In Brief

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Over the last several decades there has been a renewed interest in hernia repair and the study thereof. This has largely been driven by the transition to evidence-based practice of medicine and surgery and the lack of objective data supporting some of the practices in the management of inguinal hernias. In addition there has been an explosion of new mesh-based devices from which the surgeon can choose to repair the inguinal hernia as well as new approaches to this common problem. As the use of mesh for repair of inguinal hernias increased, the recurrence rate decreased, allowing surgeons and patients to concentrate on other measures of outcome such as return to activities and pain.

Inguinal hernia is a common problem and inguinal hernia repair is the most common operation in the United States. A basic knowledge of the history of the management of inguinal hernias is therefore compulsory for those who evaluate these patients in their practice. Although one might opine that the history is not necessary, history now is one of the few places one finds reference to many of the tissue repairs that might be needed in special circumstances, such as a contaminated field in which a Bassini or McVay repair is indicated, or in a young man in whom a Marcy repair might be enough of a variation from high ligation of the hernia sac to prevent further problems without the use of a prosthetic sheet of mesh.

An in-depth understanding of groin anatomy is required for those who undertake repair of hernias in any setting (eg, pediatric, women, and men). Knowledge about the specific layers of the inguinal region along with the nerves that traverse this area will help the herniorrhaphist avoid potential long-term complications. The naturally occurring shutter mechanism is likely a very important apparatus to attempt to replicate in some repairs. The Lichtenstein mesh repair (perhaps the most widely used open repair) specifically attempts to recreate this mechanism by tacking the inferior edge of the upper wing and the inferior edge of the lower wing to the inguinal ligament at the lateral aspect of the newly created internal ring.

As more and more randomized trials have been reported and more techniques are developed, the use of a standardized classification scheme is helpful. At a minimum, defining the hernias first as recurrent or primary and then according to their anatomy (eg, direct, indirect, femoral) helps to characterize the type of hernia as well as its potential for recurrence. In every study to date, repair of a recurrent hernia results in the highest recurrence rates compared with repair of primary hernias.

Over the last 2 decades, data from randomized trials have led to the widespread adoption of mesh in the repair of primary hernias. Large meta-analyses have reported a 50% decrease in the recurrence rates when mesh is used for repair. The only tissue repair that compares in most series to mesh-based repairs is the Shouldice repair, which is still in use in several specialized centers including the Shouldice hernia clinic. The approach to placing the mesh has been more controversial. Many open repairs combine anterior mesh with some type of preperitoneal mesh (“plug and patch” repair, Prolene Hernia System), provide access for placement of preperitoneal mesh (Kugel Hernia Patch), or direct access to the preperitoneal space (Giant Prosthetic Reinforcement of the Visceral Sac). Nearly all laparoscopic repairs involve preperitoneal or intraperitoneal mesh placement but vary in their approach (totally preperitoneal versus access via the abdominal cavity).

Selection of the operative approach depends on the surgeon’s experience with each of the repairs but should also depend upon the characteristics of the patient and the hernia. Large scrotal hernias are difficult to repair by any approach, but should particularly be avoided by the novel laparoscopic herniorrhaphist. Patients with symptomatic hernias who also have significant comorbidities may fare better with open mesh repair that can be achieved with a local anesthetic and intravenous sedation. Children with hernias and women present different anatomic and physiologic considerations; children seem to fare exceedingly well with high ligation of the sac alone whereas women appear to benefit as much as men from mesh repair with regard to recurrence. Women may also benefit from a laparoscopic approach to confirm or refute the presence of a femoral hernia.

As operations for inguinal hernia repair have evolved, with recurrence rates now in the range of approximately 5% or less in many studies, consideration of “patient-centered” outcomes has blossomed. Chronic postoperative pain and return to work or activities are common endpoints to consider when choosing a repair (and whether or not to repair the hernia in the first place). Most randomized trials have shown some decrease in pain after laparoscopic repairs, although the differences are small and tend to resolve with time. Pain is consistently more common in younger patients compared with older patients no matter which repair technique is used. Although the pain story is still being sorted out, one thing is very clear: the risk of chronic postoperative pain is high enough (may be as much as 11%) to warrant a discussion of this risk with patients preoperatively.

Return to activities has also been shown to be faster after laparoscopic repairs but in the VA trial wherein patient instructions were the same for both types of repair and a validated instrument was used to determine return to activities, the difference was small (4 days in the laparoscopic group compared with 5 days in the open group).

Although laparoscopic hernia repair has its clear proponents and may provide some benefits, the learning curve is steep and long. Outside of specialized centers concentrating on this repair, it may take as many as 250 repairs before a surgeon is facile at this repair, at least as measured by a drop in recurrence rates. Although the learning curve for open repair appears to be mastered during residency, with only 15% to 20% of inguinal hernia repairs approached laparoscopically at this time, it is unlikely that most surgery residents will have mastered this technique without fellowship training. It is unclear what might shorten the learning curve for laparoscopic repairs, but it seems that an objective, detailed monitoring of technique and results could be at least part of the answer.

Outside of the ongoing heated debate about repair technique, other controversies in hernia repair have surfaced. These include whether or not prophylactic antibiotics should be used (no data to clearly refute or support) and what type of anesthesia (general versus local or regional) results in better patient outcomes. In addition, the long-held principle of repairing an inguinal hernia based on its presence is now debated. This principle was based on the thought (not data) that there was a significant risk of strangulation with its subsequent difficulties. The rate of strangulation is actually quite low and now it has been shown that for asymptomatic or minimally symptomatic hernias, watchful waiting is a safe alternative. The most common reason for patients to seek repair after a period of observation is an increase in their symptoms.

In the end, the management of inguinal hernia in the 21st century can be based on good evidence, something that was lacking 50 years ago. Generalization of that evidence to one’s personal practice can be accomplished, but should be supported with one’s own experience, training, and most importantly, monitoring of outcomes such as complications, recurrence, rate of chronic pain, and other outcomes. Although this amount of data collection seems onerous, it is only through objective evaluation of the processes that one can truly improve the outcomes.