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INTRODUCTION — The definitive treatment of all hernias, regardless of origin or type, is surgical repair . Groin hernia repair is one of the most commonly performed operations. Over 20 million inguinal or femoral hernias are repaired every year worldwide , including over 700,000 in the United States .
An inguinal or femoral hernia repair is performed urgently in patients who develop complications such as incarceration or strangulation. For patients without a complication, the optimal timing of repair (watchful waiting versus early repair) and the optimal surgical technique (open versus laparoscopic) are controversial and are the focus of this topic.
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" and "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults" and "Overview of complications of inguinal and femoral hernia repair" and "Recurrent inguinal and femoral hernia".)
INDICATIONS FOR SURGICAL REPAIR — 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, sex, and the type of hernia (inguinal versus femoral).
Complicated hernia — Patients who develop strangulation or bowel obstruction should undergo urgent surgical repair. Surgery performed within four to six hours from the onset of symptoms may prevent bowel loss due to one of these complications.
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. 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.
The clinical manifestations and diagnosis of incarcerated/strangulated inguinal or femoral hernias can be found elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults".)
Uncomplicated hernias — In patients with uncomplicated inguinal or femoral hernias, surgical repair is intended to relieve symptoms and to prevent future complications. The indications for surgical repair of uncomplicated hernias are less rigid than complicated hernias, and depend upon the type of hernias (inguinal versus femoral) involved, the severity of symptoms, patient sex, and patient preference. In select patients, watchful waiting is an alternative to surgery. (See 'Asymptomatic hernia' below.)
Femoral hernia — For all patients with a newly diagnosed femoral hernia, we suggest elective surgical repair, rather than watchful waiting, regardless of the patient’s sex and symptoms. Femoral hernias are associated with a high risk of complications and therefore urgent surgical repair.
Femoral hernias are associated with a higher risk of developing complications than inguinal hernias. 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 .
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 .
For patients who have a long-standing (>3 months) femoral hernia that is asymptomatic, surgery is preferred but observation is a reasonable option.
Inguinal hernia — For female patients with a newly diagnosed inguinal hernia, we suggest elective surgical repair, rather than watchful waiting, regardless of symptoms. For male patients, the decision is individualized depending upon the patient’s symptoms and preference.
Female patients — Female patients with an inguinal hernia have a higher risk of developing complications than male patients . Thus, female patients should undergo inguinal herniorrhaphy once a diagnosis is established regardless of symptoms, rather than watchful waiting.
Male patients — For male patients with moderate to severe symptoms from an inguinal hernia, surgical repair is indicated. In addition, surgery is indicated for men with minimal or no symptoms if they have scrotal or recurrent hernias, or if they are older than 70 years. However, for other male patients with minimal or no symptoms from an inguinal hernia, watchful waiting until significant symptoms develop is an option.
The only nonsurgical therapy for groin hernia in men 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 [7,8]. In addition, inappropriate use of a truss may harm abdominal contents in a hernia sac or complicate subsequent surgical repair .
Symptomatic hernia — Male patients with significant symptoms attributable to an inguinal hernia should undergo elective surgical repair . Typical symptoms include:
●Groin pain with exertion (eg, lifting)
●Inability to perform daily activities due to pain or discomfort from the hernia
●Inability to manually reduce the hernia (ie, chronic incarceration)
Asymptomatic hernia — For male patients with minimal or no symptoms from an inguinal hernia, we suggest elective hernia repair. However, those who wish to avoid surgery can be managed with watchful waiting, provided that they are counseled of the risks of developing hernia complications (eg, incarceration, strangulation, or bowel obstruction). Patients who choose not to have hernia repair should refrain from heavy lifting and understand the need for prompt medical attention should symptoms develop or complications occur.
Historically, groin hernias were repaired once detected, under the assumption that complications from unrepaired hernias were common and could increase operative morbidity. Randomized trials comparing watchful waiting with surgical repair of inguinal hernias, however, demonstrated that delaying surgical repair in asymptomatic patients was safe, as acute complications rarely occurred. However, for most patients, surgical repair was required eventually because symptoms gradually increased over time.
