Open Inguinal Hernia Repair

Hernias are abnormal protrusions of a viscus (or part of it) through a normal or abnormal opening in a cavity (usually the abdomen). They are most commonly seen in the groin; a minority are paraumbilical or incisional. In the groin, inguinal hernias are more common than femoral hernias.

Inguinal hernias occur in about 15% of the adult population, and inguinal hernia repair is one of the most commonly performed surgical procedures in the world.[1] Approximately 800,000 mesh hernioplasties are performed each year in the United States,[2] 100,000 in France, and 80,000 in the United Kingdom.

There is morphologic and biochemical evidence that adult male inguinal hernias are associated with an altered ratio of type I to type III collagen.[3] These changes lead to weakening of the fibroconnective tissue of the groin and development of inguinal hernias. Recognition of this process led to acknowledgment of the need for prosthetic reinforcement of weakened abdominal wall tissue.

Given the evidence that the use of mesh lowers the recurrence rate,[4, 5] as well as the availability of various prosthetic meshes for the reinforcement of the posterior wall of the inguinal canal, most surgeons now prefer to perform a tension-free mesh repair. Accordingly, this article focuses primarily on the Lichtenstein tension-free hernioplasty, which is one of the most popular techniques used for inguinal hernia repair.[6, 7]

Types of hernia

An indirect hernia is defined as a defect protruding through the internal or deep inguinal ring, whereas a direct hernia is a defect protruding through the posterior wall of the inguinal canal. To put it in a more anatomic way, an indirect hernia is lateral to the inferior epigastric artery and vein, whereas a direct hernia is medial to these vessels. The Hesselbach triangle is the zone of the inguinal floor through which direct hernias protrude, and its boundaries are the epigastric vessels laterally, the rectus sheath medially, and the inguinal ligament inferiorly.[8]

An incomplete hernia is confined to the inguinal canal, whereas a complete hernia comes out of the inguinal canal through the external or superficial ring into the scrotum. Direct hernias are always incomplete, whereas indirect hernias can also be complete.

A sliding inguinal hernia is one in which a portion of the wall of the hernia sac is made up of an intra-abdominal organ. As the peritoneum is stretched and pushed through the hernia defect and becomes the hernia sac, retroperitoneal structures such as the colon or bladder are dragged along with it and thus come to make up one of its walls.

Bilateral pediatric hernias are most commonly indirect hernias and arise because of the patency of the processus vaginalis. Simple ligation of the hernia sac (herniotomy) alone is enough. Surgical treatment of indirect hernias in adults, unlike that in children, requires more than simple ligation of the hernia sac. This is because the patent processus is only part of the story. With time, the internal ring dilates, leaving an adult with what can be a sizable defect in the floor of the inguinal canal; this must be closed in addition to division or reduction of the indirect hernia sac.

A hydrocele is a commonly encountered pathology related to hernias. A communicating hydrocele is, by definition, a form of indirect hernia, albeit with an extremely small defect through which only peritoneal fluid enters the sac but no viscus (eg, omentum or bowel) comes out.

Types of hernia repair

Inguinal hernia repairs may be divided into the following three general types:

• Herniotomy (removal of the hernial sac only) - This, by itself, is adequate for an indirect inguinal hernia in children in whom the abdominal wall muscles are normal; formal repair of the posterior wall of the inguinal canal is not required
• Herniorrhaphy (herniotomy plus repair of the posterior wall of the inguinal canal) - This may be suitable for a small hernia in a young adult with good abdominal wall musculature; the Bassini and Shouldice repairs are examples of herniorrhaphy
• Hernioplasty (herniotomy plus reinforcement of the posterior wall of the inguinal canal with a synthetic mesh) - This is required for large hernias and hernias in middle-aged and elderly patients with poor abdominal wall musculature; the Lichtenstein tension-free mesh repair is an example of hernioplasty

Open vs laparoscopic repair

Although numerous surgical approaches have been developed to treat inguinal hernias, the Lichtenstein tension-free mesh-based repair remains the criterion standard.[1] In a Cochrane review comparing mesh with nonmesh open repair, the evidence was sufficient to conclude that the use of mesh was associated with a reduced rate of recurrence.[2]

Laparoscopic approaches are feasible in expert hands, but the learning curve for laparoscopic hernia repair is long (200-250 cases), the severity of complications is greater, detailed analyses of cost-effectiveness are lacking, and long-term recurrence rates have not been determined.[9] The role of laparoscopic inguinal hernia repair in the treatment of an uncomplicated, unilateral hernia is yet to be resolved.

Nevertheless, transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) laparoscopic inguinal hernioplasty may offer specific benefits for some patients, such as those with recurrent hernia after conventional anterior open hernioplasty, those with bilateral hernias, and those undergoing laparoscopy for other clean operative procedures.

A 2014 meta-analysis of seven studies comparing laparoscopic repair with the Lichtenstein technique for treatment of recurrent inguinal hernia concluded that despite the advantages to be expected with the former (eg, reduced pain and earlier return to normal activities), operating time was significantly longer with the minimally invasive technique, and the choice between the two approaches depended largely on the availability of local expertise.[10]

For further details on the debate over laparoscopic versus open repair, see Laparoscopic Inguinal Hernia Repair. For information on manual reduction of hernias, see Hernia Reduction.

Classically, the existence of an inguinal hernia, in and of itself, has been considered reason enough for operative intervention. However, some studies have shown that the presence of a reducible hernia is not, in itself, an indication for surgery and that the risk of incarceration is less than 1%.[11]

Patients experiencing symptoms (eg, pain or discomfort) should undergo repair; however, as many as one third of patients with inguinal hernias are asymptomatic.[11] The question of observation versus surgical intervention in this asymptomatic or minimally symptomatic population was addressed in two randomized clinical trials.[6, 7] The two trials yielded similar results: After long-term follow-up, no significant difference in hernia-related symptoms was noted, and watchful waiting did not increase the complication rate.

In one study, the substantial patient crossover from the observation group to the surgery arm led the authors to conclude that observation may delay but not prevent surgery.[11] This reasoning holds particularly true in the younger patient population. Thus, even an asymptomatic patient, if medically fit, should be offered surgical repair. A long-term follow-up study determined that most patients with a painless inguinal hernia will develop symptoms over time and concluded that surgery is recommended for medically fit patients.[12]

Koch et al found that recurrence rates were higher in women and that recurrence was 10 times more likely to be of the femoral variety in women than it was in men.[13] Such findings have led some to the conclusion that procedures providing coverage of the femoral space (eg, laparoscopic repair) at the time of initial operation are better suited for women as primary repairs.[14]

Inguinal hernia repair has no absolute contraindications. Just as in any other elective surgical procedure, the patient's medical status must be optimized. Any medical issues (eg, upper respiratory tract or skin infection, poorly controlled diabetes mellitus, chronic constipation, urinary obstruction, persisting cough, obstruction or strangulation, or allergy to local anesthesia or prosthetic devices) should be fully addressed and the operation delayed accordingly.

