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Literature review current through: Jun 2014. | This topic last updated: Oct 31, 2013.

INTRODUCTION — The definitive treatment of all hernias, regardless of their origin or type, is surgical repair [1]. Repair of inguinal or femoral hernia may be the most common operation with over 20 million hernia repairs performed per year worldwide [2], and over 700,000 in the United States [3]. Urgent/emergent repair is indicated for patients who develop complications (eg, bowel obstruction, bowel perforation) related to an inguinal or femoral hernia. For uncomplicated hernias, the optimal timing of repair (watchful waiting versus immediate) and the optimal technique for repair (open versus laparoscopic) remain controversial.

An overview of the treatment of inguinal and femoral hernias is presented here. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of inguinal and femoral hernias in adults, hernias in children, and other hernias are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults" and "Overview of inguinal hernia in children".)

INDICATIONS FOR REPAIR — Inguinal or femoral hernia repair has minimal short-term morbidity and patients generally have a rapid return to presurgical health. These excellent surgical outcomes, even among elderly individuals (particularly if local anesthesia can be used), have led to recommendations to offer surgical repair to patients with inguinal or femoral hernia who are symptomatic. Historically, recommendations were that the mere presence of a groin hernia was indication for repair due to the perception that complications were common and increased operative morbidity. Two studies conducted at the turn of the century compared watchful waiting to open mesh repair of inguinal hernia. Both studies showed a negligible rate of hernia accidents (acute incarceration with or without strangulation), but there was a measurable progression of symptoms (pain, discomfort) in the watchful waiting group that led to eventual repair. There was no apparent “penalty” for delaying repair until symptoms developed. (See 'Watchful waiting' below.)

Most large randomized trials have included only men; therefore, caution should be used when extrapolating these data and recommendations to women with groin hernias. Femoral hernias may have a higher rate of incarceration, due to anatomy, but we have no data to support repair over watchful waiting in asymptomatic or minimally symptomatic patients

Strangulated/incarcerated hernia — Urgent/emergent hernia repair should be undertaken for patients with symptoms and signs of strangulated hernia (inguinal or femoral), and in those with acutely incarcerated hernia to reduce the risk of subsequent strangulation. In patients with an acutely incarcerated inguinal hernia who do not have signs of strangulation (skin changes, peritonitis), an attempt at reduction is reasonable as long as the patient is accessible for follow-up over the next day or two. Emergency surgery within four to six hours of onset of symptoms may prevent loss of bowel from a strangulated hernia. The clinical manifestations and diagnosis of incarcerated/strangulated inguinal or femoral hernias are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults".)

Symptomatic hernia — Patients who have significant symptoms attributable to a groin hernia should undergo elective hernia repair [1]. For patients with no symptoms but with the risk factors for groin hernia incarceration or strangulation that are discussed below, we suggest hernia repair as soon as feasible. Significant symptoms would include pain on lifting or pain with any type of exertion, inability to manually reduce the hernia, or inability to perform routine activities of daily life because of discomfort or pain. Male patients with minimal symptoms can be safely observed; however, female patients, who have a higher risk for complications, should undergo repair. (See 'Watchful waiting' below.)

From randomized trials and observational studies, the cumulative probability of developing problems such as increasing pain, incarceration, or strangulation, is 2.8 percent at three months, 4.5 to 23 percent at two years, and 31 percent at four years [4-6]. It is often stated that the risk of strangulation is higher for smaller hernia defects, but there is no objective evidence proving this observation. Patients may be more likely to complain of pain with smaller hernia defects. Although it is not possible to identify with a high degree of certainty which hernias will remain uncomplicated versus those that will become symptomatic or incarcerated and/or strangulated, certain factors may increase the likelihood of hernia complications. In a retrospective review of 1034 consecutive patients with a groin hernia, patients requiring emergent hernia repair (n = 63) were significantly more likely than those having elective repair to have a femoral hernia (7.4 versus 2.5 percent), scrotal hernia (32.4 versus 16.2 percent), or recurrent hernia (30.9 versus 16.7 percent) [7]. Of those undergoing emergent repair, 33 patients (52 percent) were not previously known to have a hernia and 5 patients (17 percent) had a known hernia and were being observed.