The largest trial (the WW trial) randomly assigned 720 men with an uncomplicated inguinal hernia to watchful waiting or open surgical repair [10,11]. The patients, who were men mostly between the ages of 40 and 65, were asymptomatic or minimally symptomatic, and the hernias remained easily reducible within six weeks of the initial screening. The following results were reported:
●At two years, similar numbers of patients in each group reported pain sufficient to limit activities (5.1 with watchful waiting versus 2.1 percent with surgery). Although 23 and 31 percent of patients in the watchful waiting group required surgery at two and four years, respectively, only two patients required urgent surgery due to acute complications, at a rate of 0.0018 events per patient-year .
●After an additional seven years of follow-up, a total of 68 percent of men in the watchful waiting group had surgery, most commonly for pain (54 percent). Men older than 65 years were more likely to require surgery than younger men (79 versus 62 percent). However, only one additional patient required urgent surgery .
A subsequent trial of 160 men also found no differences in either the rate of hernia complications or pain scores between the surgery and watchful waiting groups . However, at six and twelve months, patients in the surgery group reported improvement in their general health, whereas patients in the watchful waiting group reported a decline. At 15 months, 26 percent of men in the watchful waiting group required surgery, including three urgent operations.
Most large trials only enrolled middle-aged men with primary (rather than recurrent) hernias. Thus, data from such trials may not be applicable to other patient groups. As examples:
●Men older than 70 years are more likely to require urgent surgery for their inguinal hernias, and therefore would benefit from early elective surgical repair [13,14].
●Patients with an inguinal hernia with a scrotal extension or a recurrent inguinal hernia are more likely to require urgent surgery and therefore should be offered early elective surgery. In a retrospective review of 1034 consecutive patients with a groin hernia, those with a scrotal hernia (32.4 versus 16.2 percent) or recurrent hernia (30.9 versus 16.7 percent) were significantly more likely to require urgent repair than others .
CONTRAINDICATIONS TO SURGICAL REPAIR — 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 [15,16]); most patients enjoy a rapid recovery to presurgical health shortly after surgery. Thus, there is no contraindication to urgent repair of complicated hernias. However, pregnant women should not have elective repair of an inguinal or femoral hernia until at least four weeks after delivery.
For patients who cannot tolerate general anesthesia, inguinal or femoral hernias can be repaired under local anesthesia. For patients with an active groin infection or systemic sepsis, mesh placement is contraindicated, but groin hernias can be repaired using nonmesh techniques when necessary. (See "Wound infection following repair of abdominal wall hernia".)
Pregnancy — The prevalence of inguinal hernias during pregnancy is low and estimated to be 1:2000 . Elective repair of a groin hernia during pregnancy is generally contraindicated. 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 . Although combined cesarean delivery and hernia repair have been reported [17,19], elective hernia repair should generally be deferred for at least four weeks postpartum to allow the lax abdominal wall to return to its baseline.
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 .
CHOOSING A SURGICAL APPROACH — While all surgeons perform open groin hernia repairs, some also perform laparoscopic repairs. In general, surgeons should choose the approach with which they are most comfortable and most experienced. For surgeons who are equally facile with both repairs, the choice of a surgical approach depends upon hernia and patient characteristics. The process described below and outlined in the accompanying algorithm reflects the author’s preference and should not be regarded as the only approach (algorithm 1).
Patients precluded from laparoscopic repair — While open repair of an inguinal or femoral hernia is feasible in almost all patients, laparoscopic repair cannot be safely performed in certain patients due to patient or technical reasons.
Patients with prior surgery involving the preperitoneal space — Laparoscopic repair, especially with the totally extraperitoneal (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.
Thus, we perform an open hernia repair 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). Although laparoscopic surgery is feasible in such patients (especially with the transabdominal preperitoneal patch [TAPP] technique), it is technically challenging, requires a longer operative time, and is associated more complications than open surgery in such patients [21,22].
Patients with complicated hernia — We repair all incarcerated or strangulated groin hernias with an open approach to minimize the risk of bowel injury. A laparoscopic approach is theoretically possible but difficult to perform [23-25].