Patients with elevated American Society of Anesthesiologists (ASA) scores and high operative risk should undergo a full preoperative workup and determination of the risk-to-benefit ratio.

Recurrences after a primary posterior technique (eg, TEP, TAPP, or open posterior repair) may be treated with Lichtenstein hernioplasty.[5] Recurrence after a primary anterior technique should preferably be dealt with by means of TEP, TAPP, or open posterior repair.

Anatomy

A useful learning tool for gaining a working knowledge of the inguinal region is to visualize the region as it is surgically approached in the open technique of hernia repair. The inguinal region is part of the anterolateral abdominal wall, which is made up of the following nine layers, from superficial to deep:

• Skin
• Camper fascia
• Scarpa fascia
• External oblique aponeurosis
• Internal oblique muscle
• Transversus abdominis
• Transversalis fascia
• Preperitoneal fat
• Peritoneum

The first layers encountered upon dissection through the subcutaneous tissues are the Camper and Scarpa fasciae. Contained in this space are the superficial branches of the femoral vessels—namely, the superficial circumflex and the epigastric and external pudendal arteries, which can be safely ligated and divided when encountered.

The inguinal canal can be visualized as a tunnel traveling from lateral to medial in an oblique fashion (see the image below). It has a roof facing anteriorly, a floor facing posteriorly, a superior (cranial) wall, and an inferior (caudal) wall. The canal contents (in men, cord structures; in women, the round ligament) are the traffic that traverses the tunnel.

The external oblique aponeurosis serves as the roof of the inguinal canal and opens just lateral to and above the pubic tubercle. This is the external or superficial inguinal ring, which allows the cord structures egress from the inguinal canal to the scrotum.[15]

The floor of the canal is composed of the transversus abdominis and the transversalis fascia. The entrance to the inguinal canal is through these layers, and this entrance constitutes the internal or deep inguinal ring.

The inferior wall is the inguinal (Poupart) ligament. This ligament is formed by the lower edge of the external oblique aponeurosis and extends from the anterior superior iliac spine to its attachments at the pubic tubercle and fans out to form the lacunar (Gimbernat) ligament.[16, 17] The inguinal ligament folds over itself to form the shelving edge. This folded-over sling of external oblique aponeurosis is the true lower wall of the inguinal canal.

The superior wall consists of a union of the internal oblique muscle and the transversus abdominis aponeurosis, which arches from its attachment at the lateral segment of the inguinal ligament over the internal inguinal ring, ending medially at the rectus sheath and coming together inferomedially to insert on the pubic tubercle, thus forming the conjoined tendon.[17, 8]

In males, the contents of the inguinal canal include the obliterated processus vaginalis (which, when patent, forms the sac of the indirect inguinal hernia), the spermatic cord, and the ilioinguinal nerve (which comes out of the superficial inguinal ring along with the spermatic cord). In females, the inguinal canal contains the ilioinguinal nerve and the round ligament of the uterus.

The coverings of the spermatic cord include the following:

• Internal spermatic fascia, derived from the transversalis fascia at the deep inguinal ring
• Cremaster muscle, derived from the internal oblique muscle at the deep inguinal ring
• External spermatic fascia, derived from the external oblique aponeurosis at the superficial inguinal ring (present only in the scrotum and not in the inguinal canal)

The contents of the spermatic cord include the following:

• Vas deferens
• Testicular artery
• Artery of the ductus deferens
• Cremasteric artery
• Pampiniform plexus
• Genital branch of the genitofemoral nerve
• Parasympathetic and sympathetic nerves
• Lymphatic vessels

The key nerves in the inguinal region are as follows (see the image below):

• Iliohypogastric nerve
• Ilioinguinal nerve
• Genital branch of the genitofemoral nerve

The ilioinguinal nerve runs medially through the inguinal canal along with the cord structures traveling from the internal ring to the external ring. It innervates the upper and medial parts of the thigh, the anterior scrotum, and the base of the penis.

The iliohypogastric nerve runs below the external oblique aponeurosis but cranial to the spermatic cord, then perforates the external oblique aponeurosis cranial to the superficial ring. It innervates the skin above the pubis.

The genital branch of the genitofemoral nerve lies within the spermatic cord and travels with the cremasteric vessels through the inguinal canal. It innervates the cremaster muscle and provides sensory innervation to the scrotum.

Some variations in the anatomic distribution of these nerves may be observed—for instance, the occasional absence of an ilioinguinal nerve.[18]

The Hesselbach triangle is bounded by the inguinal ligament below, the lateral border of the rectus abdominis medially, and the inferior epigastric vessels laterally (see the image below). The sac of a direct hernia lies in this triangle, whereas the neck of an indirect hernia sac lies outside the triangle (lateral to the inferior epigastric vessels).

Best practices

Lichtenstein open tension-free mesh hernioplasty is suitable for all adult patients, irrespective of age, weight, general health, and the presence of concomitant medical problems. For patients with large scrotal (irreducible) inguinal hernias, those who have undergone major lower abdominal surgery, and those in whom no general anesthesia is possible, the Lichtenstein repair is the preferred surgical technique.

This operation, performed under local anesthesia, is not difficult to learn (learning curve, 5 cases), and trained surgical residents are able to perform it without compromising the patient’s care and long-term outcome.[19, 20] The procedure is time-tested, safe, and economical, and it does not involve the long operating time characteristic of laparoscopic repairs.[5] In addition, it has a low complication rate and has become the gold standard in open tension-free hernioplasties.[21, 22]

Lichtenstein hernioplasty is well suited for smaller community-based, regional, and teaching hospitals, and it offers good immediate and long-term results. Moreover, the excellent results achieved with this repair appear to be unrelated to the surgeons’ level of experience. The technique has been evaluated in large series and has become popular among surgeons all around the world.

In a comparative study of open mesh techniques for inguinal hernia repair, Lichtenstein’s operation was similar to mesh-plug or Prolene Hernia System (PHS; Ethicon, West Somerville, NJ) repair in terms of time to return to work, complications, chronic pain, and hernia recurrence in the short-to-middle term.[23] Indeed, postoperative pain after a Lichtenstein hernioplasty is minimal; according to a meta-analysis of all reported randomized studies, the pain is comparable to that occurring after laparoscopic repair.[24]

Use of mesh for repair

Emphasizing the Halsted principle of no tension, the Lichtenstein group advocated routine use of mesh in 1984. The prosthesis used to reinforce the weakened posterior wall of the inguinal canal is placed between the transversalis fascia and the external oblique aponeurosis and extends well beyond the Hesselbach triangle. Mesh implants do not actively shrink, but they are passively compressed by the natural process of wound healing. Mesh shrinkage occurs only to the extent to which the tissue contracts.

