general anesthesia. Local anesthesia is preferred especially in patients with comorbidities (eg, advanced liver disease). The use of local anesthesia reduces complications and cost in both older and younger patients [112].

In a randomized trial of 616 patients undergoing open inguinal hernia repairs, the use of local anesthesia resulted in less postoperative pain and nausea, a shorter recovery room stay (3.1 versus 6.2 and 6.2 hours), and fewer unplanned overnight admissions (3 versus 14 and 22 percent) compared with the use of regional and general anesthesia, respectively [110]. Another randomized trial of open inguinal hernia repairs also found that local anesthesia resulted in less postoperative pain, shorter operating time, and fewer overnight stays than spinal anesthesia [113].

A retrospective study of over 97,000 veterans undergoing open inguinal hernia repairs associated local anesthesia with a 37 percent decrease in the odds of postoperative complications, a 13 percent decrease in operative time, and a 27 percent shorter recovery room stay compared with general anesthesia [114]. Another study from the same group of over 100,000 patients associated open inguinal hernia repair under local anesthesia with a similar risk of short-term postoperative complications (difference, -0.05 percent) but reduced operative time compared with laparoscopic repair (difference, 10.42 minutes), especially for complex hernias (difference, 31.4 minutes) [115].

Local anesthesia can be administered as a nerve block of the ilioinguinal and iliohypogastric nerves or as direct infiltration into the incision site(s). Nerve block may be more difficult to administer but causes less soft tissue edema than direct infiltration. Some surgeons use a combination of both nerve blocks and local infiltration. Local anesthesia for open groin hernia repair is typically given in the context of "monitored anesthesia care," which also provides intravenous sedatives for patient relaxation and additional intravenous analgesics. (See "Abdominal nerve block techniques", section on 'Ilioinguinal and iliohypogastric nerve block'.)

The main disadvantage of local anesthesia is that it may not provide adequate anesthesia during the repair of large hernias, particularly in patients who have a loss of abdominal domain. In such patients, general anesthesia is preferred. General anesthesia can also be used in open hernia repair by patient or surgeon preference.

Anesthesia for laparoscopic repair — Anesthesia requirements for laparoscopic inguinal or femoral hernia repairs vary depending upon the technique used:

Transabdominal preperitoneal patch (TAPP) repair requires general anesthesia.

Intraperitoneal onlay mesh (IPOM) repair requires general anesthesia.

Totally extraperitoneal (TEP) repairs are most often performed under general anesthesia but can also be performed under spinal or epidural anesthesia.

Since laparoscopic groin hernia repair is typically performed under general anesthesia, patients who cannot tolerate general anesthesia for medical reasons should undergo open repair under local or regional anesthesia.

PATIENT OUTCOMES

Quality of life — There is heterogeneity in the use of patient-reported outcome measures in the field of groin hernia research. In a systematic review, 929 studies covered 81 different patient-reported outcome measures [116]. Of these, the Short-Form 36 was the most commonly used generic instrument (14 percent), the Carolinas Comfort Scale [117] was the most commonly used hernia-specific instrument (5 percent), and the Visual Analogue Scale was the most commonly used domain-specific instrument (70 percent). There was a proportional decrease in the use of generic instruments, from 24 percent of studies in 2000 to 2004 to only 14 percent of studies in 2015 to 2019. Conversely, there was an increase in the use of hernia-specific instruments, from 0 percent in 2000 to 2004 to 18 percent in 2015 to 2019, and the use of domain-specific instruments remains consistently high.

Mortality — The 30 day mortality rate for inguinal or femoral hernia repair is 0.1 percent after elective surgery and 2.8 to 3.1 percent after urgent surgery [60,118,119]. The mortality rate is higher when bowel resection is performed with hernia repair [120]. Other risk factors associated with a higher mortality rate include older age [119], femoral hernia [59,120], female sex [59], and urgent repair. (See "Complications of inguinal and femoral hernia repair", section on 'Mortality'.)