Furthermore, in cases where bowel perforation has occurred due to bowel ischemia or necrosis, the placement of mesh is contraindicated, thereby precluding a laparoscopic repair. Open repair can be performed with or without mesh, and therefore is the preferred treatment for complicated hernias in which the risk of active infection or contamination (from perforation) is high. (See 'Open techniques' below and "Wound infection following repair of abdominal wall hernia".)
We also prefer to repair large scrotal hernias (>3 cm) with an open approach because of the technical difficulty associated with managing and reducing a large hernia sac laparoscopically .
Patients with ascites — In patients with ascites, we prefer an open approach to laparoscopic approaches. In particular, the laparoscopic TAPP approach (which is transperitoneal) should be avoided. 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".)
Patients eligible for both open and laparoscopic repair — Patients who do not have a history of prior preperitoneal surgery, ascites, or a complicated hernia are eligible for both open and laparoscopic repairs of a groin hernia. The choice of the surgical procedure then depends upon whether the hernia is primary or recurrent, unilateral or bilateral, and femoral or inguinal.
Primary hernia — A primary, unilateral inguinal hernia can be repaired open or laparoscopically based upon surgeon and patient preference. A primary, unilateral femoral hernia, and all bilateral hernias (both inguinal and femoral), should be repaired laparoscopically.
Inguinal hernia — There is no consensus as to whether the optimal approach to inguinal hernia repair is open or laparoscopic [27-29]. Some surgeons prefer to repair a primary, unilateral inguinal hernia with an open technique, while others prefer a laparoscopic approach. (See 'Open tension-free mesh repairs' below.)
Open and laparoscopic approaches have been directly compared most often in inguinal hernia repairs. In general, laparoscopic repair has been associated with less postoperative pain and quicker recovery, but longer operative time and higher recurrence rates [24,30-42]. Laparoscopic repair could also result in serious complications (eg, massive pelvic bleeding) that would rarely occur during open repairs.
The largest trial randomly assigned 1983 men with inguinal hernias to receive open or laparoscopic mesh repair at 1 of 14 United States veterans affairs medical centers . Patients treated laparoscopically had less pain on the day of surgery and at two weeks, and returned to work one day earlier. However, they suffered more postoperative complications (39 versus 33.4 percent), life-threatening complications (1.1 versus 0.1 percent), and hernia recurrences (10.1 versus 4.9 percent at two years). In subgroup analysis, the difference in recurrence rate was significant for primary (10.1 versus 4 percent), but not recurrent hernias (10 versus 14 percent). This trial has been criticized for higher than average rates of recurrences in both groups due to surgeon inexperience, as well as for a patient population that is older (average age 58) and less healthy (only 34 percent were American Society of Anesthesiologists class I) than the average patient who needs inguinal hernia repair.
A subsequent trial randomly assigned 389 patients with a primary unilateral inguinal hernia to receive either open Lichtenstein repair under local anesthesia or laparoscopic total extraperitoneal (TEP) repair under general anesthesia . Fewer patients in the laparoscopic group reported having persistent groin pain at one year (21 versus 33 percent). However, this difference may not be clinically relevant, as most patients reported mild pain (described as “can be easily ignored” on the questionnaire); only a few patients in each group (2 percent in the laparoscopic versus 3 percent in open group) reported severe pain. In addition, fewer patients in the laparoscopic group reported having groin pain that limited their ability to perform physical exercise (3 versus 8 percent). The recurrence rates at one year were similarly low in both groups (1 percent laparoscopic versus 2 percent open).
Femoral hernia — We prefer to repair a femoral hernia laparoscopically because of its 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. In one study, posterior repair of femoral hernias was associated with a lower recurrence rate than anterior repair . Posterior repairs are mostly done laparoscopically, as the only open posterior repair (Kugel) is rarely performed.
In addition, laparoscopic femoral hernia repair is also better at identifying occult hernias . In one study of 250 men undergoing laparoscopic repair of presumed inguinal hernias, femoral hernias were detected in additional to (29) or in lieu of (4) inguinal hernias in 33 patients (13.2 percent) . 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.
Bilateral hernias — We prefer to repair bilateral groin hernias laparoscopically because:
●Both hernias can be repaired through the same incisions, which improves cosmesis.