A mesh with a small pore size is likely to shrink more. Shrinkage of the different types of mesh in vivo is in the range of 20-40%; thus, it is important for the surgeon to ensure that the mesh adequately overlaps the defect on all sides. It is advisable to use a large (eg, 7.5 × 15 cm) sheet of mesh extending approximately 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring so as to allow for mesh shrinkage.

Although the use of traditional microporous or heavyweight polypropylene meshes over the past two decades has reduced the recurrence rate after hernia surgery to less than 1%, a major concern has been the formation of a rigid scar plate that causes patient discomfort and chronic pain, impairing quality of life. More than 50% of patients with a large mesh prosthesis in the abdominal wall complain of paresthesia, palpable stiff edges of the mesh, or physical restriction of abdominal wall mobility.[4]

It was assumed that the flexibility of the abdominal wall is restricted by implantation of excessive foreign material and by excessive scar tissue formation. A better knowledge of the biomechanics of the abdominal wall and the influence of mesh on those mechanics has led to the current understanding that “less is more.”

In other words, a less-dense, lighter-weight mesh with larger pores, though still stronger than the abdominal wall and thus usable for the purposes of repair, will result in less inflammation, better incorporation, better abdominal wall compliance, greater abdominal wall flexibility, less pain, and possibly less scar contraction; therefore, its use will lead to a better clinical outcome.[5, 25]

Lightweight composite mesh was developed in the conviction that the ideal mesh should be just strong enough to handle the pressure of the abdominal wall while remaining as low in mass and as thin as possible. The advantage of increasing the mesh pore size is that it makes it easier for tissue to grow through the pores and thereby create a thinner, better-integrated scar.

The newer lightweight composite meshes offer a combination of thinner filament size, larger pore size, reduced mass, and increased percentage of absorbable material. Thus, less foreign material is implanted, the scar tissue has greater flexibility (with almost physiologic abdominal wall mobility), there are fewer patient complaints, and the patient’s quality of life is better.

The use of lightweight mesh for Lichtenstein hernia repair has not been shown to affect recurrence rates, but it has been found to improve some aspects of pain and discomfort 3 years after surgery.[26] According to data from randomized, controlled trials and retrospective studies, light meshes seem to have some advantages with respect to postoperative pain and foreign body sensation.[5, 27]

Complication prevention

Since the widespread acceptance of mesh-based repairs and the significant reduction of inguinal hernia recurrence, the most vexing complication of herniorrhaphy has been chronic groin pain. Causalgia syndromes of each of the three nerves of the groin (ilioinguinal, iliohypogastric, and genitofemoral) are well described.[17, 8] There remains some controversy as to whether the nerves should be sectioned or preserved.[28, 29] Current recommendations favor nerve identification and preservation.[14, 30, 31]

The ilioinguinal nerve, which runs anterior to the spermatic cord, can be protected by employing gentle dissection and by isolating the nerve behind a leaf of the incised external oblique aponeurosis with a straight hemostat clamp.

The iliohypogastric nerve can be injured when creating the superior flap of the external oblique aponeurosis and by a bite taken when fixing the mesh to the conjoint tendon.

Another cause of significant postherniorrhaphy pain is the placement of a stitch into the periosteum. This is often the point of maximal postoperative tenderness; accordingly, the surgeon must maneuver with care when anchoring the pubic tubercle bite.[32, 33]

Toward the deep inguinal ring, the hernia sac becomes thin and fragile and adheres more closely to the spermatic cord. Caution should be exercised in dissecting the hernia sac to avoid injury to the cord structures and splitting of the neck of the sac. In adults, the rate of vas deferens injury is estimated at 0.3%. To protect against such injury, the surgeon must always remain aware of the posterior location of the vas deferens when dissecting the hernia sac.

If reduction of the hernial sac proves difficult at operation, a sliding hernia should be suspected. The cecum (on the right side), the sigmoid colon (on the left side), and the urinary bladder (on either side) form the wall of the sac of a sliding hernia; they are not the contents of the hernial sac and are not inside the sac. In a sliding hernia, it is difficult to separate the hernial sac from the structures that form its wall; thus, the hernial sac should be reduced en masse along with these structures, without any attempt to separate them from the hernial sac.

In a complete indirect inguinal hernia, which descends into the scrotum, it is not necessary to remove the entire hernial sac; the sac may be transected in the distal inguinal canal, and the distal part of the sac in the scrotum can be left behind. Hemostasis, however, should be ensured at the cut edge of the distal part of the hernial sac to prevent bleeding and scrotal hematoma. In addition, to prevent the formation of a hydrocele, the distal sac should not be closed.

If it is not possible to return the contents of the hernial sac to the peritoneal cavity even after the sac has been opened, a sliding hernia is likely. Because the viscus is not inside the sac but makes up part of the wall of the sac, any attempt to excise the complete sac is likely to injure the viscus. Only that part of the sac that is distal to the sliding viscus should be excised; the sac is then closed, and the remaining sac, along with the viscus, is reduced into the extraperitoneal space.

Inguinal hernia in a child (even a neonate) should be repaired as early as possible; because the neck of the hernia sac is very narrow, the risk of complications is very high. In children, the superficial and deep inguinal rings almost overlap each other, with the result that that the inguinal canal is very short. A very small incision is made over the superficial inguinal ring; there is no need to open the inguinal canal. Herniotomy alone is performed, with the hernia sac divided at the superficial ring.

Vascular injury is a less common but reported and potentially disastrous pitfall. It can be avoided by respecting the proximity of the femoral vessels, particularly when the mesh is being sutured to the inguinal ligament.[33] Hematoma formation can be due either to injury of the inferior epigastric vessels or to failure to ligate the superficial subcutaneous veins.

Any aggravating factors (eg, chronic cough, chronic constipation, or urinary straining) should be looked into and controlled, if possible, before any hernia is repaired so as to prevent or reduce postoperative stress on the hernia repair, which may increase the risk of recurrence.

The use of an amply sized (eg, 7.5 × 15 cm) piece of mesh is crucial for minimizing recurrence. It must be large enough to extend 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring. It should not be laid under tension, so that its center can achieve a slightly domed configuration, which compensates for the forward protrusion of the transversalis fascia upon standing and for the shrinkage of the mesh over time.

In male patients, a testis may be pulled out of the scrotum while the spermatic cord is being manipulated; accordingly, it is important always to remember to pull the testes gently back down to their normal scrotal position after the procedure is completed.

As in all operations, infection is a concern, but in clinical settings where the rate of wound infection is low (< 5%), there is no indication for the routine use of antibiotic prophylaxis in low-risk patients. However, if any risk factors for wound infection (eg, recurrent hernia, advanced age, diabetes mellitus, immunosuppressive conditions, or expected prolonged operating times) are present, antibiotic prophylaxis should be considered. Such prophylaxis should also be used at centers where high wound infection rates are observed in elective settings.[34, 35]

Anticoagulation prophylaxis is generally unnecessary; the duration of the operation is not long, and the patient can be mobilized the same evening.

