Treatment

Surgical repair of the hernial defect is the only definitive treatment for inguinal hernia. The management of direct inguinal hernia and indirect inguinal hernia does not differ.

Once the hernial contents are reduced (i.e., returned to the abdominal cavity), the goal of hernia surgery is to reinforce the posterior wall of the inguinal canal with a synthetic mesh or through primary tissue approximation. Emergency surgery is associated with an increased risk of complications; elective surgery is preferred when it is an option.

Hernioplasty (mesh repair)

• Definition: repair of a hernial defect using a synthetic mesh

• Indication: gold standard for inguinal hernia repair [6]

• Open surgery

  • Preferred in patients with complicated inguinal hernia or contraindications for laparoscopic repair [8]

  • Procedures include Lichtenstein repair, in which a synthetic mesh is placed between the transversalis fascia and the external oblique aponeurosis to reinforce the posterior wall of the inguinal canal. [11]

• Laparoscopic surgery: preferred in patients with bilateral or recurrent inguinal hernia [8]

  • Transabdominal preperitoneal repair (TAPP): laparoscopic, preperitoneal mesh implementation between the parietal peritoneum and transverse fascia

  • Total extraperitoneal repair (TEP): laparoscopic, extraperitoneal mesh implementation between parietal peritoneum and transverse fascia

• Definition: open surgical repair of a hernial defect using autologous tissue

• Indication: Consider in patients at high risk of surgical site infection. [8][25]

• Options: Shouldice repair

  • A pure tissue repair that involves a multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique.

• Important consideration: Herniorrhaphy is associated with a greater risk of recurrence than hernioplasty.

• Epidemiology

  • Incidence: ∼ 1–5% of all children

  • ♂ > ♀ (∼ 4:1)

  • Occurs more often on the right side

• Etiology and risk factors

  • Due to patent processus vaginalis (see “Etiology” above) in males or patent diverticulum of Nuck in females

  • Premature birth

  • Urogenital dysplasia syndromes

  • Increased intraabdominal pressure

  • Weakness of the connective tissue (e.g., Ehlers-Danlos syndrome)

• Therapy: surgery

  • Premature infants with uncomplicated inguinal hernia: Surgery should be performed after discharge from the neonatal intensive care unit (NICU).

  • If hernia can be reduced manually: Wait 24–48 hours before performing surgery to allow enough time for edema to decrease. [32]

  • If hernia cannot be reduced manually: immediate surgery

  • Asymptomatic inguinal hernia: within 14 days of diagnosis