●A single large piece of mesh can be used with a laparoscopic TEP repair, reducing costs and potentially the risk of direct hernia recurrence medially .
●A laparoscopic approach permits exploration of the contralateral groin in patients with symptoms suggestive but not diagnostic of a contralateral hernia .
Three randomized trials have independently concluded that laparoscopic compared with open repair of bilateral inguinal hernias caused less postoperative pain, faster recovery, and similar rates of recurrence [49-51]. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom advocates laparoscopic repair for patients with bilateral hernias .
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 .
Recurrent hernia — We prefer to repair a recurrent groin hernia with a laparoscopic approach if the initial repair was open, but with an open approach if the initial repair was laparoscopic. The rationale is that recurrent hernia repair is optimal if performed in a previously undissected tissue plane.
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 [32,36]. As with primary repairs, a laparoscopic repair of recurrent hernias was also associated with faster recovery, less postoperative pain, and fewer complications [36,51,54-56]. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom also advocates laparoscopic repair for recurrent hernias .
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 preperitoneal space' above.)
Cost-effectiveness — Studies have generally found an overall cost benefit for open, as opposed to laparoscopic, hernia repair [57-61]. Factors considered in such studies included the cost of operating room time and equipment (especially single-use items), length of hospital stay, and the cost of treating potential complications. Variations in one or more of these factors (eg, by using reusable equipment) could make laparoscopic surgery more cost-effective .
Female patients — Groin hernias are uncommon in females; less than 8 percent of hernia repairs are performed in women [5,6,62,63]. Compared with men, women are more likely to have femoral hernias, complicated hernias (incarceration or strangulation), or recurrent hernias . (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'.)
All women with a newly diagnosed groin hernia who are not pregnant should undergo early surgical repair of the hernia. For women who have had a prior surgery involving the preperitoneal space (eg, cesarean section or hysterectomy), an open anterior mesh repair is the best option. In others, a laparoscopic approach is preferred because it allows identification and repair of occult hernias (especially femoral hernias).
SURGICAL TECHNIQUES — Specific techniques of inguinal or femoral hernia repair are briefly discussed below. Detailed information can be found in other topics. (See "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".)
Open techniques — Open techniques approach the hernia defect anteriorly, and include tension-free mesh repairs as well as primary tissue approximation nonmesh repairs. For patients in whom mesh placement is not contraindicated, we recommend using a mesh repair technique to achieve a tension-free repair rather than a nonmesh repair technique. 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).
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 [1,2,26,64-67]. Thus, the tension-free mesh techniques are most widely used and endorsed by various hernia societies [1,27,28]. Tension-free repairs that use mesh include Lichtenstein (our preferred method of open repair), plug and patch, and Kugel (preperitoneal repair). (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Mesh versus non-mesh repair' and "Open surgical repair of inguinal and femoral hernia in adults", section on 'Hernia repair techniques'.)
Open primary tissue approximation nonmesh repairs — Shouldice, Bassini, and McVay repairs are open techniques that achieve primary tissue approximation without the use of mesh [66,68-72]. 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'.)
Laparoscopic techniques — Laparoscopic 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 . (See "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Laparoscopic repair approaches'.)
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.
Confirm presence and location of hernia — The diagnosis of an inguinal or femoral hernia is clinical for most patients. Immediately prior to surgery, the patient should be reexamined to confirm the presence of a hernia and mark its laterality. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults".)
Obtain informed consent — The risks and benefits of hernia repair versus watchful waiting, including potential complications of each approach, should be reviewed with the patient. If surgical repair is elected, the risks and benefits of an open versus laparoscopic approach should also be discussed with the patient. (See 'Choosing a surgical approach' above.)
Medical risk assessment — Much of the preoperative medical evaluation is directed toward ensuring that the patient can tolerate anesthesia, especially if general anesthesia is planned. (See "Preoperative medical evaluation of the healthy patient" and "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of preoperative pulmonary risk" and "Perioperative management of blood glucose in adults with diabetes mellitus".)