Since the widespread acceptance of mesh-based repair, the rate of hernia recurrence has fallen substantially, to 1% or less. Consequently, more attention is being paid to other complications, such as postherniorrhaphy chronic pain.[36]

Large studies examining mortality risk from various groin operations found that elective inguinal herniorrhaphy was safe and had a low mortality risk that was similar to or even lower than the standardized mortality in the studied population.[1, 37]

Although pain is more common in the acute postoperative period, it remains chronically severe in 3% of patients, having significant effects on their work and social activities.[38] A large Swedish study found that 30% of postherniorrhaphy patients reported long-term pain or discomfort, 6% of whom experienced pain intense enough to alter their activities of daily living.[39]

Another phenomenon that can be experienced after hernia repair is groin numbness. In a large Scottish study that included more than 5500 patients, this was reported to various degrees in as many as 9%.[39]

Other complications include seroma formation, bruising and hematoma (7% of cases), and wound infection (1-7% of cases).[1, 40]

Ischemic orchitis leading to testicular atrophy or even necrosis is a catastrophic but well-known complication of inguinal hernia repair. Symptoms include painful testicular swelling and fever commencing 2-3 days after surgery.[41] The exact cause of this rare complication is unclear, but it is thought to be secondary to venous thrombosis rather than arterial injury. A high index of suspicion for postoperative ischemic orchitis, in conjunction with emergency testicular ultrasonography, may help avoid orchiectomy.

For better hemostasis, sharp dissection is preferred to blunt dissection. This is one operation in which, as the saying goes, every red blood cell must be caught.

If a lipoma is present in the spermatic cord, as is often the case, it should be excised to reduce the bulk of the cord; cord structures, however, must be protected. Some surgeons excise the cremaster muscle fibers in the cord; others prefer not to.

With a direct hernia, the sac is not dissected and opened, as is done with an indirect inguinal hernia. Rather, it is inverted (pushed back) into the extraperitoneal space, sometimes with plication of the transversalis fascia.

Bilateral hernias can be repaired in a single procedure, especially with a Lichtenstein tension-free mesh hernioplasty. Some surgeons, however, prefer to repair only one hernia at a time, deferring repair of the other for about 4-6 weeks; this avoids the risk of bilateral infection and the higher risk of penile and scrotal edema after bilateral inguinal hernia repair.

If the hernia is irreducible or obstructed, the sac should be opened first at its fundus, before it is dissected up to its neck, to allow evacuation of toxic fluid and inspection of the bowel for ischemia. If the conventional technique, in which the sac is first completely dissected up to its neck, is followed, the ischemic bowel may slip back into the peritoneal cavity before the sac is opened at its fundus and may then be difficult to retrieve for inspection.

Ischemic bowel is blue-black and thick-walled, lacks luster, feels firm to the touch, and has no peristalsis. The bowel must be wrapped in moist warm packs, and 100% oxygen should be delivered for a few minutes. The bowel is then reassessed for viability. Any nonviable bowel will have to be resected.

No special equipment is required for inguinal hernia repair. Standard operating room anesthesia equipment, outfitted for possible conversion to general anesthesia and endotracheal intubation, is required. For high-risk patients with comorbid conditions, a cardiac monitor and a pulse oximeter should be available.

A standard open surgical tray should be available. Instruments and materials on hand may include the following:

• Syringe
• 25-Gauge needle
• Surgical knife with blade
• Mosquito forceps
• Dissecting scissors
• Polypropylene (Prolene) or polyester mesh
• Langenbeck retractors
• Adson thumb forceps
• Needle holder
• Sutures (absorbable or nonabsorbable)
• Penrose drain or umbilical tape
• Noncrushing intestinal clamps (in case bowel resection is required, in a strangulated hernia)

A self-retaining (eg, Adson) retractor, though not essential, may eliminate the need for an assistant. The umbilical tape or Penrose drain may be used to retract the mobilized spermatic cord, but a hernia ring forceps can also be used. If the neck of the hernia sac is particularly tight, the use of a grooved probe or dissector may help minimize injury to the contents.

The mesh must be a permanent material large enough to produce a wide overlap beyond the defect’s edges (eg, 5 × 10 cm to 7.5 × 15 cm). Many manufacturers have now shifted toward lighter, more porous constructions that maintain the strength of the repair but putatively reduce the inflammatory response.[11, 42, 43, 44, 45] These meshes may decrease long-term discomfort, but possibly at the cost of increased recurrence rates (eg, from inadequate fixation or overlap).[5]

The question of absorbable versus permanent sutures to secure the mesh is based on surgeon preference; to date, there has been no evidence conclusively favoring one type over the other. Sutures made of polyglactin or polypropylene are commonly used, with undyed polyglactin often preferred for subcutaneous tissue. A theoretical advantage of absorbable suture is that if nerve impingement is inadvertently caused, the suture material disappears with time. The authors prefer to use absorbable (2-0 polyglactin) sutures for mesh fixation.

Anesthesia

Inguinal hernia repair can be performed with the following types of anesthesia:

• General
• Regional (spinal epidural)
• Local (infiltration field block)

The choice of anesthesia technique may be influenced by patient preferences and the medical history. The current trend toward increasing utilization of ambulatory surgery tends to favor local anesthesia, which allows quick recovery time and thus is safe for early discharge. For older patients or those with high American Society of Anesthesiologists (ASA) scores (indicating underlying cardiovascular or pulmonary disease), local anesthesia causes much less hemodynamic compromise and is far better tolerated than general anesthesia.

For Lichtenstein hernioplasty, local anesthesia is safe and generally preferable. By permitting immediate postoperative mobilization and discharge of the patient on a day-care basis, it helps minimize the length of the hospital stay, the incidence of complications, and the cost of treatment. In addition, a patient under local anesthesia can be asked to cough during the procedure to help the surgeon identify any additional hernias that may be present and to confirm the adequacy of the prosthetic repair.

Large randomized control trials have found overall anesthesia time, urinary retention, and postoperative pain to be less after local anesthesia than after regional or general anesthesia.[46, 47] Although a follow-up study of recurrence by Nordin et al reported an increase in reoperation for recurrence in the local anesthesia group, the investigators suggested that this increase may be negated with increasing use of the Lichtenstein mesh technique and concluded that further follow-up is warranted.[48]

When hernia repair is performed under local anesthesia, patients still feel the discomforts of pressure and traction; such discomforts can be minimized by administering anxiolytic agents. Additionally, the patient must always give consent for the possibility of conversion to general anesthesia should he or she experience difficulty in tolerating the procedure because of anxiety or discomfort.