Femoral hernia — Femoral hernias account for 2 to 4 percent of groin hernias, and are more common in women. Due to the high risk of hernia complications and better outcomes for elective versus emergent hernia repair, long-standing femoral hernias that are asymptomatic may be considered for watchful waiting, while recently identified hernias should be considered for elective repair, even if asymptomatic [1,8].

The Swedish Hernia Register documented 3980 femoral hernia repairs (2524 elective and 1409 emergent) between 1992 and 2006 [8]. Femoral hernia operations accounted for 23 percent of groin hernia operations in women, compared with only 1 percent in men. The repairs were done as emergencies in women 40 percent of the time compared with 28 percent for men. Bowel resection was required in 23 percent of emergent femoral hernia repairs, but in only 0.6 percent of elective repairs. Additionally, the risk of mortality for emergency operations was significantly higher than for elective operations (OR 5.37, 95% CI 3.24-8.91), highlighting the importance of repairing femoral hernias in an elective setting.

CONTRAINDICATIONS TO ELECTIVE REPAIR — There are few contraindications to inguinal or femoral hernia repair, provided the procedure can be performed under local anesthesia (with or without sedation). For patients in whom the hernia cannot be repaired using local anesthesia, the main contraindication relates to the type of anesthesia that would be used.  

Active infection, which includes any infection from local infection or systemic sepsis, is a contraindication to the placement of prosthetic material, which is usually needed to provide a tension-free repair. (See "Wound infections following abdominal wall hernia repair: Epidemiology, pathogenesis, and prevention".)

Pregnancy — The prevalence of inguinal hernia during pregnancy is overall low and estimated to be 1:2000 [9]. Complications of groin hernia during pregnancy account for <5 percent of intestinal obstructions [10]. In general, elective repair of groin hernia during pregnancy is not recommended; however, if severe discomfort or a hernia complication develops, repair will need to be undertaken during pregnancy.

Expectant management of inguinal hernia during pregnancy is associated with a minimal risk of serious hernia-related complications over the short-term. In one study of hernias in pregnancy, seven women with groin hernias were successfully observed nonoperatively and each had their hernia repaired after delivery [11]. Nonemergent repair should ideally be deferred until after the lax abdominal wall has returned to its baseline (four or more weeks postpartum).

Combined cesarean delivery and hernia repair has been reported, with the goal of minimizing the need for additional hospitalization and anesthetics [9,12]. However, the combined procedure has not been rigorously evaluated.

WATCHFUL WAITING — Although surgery is indicated for most patients with complicated hernia or those with significant symptoms related to the hernia, it may be reasonable to take a more conservative approach in men who have minimal or no symptoms [1]. Because women are at higher risk for hernia complications, in general, they should be offered repair when diagnosed. (See 'Indications for repair' above and 'Gender differences' below.)

The largest study evaluating watchful waiting (the WW trial) randomly assigned 720 men with an inguinal hernia to watchful waiting or open surgical repair (tension-free hernia repair) [5,13]. The men, who were mostly between the ages of 40 and 65, were asymptomatic or had only minimal symptoms, and the hernia remained easily reduced within 6 weeks of initial screening. The following results were noted:

At two years follow-up, there were no differences between the groups for the primary end points of pain sufficient to limit activity, or change in physical health scores.

Twenty-three percent of patients in the watchful waiting group had surgery within two years and 31 percent at four years.

With longer-term follow-up (maximum 11.5 years), the estimated cumulative crossover rates using Kaplan-Meier analysis was 68 percent. Crossover rates were higher for men older than 65 years compared with younger men (79 versus 62 percent). The most common reason for crossover was pain (54.1 percent).

Significant hernia complications did occur in patients being watched, but were rare with only 0.0018 hernia-related adverse events per patient-year.

The rate of postoperative complications was not significantly different between patients who were assigned to and received surgical repair compared with those who were assigned to watchful waiting and then crossed over to receive surgical repair (21.7 versus 27.9 percent). At the time of maximum follow-up, a total of three patients required an emergency operation, but there was no mortality.

A smaller study of 160 men, published subsequent to the WW trial, also found no difference in the rate of hernia complications or pain scores between the surgery and watchful waiting groups; however, patients who had immediate surgery responded that their general health had improved at one year, compared with a perception of health decline in the observation group [6].