Treat hernia complications if present — Patients with complicated hernias should receive complication-specific treatment prior to hernia repair. As examples, patients with bowel obstruction require fluid resuscitation and nasogastric decompression; patients with bowel ischemia or perforation require antimicrobial coverage. (See "Overview of management of mechanical small bowel obstruction in adults" and "Overview of gastrointestinal tract perforation", section on 'Initial management'.)
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) or surgical site infection (SSI).
Thromboprophylaxis — Thromboprophylaxis is administered according to the patient’s risks of developing VTE perioperatively (table 1). 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 may be applied to patients undergoing general anesthesia, or at the surgeon’s discretion. (See "Prevention of venous thromboembolic disease in surgical patients".)
Antibiotics — For patients undergoing uncomplicated inguinal or femoral hernia repair with planned mesh placement, we recommend 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 [74-79]. Uncomplicated hernia surgery is considered clean surgery, for which prophylactic antibiotics are not indicated. Some surgeons, however, prefer to administer antibiotics to patients undergoing hernioplasty (ie, hernia repair with mesh) to prevent potential mesh infection [79,80]. Others omit routine prophylactic antibiotics because the risk of SSI after groin hernia surgery is low, and most SSIs that occur are superficial and can be easily treated with oral antibiotics. (See "Overview of complications of inguinal and femoral hernia repair", section on 'Superficial wound infection'.)
A 2012 Cochrane review of 17 randomized trials demonstrated a lower rate of SSI in patients who received, compared with those who did not receive, prophylactic antibiotics (3.1 versus 4.5 percent, odds ratio 0.64, 95% CI 0.50-0.82) . In subgroup analyses, however, the difference was smaller in patients without mesh placement (3.5 versus 4.9 percent, odds ratio 0.71, 95% CI 0.51-1.00) than in those with mesh placement (2.4 versus 4.2 percent, odds ratio 0.56, 95% CI 0.38-0.81).
Prophylactic antibiotics should cover the usual skin flora, including aerobic gram-positive organisms, aerobic streptococci, staphylococci, and enterococci  (table 2). To be effective, prophylactic antibiotics must be administered within one hour before the time of incision [82,83]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Control measures to prevent 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 2). Once an intraoperative culture has been obtained, further antibiotic therapy should be guided by microbiology data. (See "Overview of gastrointestinal tract perforation".)
Choice of anesthesia — Inguinal or femoral hernia repair can be performed using general, neuraxial (spinal or epidural), or regional anesthesia (peripheral nerve block, local) [84,85]. The choice of anesthesia depends upon the type and size of the hernia, surgical approach, and patient/surgeon preferences. (See "Overview of anesthesia and anesthetic choices".)
Anesthesia for open repair — We prefer to perform open groin hernia repair with local anesthesia, especially in patients with comorbidities (eg, advanced liver disease).
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 . Another randomized trial of open inguinal hernia repairs also found that local anesthesia resulted in less postoperative pain, a shorter operating time, and fewer overnight stays than spinal anesthesia .
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. (See "Nerve blocks of the scalp, neck, and trunk: 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 often performed under general anesthesia, but can also be performed under spinal or epidural anesthesia.
MORBIDITY AND MORTALITY
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 [6,13,87]. The mortality rate is higher when bowel resection is performed with hernia repair . Other risk factors associated with a higher mortality rate include:
●Older age – Older patients have higher mortality rates after emergency hernia repair. In one study, the mortality rates were 1, 5, and 16 percent, respectively, for patients who were in their sixties, seventies, and eighties .
●Femoral hernia – Femoral hernia repairs are associated with higher mortality than inguinal hernia repairs . In one study, the 30-day standardized mortality ratios were higher for femoral than inguinal hernia repairs in both men (6.81 and 1.29) and women (7.16 versus 2.82) .
●Women – Women have higher mortality after groin hernia repair than men . However, it is not clear if female sex is an independent risk factor, as women who require groin hernia surgeries tend to be older, have more femoral hernias, and are more likely to require emergency operations.
Morbidity — Minor complications of inguinal or femoral hernia repair, including superficial wound infection and seroma/hematoma formation, are common and easily managed. Other complications, such as post-herniorrhaphy neuralgia and hernia recurrence, are less frequently seen but more debilitating. Complications of groin hernia repairs are discussed separately in other topics. (See "Post-herniorrhaphy groin pain" and "Overview of complications of inguinal and femoral hernia repair".)