Commonly used local anesthetics include the following[49] :

• 0.5-1% lidocaine with epinephrine
• 0.25% bupivacaine
• A combination of these two agents in a 50:50 mixture

A field block is applied by injecting along the site of incision, from superficial to deep, and lateral to the pubic tubercle, to provide anesthesia to the deeper structures. (See Local Anesthetic Agents, Infiltrative Administration.) To block the ilioinguinal nerve, an injection is placed just medial to the anterior superior iliac spine.[50]

Additional amounts of the local agent may be injected throughout the procedure. For example, administration of the agent below the fibers of the external oblique aponeurosis, as described by Lichtenstein’s group, anesthetized the three major nerves by flooding the enclosed inguinal canal and served to hydrodissect the underlying ilioinguinal nerve (thus making it less prone to injury when the aponeurosis was incised).[51]

Other techniques, such as epidural anesthesia, have been widely reported, but results depend largely on local expertise.

Elective inguinal hernia repair is considered a clean procedure and, as such, should carry a surgical site infection rate of less than 2%. The data remain controversial, but one meta-analysis supported the use of antibiotic prophylaxis in the performance of a mesh-based repair.[51] Cephalosporins (eg, cefazolin) are commonly administered by the anesthesiologist in a single dose before the skin incision.[52] A properly powered, prospectively randomized study is needed to determine whether such prophylaxis is necessary.

Positioning

The correct surgical side (left or right) should be confirmed and marked preoperatively in the holding area.

The patient should be placed in the supine position, with the upper extremities comfortably secured. He or she should be at ease, and the position should be comfortable for the surgical team. For large defects, slight Trendelenburg positioning may facilitate exposure by reducing the visceral contents into the abdomen.

The surgical site is prepared and draped in standard surgical fashion, so that the patient’s upper abdomen and lower limbs are covered and only the intended operative groin site is exposed. The patient’s head is left open to allow conversation with the surgeon. The surgeon stands on the side of the patient where the hernia is located, and the assistant stands on the opposite side.

With the routine use of mesh for hernia surgery, the recurrence rate has fallen to less than 1%. Although some recurrences occur early, cases may be reported many years later. A thorough clinical evaluation, a high degree of suspicion, and appropriate follow-up are advised for keeping track of recurrences. A follow-up visit is routinely scheduled for 1 week after the procedure. Thereafter, follow-up is scheduled on an as-needed basis.

Although the postoperative course is generally uncomplicated, patients must be routinely instructed to recognize certain signs and symptoms that can alert them to potential complications.[1, 40]

Patients with chronic groin pain, postoperative neuralgia, paresthesias, neurapraxia, or hypoesthesia for more than 6 months after surgery should be referred for further evaluation, surgical exploration, and, if required, excision of the involved nerve. A multidisciplinary approach at a pain clinic is an option for the treatment of chronic postherniorrhaphy pain. Surgical means of treating specific causes of such pain include the following:

• Resection of entrapped nerves
• Mesh removal (in mesh-related pain)
• Removal of fixating sutures
• Burying the nerve endings in the internal oblique muscle

Large-scale studies examining the convalescence period after elective inguinal hernia repair convincingly demonstrated that the median length of absence from work was 7 days when patients were advised by their surgeons to limit the recuperation period and to resume normal activities within 1 day after the procedure.[1, 53]  Moreover, these studies confirmed that the risk of recurrence was not increased by early resumption of activities. Thus, with adequate analgesia, patients can safely return to their daily duties.

Inguinal hernia repairs are of the following three general types:

• Herniotomy (removal of the hernial sac only)
• Herniorrhaphy (herniotomy plus repair of the posterior wall of the inguinal canal
• Hernioplasty (herniotomy plus reinforcement of the posterior wall of the inguinal canal with a synthetic mesh)

The ensuing discussion focuses primarily on the Lichtenstein tension-free mesh repair, which is an example of hernioplasty and is currently one of the most popular techniques of inguinal hernia repair.[6, 7] The Bassini, Shouldice, and darn repairs (all examples of herniorrhaphy) are also briefly discussed. The key technical point is that in the Lichtenstein tension-free repair, there is no attempt to repair the posterior wall, as is done in Bassini or Shouldice repairs; the weak posterior wall is reinforced with mesh.

Incision

The incision is placed about 1 cm above and parallel to the inguinal ligament, beginning from the pubic tubercle and extending 5-6 cm laterally up to the midinguinal point (see the images below). The subcutaneous fat is then opened along the length of the incision, and careful hemostasis is achieved by ligating superficial pudendal and superficial epigastric vessels.

The Scarpa fascia is similarly opened along the length of the incision, down to the external oblique aponeurosis, and the external inguinal ring and the lower border of the inguinal ligament are visualized (see the images below). Below the inguinal ligament, on the medial aspect, the deep fascia of the thigh is opened, the femoral canal exposed, and a check made for any concomitant femoral hernia. Although the risk is very low, routine exploration of the femoral canal is advised in the absence of an inguinal hernia and in women.[5]

Division of external oblique aponeurosis and exposure of inguinal canal

The external oblique aponeurosis is then opened along the line of incision, starting from the external ring and extending laterally for up to 5 cm (see the image below). The ilioinguinal nerve, lying underneath the aponeurosis, is safeguarded during this procedure.

The superior and inferior flaps of the external oblique aponeurosis are gently freed from the underlying contents of the inguinal canal and overturned and separated to expose the cremaster with the cord structures, the ilioinguinal and iliohypogastric nerves, the uppermost aponeurotic portion of the internal oblique muscle and conjoined tendon, and the free lower border of the inguinal ligament (see the images below). Wide separation of the two flaps provides ample space for placement and fixation of mesh under vision while protecting the nerves.

Dissection of spermatic cord

The spermatic cord, along with the cremaster, is then lifted up and separated from the pubic bone for about 2 cm beyond the pubic tubercle to create space for extending the mesh well beyond the pubic tubercle.

When lifting the cord, the surgeon must be sure to include the ilioinguinal nerve, the genitofemoral nerve, and the spermatic vessels along with it. All of these structures may then be encircled in a tape for ease of handling. The anatomic plane between the cremaster and the aponeurotic tissue attached to the pubic bone is avascular, and cord structures encircled in the tape can be separated from the floor of the inguinal canal up to the internal ring. (See the images below.)

A visible landmark for safeguarding the genitofemoral nerve is the external spermatic vein, usually referred to as the “blue line.” If the blue line is kept with the spermatic cord, the surgeon can be sure that the genital branch of the genitofemoral nerve, which is always adjacent to this vein, is well protected.[54]

Identification and management of hernia sac

The cord structures and all of the nerves of the inguinal canal having been visualized, the next step is to identify and isolate the hernia sac. The patient is asked to cough, and the groin region is examined for the presence of an indirect hernia, a direct hernia, a femoral hernia, a combined hernia, or a spigelian hernia.

