Inguinal Hernia: Adult
With Dr. Michael Rosen · hosted by Dr. Jeffrey Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years.
In the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.
In long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.
For an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan.
For younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right.
Inguinal hernia repairs can be performed under local anesthesia in high-risk patients.
For symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair.
For unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.
The best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.
The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.
For young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve.
In laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly.
Chronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable.
TAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.
TEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.
TAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction.
TAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation.
Laparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.
Laparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely.
In elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients.
In a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk.
Pneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return.
The benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.
Surgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach.
Previous lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time.
Previous prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.
Basic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element.
Parietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.
The length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence.
The inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels.
When surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.
All mesh contracts to some degree and can move.
According to Stoppa's original descriptions, for a unilateral inguinal hernia, surgeons should never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes being placed.
For large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.
Heavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).
Mesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.
Midweight mesh is between 40 to 50 grams per meter squared.
Lightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.
Advantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.
Disadvantages of lightweight mesh include having half the material, and in direct hernias where the mesh bridges and muscles never come together, the mesh is at risk for fracturing, with reports now showing central mesh failures.
Heavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.
Pre-formed meshes for inguinal hernia anatomy are technically easier to place but surgeons commonly downsize to a much smaller piece of mesh, which is problematic.
For laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.
If the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.
Dr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.
Even surgeons who advocate no fixation will selectively use fixation for large direct hernias.
There is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.
If a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.
Dr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.
There is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.
Depending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.
For incarcerated femoral hernias with bowel compromise, Dr. Rosen makes a vertical incision (vascular exposure), dissects onto the hernia sac, and can resect compromised bowel infrainguinally without dividing the inguinal ligament.
To gain space for reducing femoral hernia contents without dividing the inguinal ligament, surgeons can release the lacunar ligament medially (which gives off from the inguinal ligament and goes to the pectineal line) to gain an extra 1 centimeter.
Dr. Rosen performs a 'reverse McVay' repair for femoral hernias from the infrainguinal approach, sewing the inferior border of the inguinal ligament down to Cooper's ligament starting medially to avoid impinging on the femoral vein.
Dr. Rosen does not use mesh plugs in femoral hernia repair because femoral hernias tend to occur in thin women and he has had a DVT occur due to irritation of the femoral vein from the plug.
For recurrent inguinal hernias, surgeons should approach from where nobody has been before, or if both spaces have been operated, go where they are most skilled.
For known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.
Surgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, even though these patients might benefit most from laparoscopy, because these cases are twice as hard.
For large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.
For incarcerated hernias that are difficult to reduce, Dr. Rosen puts patients to sleep and reduces the hernia under general anesthesia, then can proceed with TAPP repair.