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 information: Inguinal and femoral (groin) hernias (The Basics)")
SUMMARY AND RECOMMENDATIONS
●The definitive treatment of all hernias, regardless of origin or type, is surgical repair. Inguinal/femoral hernia repair is one of the most commonly performed operations in the world. (See 'Introduction' above.)
●Patients who develop strangulation or bowel obstruction from an inguinal or femoral hernia should undergo urgent surgical repair. Patients with an acutely incarcerated inguinal hernia but without signs of strangulation or obstruction also require surgery, typically urgently. However, for those who wish to delay surgery, nonsurgical hernia reduction can be attempted and, if successful, elective hernia repair can be performed at a later time. (See 'Complicated hernia' above.)
●Patients with an uncomplicated inguinal or femoral hernia may undergo surgical repair or be managed with watchful waiting depending upon the hernia type, severity of symptoms, as well as the sex and preferences of the patient, as follows:
•For all patients with newly diagnosed femoral hernia, we recommend elective repair, rather than watchful waiting, regardless of the patient’s sex or whether or not s/he has symptoms (Grade 1B). In patients with long-standing femoral hernias (>3 months), surgery is preferred but observation is a reasonable option. (See 'Femoral hernia' above.)
•For female patients with a newly diagnosed inguinal hernia, we recommend elective repair rather than watchful waiting regardless of whether or not she has symptoms (Grade 1B). (See 'Female patients' above.)
•For male patients with minimal or no symptoms attributable to an inguinal hernia, we suggest elective hernia repair rather than watchful waiting (Grade 2B). Although there is evidence that delaying surgical repair is safe, most patients eventually require surgery because of worsening symptoms. (See 'Asymptomatic hernia' above.)
•Patients with an inguinal hernia with minimal or no symptoms, who wish to avoid surgery, can be managed with watchful waiting provided that they are counseled of the risk of developing hernia complications (incarceration and strangulation) and understand the need for prompt medical attention should such complications occur. Trusses are associated with negative consequences and should not be used to manage symptoms related to inguinal hernias. (See 'Asymptomatic hernia' above.)
●The surgical approach to groin hernia repair should be the one that the surgeon is most comfortable with and most experienced in performing. For surgeons who are equally facile with both open and laparoscopic repairs, the choice of a surgical approach depends upon hernia and patient characteristics as follows (algorithm 1):
•We prefer an open approach for patients with prior surgery involving the preperitoneal space (including laparoscopic groin hernia repair, prostatectomy, hysterectomy, cesarean section, and laparotomy via lower midline incision), complicated inguinal hernias (infected, incarcerated, strangulated, large scrotal), or ascites. Laparoscopic repair is relatively contraindicated in these patients. (See 'Patients precluded from laparoscopic repair' above.)
•A primary, unilateral inguinal hernia can be repaired open or laparoscopically based upon surgeon and patient preference. (See 'Inguinal hernia' above.)
•We prefer to repair a femoral hernia laparoscopically. (See 'Femoral hernia' above.)
•We prefer to repair bilateral inguinal or femoral hernias laparoscopically. (See 'Bilateral hernias' above.)
•We prefer to repair a recurrent groin hernia with a laparoscopic approach if the initial repair was open, but with an open approach if the initial repair was laparoscopic. (See 'Recurrent hernia' above.)
●For patients with uncomplicated inguinal and femoral hernias, we recommend performing a tension-free repair, which typically requires the use of mesh, rather than a repair that produces tension (ie, most nonmesh primary tissue approximation repairs except Shouldice) (Grade 1B). 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), or when the use of a mesh is cost-prohibitive. (See 'Surgical techniques' above.)
●For patients undergoing elective inguinal or femoral hernia repair requiring mesh placement (eg, laparoscopic, Lichtenstein), we suggest using preoperative prophylactic antibiotics (Grade 2B). (See 'Antibiotics' above.)
●We prefer to perform open groin hernia repair under local anesthesia, especially in patients with comorbidities (eg, advanced liver disease). Most laparoscopic repairs require general anesthesia. (See 'Choice of anesthesia' above.)
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