A hernia sac can be managed by means of inversion, division, resection, or ligation. Resection and ligation of a small hernia sac should not be performed unnecessarily, because postoperative pain commonly results. However, the hernia sac must be well separated from the internal ring before it is invaginated. The risk of recurrence is not increased when a small or medium-sized indirect hernia sac is not ligated.[54] Excision of an indirect inguinal hernia sac is associated with a lower risk of hernia recurrence than is division or invagination.[55]

When the hernia sac is excised or divided, the proximal sac should never be left open; doing so may lead to recurrence. The proximal sac is dissected free of cord structures well above the internal ring, and a high ligation of the neck of the sac should be performed.

The indirect hernia sac lies anterolateral to the cord structures and is visualized by dividing the cremaster muscle longitudinally (see the image below). The cremaster muscle should not be divided transversely or excised, because doing so may result in low-lying testes and dysejaculation.

The peritoneal sac is identified and separated from the spermatic vessels and the vas deferens up to its neck (see the images below). A small or medium-sized hernia sac may be isolated and inverted into the preperitoneal space without suture ligation. For a voluminous scrotal hernia sac, no attempt should be made to dissect it completely and excise it; such an attempt can result in ischemic orchitis.[5]

The neck of a large hernia sac is transected at the midpoint of the inguinal canal (see the first image below), and the proximal part is suture-ligated. A high ligation of the proximal sac is recommended, and the stump is reduced deep underneath the internal ring (see the second image below). The distal sac is left in place; however, the anterior wall of the distal sac is incised to prevent postoperative hydrocele formation (see the third image below).

A direct inguinal hernia lies posteromedial to the cord structures. The direct hernia sac is isolated and dissected free. Its contents are reduced, and the peritoneal sac is inverted and maintained in position with a purse-string suture.

If a femoral hernia is suspected, the femoral ring should be evaluated by incising the medial part of the iliopubic tract. If a sac is seen entering the femoral ring, it is reduced and dealt with by inverting or ligating the neck of the sac. A spigelian hernia is managed in a similar manner. A sliding hernia is simply dissected free and inverted in the preperitoneal space.

Placement and fixation of mesh

A 7.5 × 15 cm piece of polypropylene mesh is commonly used for a Lichtenstein hernioplasty. On the medial side, the sharp corners of the mesh are trimmed to conform to the patient’s anatomy. For a femoral hernia, the mesh is tailored so that it has a triangular extension from its lower edge on its medial side.

To compensate for future shrinkage, the mesh should be wide enough to extend 3-4 cm beyond the boundary of the inguinal triangle. To compensate for increased intra-abdominal pressure when the patient stands up, the mesh should be placed lax in the posterior wall of the inguinal canal in such a way that it acquires a domelike wrinkle.

The first medialmost stitch fixes the mesh 2 cm medial to the pubic tubercle, where the anterior rectus sheath inserts into the pubic bone (see the image below). Care should be taken not to pass the needle through the periosteum of the bone or through the pubic tubercle; this is one of the most common causes of chronic postoperative pain.

The same suture is then used as a continuous suture to fix the lower edge of the mesh to the free lower border of inguinal ligament up to a point just lateral to the internal ring (see the images below). No more than four or five passes are required.

For a femoral hernia, the medial portion of the iliopubic tract is excised, and the Cooper ligament is exposed. The lower triangular extension on the medial side of the mesh is stitched to the Cooper ligament, and the suture is continued to fix the lower edge of the mesh to the inguinal ligament, as above.

Next, a slit is made in the lateral end of the mesh to create a narrower lower tail (the lower one third) and a wider upper tail (the upper two thirds). The slit extends up to a point just medial to the internal inguinal ring (see the image below).

The upper tail is then passed underneath the cord in such a way as to position the mesh posterior to the cord in the inguinal canal (see the image below), and the spermatic cord is placed between the two tails of the mesh. The upper tail is then crossed over the lower one, and the two tails are held in an artery forceps.

With the mesh kept lax, its upper edge is then fixed to the rectus sheath and the internal oblique aponeurosis with two or three interrupted nonabsorbable sutures (see the first image below). On occasion, the iliohypogastric nerve is found to be in the way of upper edge of the mesh. In such cases, the mesh may be split to accommodate the nerve (see the second image below).

The two tails are then tucked together and fixed to the inguinal ligament just lateral to the internal ring, thus creating a new internal ring made of mesh (see the first image below). The tails are trimmed 5 cm beyond the internal ring and placed underneath the external oblique aponeurosis (see the second image below).

Suturing the mesh beyond the internal ring is unnecessary; doing so may cause injury to the femoral nerve. Similarly, fixation of the tails of the mesh to the internal oblique muscle, lateral to the internal ring, may cause entrapment of the ilioinguinal nerve. Trying to suture the two tails without crossing them or trimming the tails shorter than 5-6 cm beyond the internal ring may result in recurrence at the deep inguinal ring.[54]

If any of the nerves is injured or of doubtful integrity, it can be resected and its proximal end ligated and buried within the fibers of the internal oblique muscle to keep the stump of the nerve away from scarring.

In male patients, the testes should always be gently pulled back down to their normal scrotal position after fixation of the mesh.

Closure

Spermatic cord layers are closed with fine sutures, with care taken to avoid damaging the cord contents. Hemostasis is ensured in the inguinal canal, which is then closed by suturing the two flaps of the external oblique aponeurosis (see the images below), with care taken not to injure the underlying ilioinguinal nerve. Suturing is started laterally and continued medially, where an adequate opening is left at the newly created superficial inguinal ring so as not to occlude the emerging spermatic cord.

Subcutaneous tissue is approximated with interrupted sutures to obliterate any dead space, and the skin is approximated with sutures, clips, or adhesive strips (see the images below). A subcuticular continuous stitch with 3-0 absorbable sutures obviates any need for stitch or clip removal and provides better cosmetic results.

The operative site is cleaned and a sterile dressing applied. Local infiltration of a long-acting anesthetic agent (eg, bupivacaine or ropivacaine) into the subcutaneous tissue around the incision provides good immediate postoperative pain relief. A bupivacaine-containing bioresorbable collagen implant is available for management of pain after open inguinal hernia surgery.[56]

Open inguinal hernia repairs other than Lichtenstein hernioplasty are not merely of historical interest. Surgeons must know and understand these repairs so that they can be carried out when they are appropriate. Specifically, cases that involve a contaminated field (eg, necrotic or perforated bowel secondary to hernial strangulation) are not amenable to prosthetic repair. In such cases, either a primary tissue repair or a biologic implant repair is necessary.[57, 31, 32]

Plug-and-patch repair

The plug-and-patch repair adds a polypropylene plug shaped as a cone, which can be deployed into the internal ring after reduction of an indirect sac. The plug then acts as a toggle bolt to reinforce the defect.