These findings suggest that a strategy of watchful waiting rather than elective repair is an option for white, middle-aged male patients with asymptomatic or minimally symptomatic inguinal hernia, provided the patient is aware of the risk of potential hernia complications and understands the need for prompt medical attention if symptoms develop. However, there are insufficient data regarding the risk of watchful waiting in older patients who are at the greatest risk of strangulation, and the risk associated with emergency hernia repair [14]. In addition, it is not clear whether the above studies are generalizable to young individuals, women, other ethnic groups, or other types of hernia.

Negative side effects of trusses — The only nonsurgical therapy for groin hernia in men is a truss. Although the use of a truss may be appropriate in certain situations, we generally discourage their use.

A truss is a device consisting of a strap similar to an athletic supporter with a metal or hard plastic plug that is positioned to lie over the hernia defect. The hard disc or plug applies pressure, maintaining the contents of the hernia in the abdomen.

There are insufficient data to determine the efficacy of trusses for controlling symptoms [15,16]. The truss may potentially lead to harm if the disc impinges on the hernia contents. In addition, prolonged tissue pressure from can lead to atrophy of the spermatic cord or fusion to the hernia sac, and atrophy or deterioration of the fascial margins can also occur, complicating surgical repair [17].

PREOPERATIVE EVALUATION — The diagnosis of inguinal or femoral hernia is based upon clinical grounds in the majority of cases. Prior to hernia repair, the patient should be re-examined to confirm the presence of the hernia. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults".)

The risks and benefits of hernia repair versus watchful waiting, and the potential complications of each approach, should be reviewed with the patient, including the risk of chronic pain. If hernia repair is elected, the benefits and risks of the open and laparoscopic approach should be discussed with the patient [1,15,18-22]. (See 'Open versus laparoscopic inguinal hernia repair' below.)

Medical risk assessment — Much of the preoperative evaluation is directed toward ensuring that the patient is adequately prepared for anesthesia. (See "Preoperative medical evaluation of the healthy patient".)

Patients with chronic medical conditions, such as coronary artery disease, pulmonary disease, and diabetes mellitus, should be optimized prior to elective hernia repair. (See "Estimation of cardiac risk prior to noncardiac surgery" and "Evaluation of preoperative pulmonary risk" and "Perioperative management of blood glucose in adults with diabetes mellitus".)

Identifying risk factors post-herniorrhaphy neuralgia — Preoperative questionnaires may help identify patients at risk for more intense postoperative pain or chronic postsurgical pain due to post-herniorrhaphy neuralgia [23-28]. Preoperative risk factors for neuralgia include younger age, preoperative pain, prior surgery, preoperative sensory disorder, female gender, and recurrent inguinal hernia repair [29-31]. (See "Persistent groin pain following hernia repair and post-herniorrhaphy neuralgia".)

Measures to prevent post-herniorrhaphy neuralgia — Instituting measures to prevent nerve injury during hernia repair and minimize excessive postoperative pain, may decrease the risk of developing post-herniorrhaphy neuralgia. Measures focus on preemptive identification and early aggressive treatment of patients at risk for chronic groin pain, proper tissue handling, the use of lighter-weight mesh for repair, using a laparoscopic approach, and prophylactic neurectomy.

Preemptive and multimodal analgesia – Intensive preemptive analgesia and longer-term postoperative multimodal analgesia may help minimize postoperative pain, which has been linked to the development of chronic postsurgical pain [29,32]. (See "Management of postoperative pain" and "Persistent groin pain following hernia repair and post-herniorrhaphy neuralgia".)

Choice and placement of mesh – Lighter-weight mesh may induce a less intense inflammatory response, and appears to reduce the risk of chronic pain [33-37]. A systematic review identified 9 trials involving 2310 patients comparing lightweight versus heavyweight mesh for open inguinal hernia repair. A pooled analysis found a lower risk of chronic pain for those treated with lighter-weight mesh relative to heavier mesh (risk ratio (RR) 0.61, 95% CI 0.5-0.74). Partially absorbable and completely absorbable mesh has also been tried [37]. However, there is a concern that lighter-weight mesh may increase the risk for hernia recurrence. In two separate metaanalyses, eliminating mesh fixation during laparoscopic hernia repair did not affect postoperative pain scores [38,39].