Morbidity — Minor complications of inguinal or femoral hernia repair, including superficial wound infection, seroma/hematoma formation, and urinary retention, are common and easily managed. Serious complications are rare and include hernia recurrence (<4 percent) and post-herniorrhaphy neuralgia (5 to 10 percent). (See "Post-herniorrhaphy groin pain" and "Complications of inguinal and femoral hernia repair".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Groin hernia in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Groin hernias (The Basics)" and "Patient education: Seroma (The Basics)")

SUMMARY AND RECOMMENDATIONS

Treatment options – Males with asymptomatic or minimally symptomatic inguinal hernias and pregnant patients with uncomplicated inguinal hernias can be observed (ie, watchful waiting). All other patients should be considered for surgical repair. (See 'Treatment options' above.)

Inguinal hernia For repair of uncomplicated inguinal hernias, we suggest a laparoscopic repair (totally extraperitoneal [TEP] or transabdominal preperitoneal patch [TAPP]) when feasible (Grade 2B). Laparoscopic repair has been associated with a faster recovery, decreased pain, and comparable recurrence rate compared with open repair. However, if the surgeon lacks sufficient experience with laparoscopic repair, open repair is a reasonable alternative. The robotic approach is not included in this suggestion, due to limited evidence comparing it with the other two approaches. (See 'Candidates for laparoscopic repair' above.)

Patients who have had previous lower abdominal surgery or have irreducible or large inguinoscrotal hernia, ascites, or intolerance to general anesthesia should undergo open repair (algorithm 1). For patients in whom mesh placement is not contraindicated, we suggest using a mesh repair technique to achieve a tension-free repair rather than a nonmesh repair technique (Grade 2C). For patients who refuse mesh or in contaminated wounds, a nonmesh repair is reasonable. (See 'Noncandidates for laparoscopic repair' above.)

Femoral hernia – For all patients with femoral hernia, we suggest surgical repair, rather than watchful waiting, regardless of the patient's sex and symptoms (Grade 1C). We further suggest a laparoscopic rather than open repair of femoral hernia whenever anatomically feasible (Grade 2C). (See 'Femoral hernia' above.)

Complicated hernia – Complicated (acutely incarcerated or strangulated) hernias require urgent repair; the approach depends on the clinical scenario (algorithm 2). A synthetic monofilament large-pore mesh can be used in clean or clean-contaminated cases but not contaminated or dirty-infected cases, which require either nonmesh repair or deferred repair. (See 'Complicated hernia' above.)

Preoperative prophylaxis – We use the following preoperative routine to optimize patient outcomes and experience. (See 'Preoperative prophylaxis' above.)

Thromboprophylaxis – Thromboprophylaxis is administered according to the patient's risk of developing VTE perioperatively (table 2). (See 'Thromboprophylaxis' above.)

Antimicrobial prophylaxis – For patients undergoing uncomplicated inguinal or femoral hernia repair with planned mesh placement, we suggest administering prophylactic antibiotics rather than no antibiotics (Grade 2C). For patients undergoing uncomplicated inguinal or femoral hernia repair without planned mesh placement, prophylactic antibiotics may be omitted based upon surgeon preference. Patients undergoing urgent inguinal or femoral hernia repairs should receive antibiotics according to the complication (eg, bowel perforation, bowel ischemia, or obstruction). (See 'Antibiotic prophylaxis' above.)

Urinary retention prophylaxis – For patients without a prior history of prostate surgery or voiding problems, we suggest asking the patient to empty the bladder just prior to the groin hernia repair (both open and laparoscopic) rather than prophylactic urinary catheterization (Grade 2B). Some surgeons also give an alpha-1-receptor antagonist preoperatively (eg, prazosin, phenoxybenzamine hydrochloride, or tamsulosin). (See 'Urinary retention prophylaxis' above.)

Anesthesia – For patients undergoing open groin hernia repair, we suggest local anesthesia, rather than neuroaxial or general anesthesia (Grade 2B). General anesthesia is required for those undergoing minimally invasive repair. (See 'Choice of anesthesia' above.)

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Topic 3687 Version 36.0

References

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