Prolene Hernia System

The Prolene Hernia System (PHS) consists of an anterior oval polypropylene mesh connected to a posterior circular component. The posterior component is deployed in a bluntly created preperitoneal space (see the first image below). The anterior portion is then laid out with a cut made to recreate the internal ring (see the second image below). The anterior portion is then sutured above to the conjoined tendon and below to the shelving edge of the inguinal ligament and is tucked behind the external oblique aponeurosis (see the third image below).

McVay repair

In the McVay repair, the conjoined (transversus abdominis and internal oblique) tendon is sutured to the Cooper ligament with interrupted nonabsorbable sutures.

Bassini repair

The Bassini technique for inguinal hernia repair involves suturing the transversalis fascia and the conjoined tendon to the inguinal ligament behind the spermatic cord with monofilament nonabsorbable suture. It also involves the so-called Tanner slide, which is a vertical relaxing incision in the anterior rectus sheath intended to prevent tension.

Shouldice repair

The Shouldice technique is a four-layer inguinal hernia repair performed with the patient under local anesthesia. The transversalis fascia is incised from the internal ring laterally to the pubic tubercle medially, and upper and lower flaps are created. These flaps are then overlapped (double-breasted) with two layers of sutures.

The conjoined tendon is then sutured to the inguinal ligament, again in two overlapping layers. This reinforces the posterior wall and narrows the deep inguinal ring. The Shouldice repair is classically done with a continuous suture of 32- to 34-gauge stainless steel wire, but synthetic monofilaments (eg, polypropylene) can also be used. The external oblique aponeurosis is then closed in a double-breasted fashion in front of the spermatic cord.

Darn repair

A darn inguinal hernia repair is a pure-tissue tensionless technique that is performed by placing a continuous suture between the conjoined tendon and the inguinal ligament without approximating the two structures.

Acellular dermal implant

Some reports describing the use of an acellular dermal implant (eg, AlloDerm; LifeCell, Bridgewater, NJ) in cases where the surgical field is contaminated have appeared in the literature, but long-term results are not yet available.[30, 37]

After the procedure, the patient is asked to rest for few hours. He or she may be discharged later the same day on a day-care basis. Early mobilization is the key to rapid convalescence. Patients can safely ambulate on the evening of the operation. If general or regional anesthesia is used, the patient may be hospitalized for a few days.

There is some pain in the postoperative period, and suitable analgesics should be prescribed. The dressing is removed on postoperative day 5, and stitches are removed on postoperative day 7. Patients should be advised to avoid strenuous activities for a few weeks. Typically, light work can be resumed after 1 week, heavier jobs after 6 weeks.

Male patients should be monitored for testicular atrophy, which may occur as a result of venous or arterial injury or obstruction in the spermatic cord. All patients should be monitored for the development of nerve pain from nerve entrapment in suture material. Finally, patients should be monitored for recurrence, which may arise as a consequence of inadequate repair, wound infection, or chronic straining (eg, from coughing, constipation, or urination).

In systematic reviews, the overall risk of complications after inguinal hernia surgery has been in the range of 15-28%. Complications may develop intraoperatively or postoperatively. Early postoperative complications include seroma formation and hematoma (8-22% of cases), urinary retention, and wound infection (1-7% of cases). Late postoperative complications include sensory loss, hyperesthesia, chronic inguinal pain, mesh-related problems, hydrocele, testicular pain, testicular swelling, atrophy, and recurrence of hernia.

Intraoperative complications

Intraoperative complications of open inguinal hernia repair include vascular injuries, injuries to abdominopelvic structures, and nerve injuries.

Vascular injuries

Superficial epigastric vessels in the incision may bleed. These vessels not only should be identified when the incision is being made but also should be ligated and divided. Inferior epigastric vessels may be injured during dissection of the spermatic cord in the inguinal canal, dissection of an indirect inguinal hernia sac within the spermatic cord, plication of the transversalis fascia, or transfixion of the hernial sac. These vessels should be identified at an early stage and protected.

External iliac or femoral vessels, especially veins, may be injured during fixation of the mesh to the inguinal ligament in its lateral part. The tissue bites in the inguinal ligament should not be very deep.

Although less common than other intraoperative complications, vascular injuries are potentially disastrous. They can be avoided by respecting the proximity of the femoral vessels, particularly when suturing the mesh to the inguinal ligament. Hematoma formation can result from injury of the inferior epigastric vessels or pampiniform plexus veins or from failure to ligate the superficial subcutaneous veins.

Injuries to abdominopelvic structures

Cord structures (eg, testicular artery, pampiniform plexus of veins, and vas deferens) may be injured during opening of the coverings of the spermatic cord or dissection of the indirect hernial sac within the spermatic cord. In particular, the surgeon should always be aware of the vas deferens and should protect it from injury.

Injury to the urinary bladder may occur during plication of the transversalis fascia. In addition, injury to the urinary bladder, cecum, or sigmoid colon may occur during transfixion of the hernial sac in a sliding indirect inguinal hernia (where these viscera are not contained in the hernial sac but form a part of the wall of the sac). A sliding hernia should be recognized early; if it is present, the entire hernial sac should not be excised.

Injury to the bowel may occur during transfixion of the neck of an indirect hernial sac. The head end of the operating table can be lowered to ensure complete reduction of contents of the sac, the sac can be twisted to push the contents into the peritoneal cavity, and a tissue bite can be taken and the suture tied under vision.

Nerve injuries

The iliohypogastric nerve, because it lies on the conjoined tendon outside the inguinal canal, may be injured during dissection of the upper flap of the external oblique aponeurosis or fixation of the mesh to the conjoined tendon. It may also become trapped in sutures during closure of the external oblique aponeurosis.

The ilioinguinal nerve, because it lies in the inguinal canal along with the spermatic cord, may be injured during dissection of the cord.

The genital branch of the genitofemoral nerve, because it lies within the spermatic cord, may be injured during dissection of the hernia sac.

Postoperative complications

Urinary retention

Urinary retention may occur after open inguinal hernia repair, especially in middle-aged and elderly male patients with prostatic enlargement. In a meta-analysis of 72 studies, the incidence of urinary retention after herniorrhaphy was 0.37% (33 of 8991 patients) with local anesthesia, 2.42% (150 of 6191 patients) with regional anesthesia, and 3% (344 of 11,471 patients) with general anesthesia.[5] Such retention is said to be due to the inhibitory effect of regional and general anesthesia on bladder function.

Seroma and hematoma

Most seromas disappear spontaneously within 6-8 weeks. If a seroma persists, it may be aspirated. A small hematoma may be treated conservatively. For larger hematomas, which are asymptomatic, evacuation under anesthesia should be considered. Meticulous dissection with adequate hemostasis will reduce the incidence of seroma and hematoma formation.

Infection

Deep and persistent infection may necessitate removal of the mesh. Wound infection can also weaken the repair and may be responsible for recurrence of the hernia.

Pain

Postoperative chronic pain is more frequent than was previously understood and has become one of the most important primary endpoints in hernia surgery. In published reports, the incidence of postherniorrhaphy pain has ranged from 0% to more than 30%. Chronic inguinodynia is defined as pain persisting more than 3 months post herniorrhaphy, after the process of wound healing is complete.

Nonfixation or inadequate mesh fixation results in folding and rolling of the mesh, which can cause chronic pain and recurrence of the hernia.

Chronic pain after mesh hernioplasty also results from neuroma formation after accidental division of the nerves. The ilioinguinal, iliohypogastric, and genitofemoral nerves are visualized and protected throughout the operation. They should not be dissected free from their natural bed; doing so can lead to perineural fibrosis and chronic pain postoperatively.

Deliberate sectioning of the nerves intraoperatively to prevent chronic groin pain has been described but is still controversial. Current recommendations consist of nerve identification, minimal handling, and preservation.[58] Prevention of nerve injury is very important because treatment of chronic neuralgias may not be successful.

Entrapment of a nerve by suture or mesh appears to be an important cause of postoperative pain. The groin nerves should be identified and protected. Fibrin or biologic glues may be used instead of sutures to secure the mesh. It appears that cyanoacrylate glue may be a viable alternative to sutures, and it is anticipated that the use of fewer sutures may be associated with less inguinodynia.[25]

Another cause of significant postherniorrhaphy pain is the placement of a stitch into the periosteum at the pubic tubercle for fixation of the mesh medially. This is often the point of maximal tenderness postoperatively. Therefore, one should avoid taking a deep bite through the periosteum of the pubic tubercle; tough, fibrous tissue in that region should instead be used for fixing the mesh.

The use of a low-density macroporous mesh with semiresorbable, self-fixing properties during tension-free repair may be a satisfactory solution to the clinical problems of pain and recurrence after inguinal herniorrhaphy.[59]

Hydrocele

Scrotal edema or hydrocele due to venous and lymphatic damage during dissection within the spermatic cord may also occur.

Ischemic orchitis and thrombosis

Ischemic orchitis leading to testicular atrophy is a rare but well-known complication of inguinal hernia surgery. The patient may complain of pain and testicular swelling postoperatively. Symptoms may last for 2-3 months, and testicular atrophy may occur. The rarity of this complication notwithstanding, the surgeon should maintain a high index of suspicion. Testicular ultrasonography and Doppler studies may facilitate early diagnosis and help avoid orchiectomy. Ischemic orchitis is thought to be secondary to venous thrombosis rather than arterial injury.

Thrombosis is caused by surgical trauma to the delicate veins of the pampiniform plexus and disruption of the collateral blood supply to the testes during an attempt at complete removal of a large hernia sac. It is also more likely in operations for recurrent hernia. It is thus advisable not to attempt complete dissection and excision of a large hernia sac. The neck of the hernia sac is transected at the midpoint of the inguinal canal, and the distal sac is left in place. However, the anterior wall of the distal sac is incised to prevent postoperative hydrocele.

Recurrence

The recurrence rate for Lichtenstein hernioplasty at specialist clinics in the United States is consistently less than 1%. In an audit of Lichtenstein hernioplasty performed with local anesthesia by surgical residents, the recurrence rate was 2.1% over a 10-year follow-up period.

Recurrence in Lichtenstein hernioplasty may be due to inaccurate execution of the technique (inadequate size or improper fixation of the mesh) or to an overlooked hernia at the primary operation. To avoid the latter, the patient should be asked to cough, and the region should be carefully examined for an indirect hernia, a direct hernia, a femoral hernia, or a combined hernia.

Recurrence may be more frequent in the presence of comorbid conditions (eg, chronic obstructive pulmonary disease) or obesity or with the use of steroids. Other contributing factors may be the use of too-small pieces of mesh placed flat under tension, failure to achieve adequate overlap (medially, 2 cm beyond the pubic tubercle; laterally, 5-6 cm beyond the internal ring), or failure to cross the tails of the mesh. A thorough clinical evaluation, a high degree of suspicion, and diligent follow-up are advised to keep track of recurrences.

Women, because of the higher frequency of femoral hernias, are at greater risk for recurrence (inguinal or femoral) after an open inguinal hernia operation than men are. In female patients, the existence of a femoral hernia should always be excluded by exposing the femoral canal.[5]

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Class Summary

Local anesthetic agents are used to increase patient comfort during the procedure.

Lidocaine anesthetic (Xylocaine)

Lidocaine is an amide local anesthetic used in a 0.5-1% concentration in combination with bupivacaine (50:50 mixture). This agent inhibits depolarization of type C sensory neurons by blocking sodium channels. Epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.

Bupivacaine (Marcaine, Sensorcaine)

Bupivacaine 0.25% may be used in combination with lidocaine plus epinephrine (50:50 mixture). It decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses.

Bupivacaine implant (XaraColl)

Surgically placed local anesthetic implant. It is indicated for management of postsurgical pain after open inguinal hernia surgery.

Class Summary

Newer locally active analgesic modalities provide nonopioid options for postoperative pain management. The combination of bupivacaine and meloxicam was approved by the FDA in May 2021. Approval was based on the EPOCH-2 phase 3 trial. Among 418 patients undergoing unilateral open inguinal herniorrhaphy, bupivacaine/meloxicam demonstrated superior, sustained pain reduction through 72 hours, significantly reduced opioid consumption, and resulted in significantly more opioid-free subjects compared with saline placebo and bupivacaine.[60]

Bupivacaine/meloxicam (Zynrelef)

Indicated as a single dose that provides postsurgical analgesia for up to 72 hours after open inguinal herniorrhaphy. Apply solution without a needle into the surgical site after final irrigation and suctioning and before the suturing of each layer (when multiple tissue layers are involved). The solution is instilled above and below the fascial repair. 

Class Summary

These agents have analgesic, anti-inflammatory properties and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity (COX) and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Diclofenac (Voltaren-XR, Cataflam, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.

Ibuprofen (Advil, Ultraprin, I-Prin, Motrin IB)

Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Sulindac (Clinoril)

Sulindac decreases the activity of COX and, in turn, inhibits prostaglandin synthesis. Its action results in the decreased formation of inflammatory mediators.

Naproxen (Anaprox, Aleve, Naprosyn, Naprelan)

Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of the enzyme COX, which results in prostaglandin synthesis.

Meloxicam (Mobic)

Meloxicam decreases COX activity, and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Flurbiprofen

Flurbiprofen may inhibit COX, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who experience moderate to severe pain.

Acetaminophen and codeine (Tylenol #3)

This combination is indicated for the treatment of mild to moderate pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet Plus, Norco, Maxidone)

This agent is indicated for the relief of moderately severe to severe pain.

Tramadol (Ultram, Ryzolt)

Tramadol is an analgesic that probably acts over monoaminergic and opioid mechanisms. Its monoaminergic effect is shared with tricyclic antidepressants. Tolerance and dependence