Prophylactic neurectomy – Neurectomy, which refers to division of a nerve, may prevent nerve dysfunction; however, neurectomy leaves an area of relative sensory deprivation on the thigh or hemiscrotum. Some surgeons, but not all, divide the ilioinguinal nerve (ilioinguinal neurectomy) during the course of open, inguinal hernia repair if it appears that the nerve may have become entangled in the mesh or is otherwise at risk for involvement in scar (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Minimizing post-herniorrhaphy neuralgia'.)

Surgical approach – With careful attention to the neural anatomy and gentle tissue handling, primary nerve injury can be avoided [40]. Techniques for hernia repair that minimize the potential for nerve damage may include preferentially using a laparoscopic approach [41]. (See 'Favoring a laparoscopic approach' below.)

Choice of anesthesia — Elective surgery for groin hernia is generally performed in an outpatient setting. The choice of anesthesia depends on the type and size of the hernia, approach to repair, and patient and surgeon preferences.

Inguinal or femoral hernia repair can be performed using general, neuraxial (spinal or epidural), or regional anesthesia (peripheral nerve block, local) [42,43]. Local anesthesia, which can be administered as a regional nerve block or subcutaneously with or without conscious sedation, is a popular option for open hernia repair. The main disadvantage of local anesthesia is that it may not provide adequate anesthesia during the repair of large hernias, and particularly those that have resulted in a loss of abdominal domain. General anesthesia can also be used for open hernia repair, but it is generally not favored unless the patient has a compelling desire to be completely anesthetized. Laparoscopic repairs using transabdominal preperitoneal patch (TAPP) or intraperitoneal onlay mesh technique (IPOM) require general anesthesia, which may be contraindicated in some patients, whereas totally extraperitoneal (TEP) repairs are often performed under general anesthesia, but can be also performed under spinal or epidural anesthesia. (See "Overview of anesthesia and anesthetic choices".)

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 achieve, but has the advantage of not causing significant soft tissue edema. (See "Peripheral nerve block: Techniques", section on 'Ilioinguinal and iliohypogastric nerve block'.)

A randomized trial of local, regional, and general anesthesia in 616 adult patients in 10 hospitals undergoing open inguinal hernia repair found that the use of local anesthesia was superior for pain control in the early postoperative period [42]. Patients who received local anesthesia had less postoperative pain and nausea, shorter time spent in the hospital (3.1 versus 6.2 hours with regional and general anesthesia), and fewer unplanned overnight admissions (3 versus 14 and 22 percent, respectively). Another multicenter, randomized trial compared spinal and local anesthesia in 100 patients undergoing open hernia repair and also found local anesthesia was associated with less postoperative pain, shorter operating time, and fewer overnight stays [44].

PREPARATION

Thromboprophylaxis — Thromboprophylaxis is administered according to the patient’s risk (table 1). Patients who are otherwise healthy, young (<40 years of age), and who have no risk factors do not require pharmacologic thromboprophylaxis. Mechanical thromboprophylaxis may be applied, unless contraindicated (eg, peripheral artery disease), at the surgeon’s discretion. (See "Prevention of venous thromboembolic disease in surgical patients".)

Antibiotics — Whether to routinely administer prophylactic antibiotics to all patients undergoing elective inguinal or femoral hernia repair or only to those at risk for mesh infection remains controversial [45-49]. Uncomplicated hernia surgery is considered clean surgery, and although antibiotics are not recommended for clean procedures, antimicrobial prophylaxis may be warranted for patients undergoing hernioplasty (table 2) [49,50]. On the other hand, the incidence of infection in untreated patients is low, and not eliminated by prophylaxis. Further, most infections are superficial and can be cleared by judicious use of oral antibiotics. Thus, some clinicians may opt to avoid prophylaxis. If prophylaxis is chosen, a single dose of an appropriate antibiotic (table 2) should be given within one hour of the incision [51,52]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Control measures to prevent surgical site infection following gastrointestinal procedures in adults".)

An updated Cochrane review (2012) identified 17 randomized trials comparing antibiotic prophylaxis with placebo for open inguinal hernia repair; six trials were performed in those who did not have mesh placement (herniorrhaphy) and 11 trials in patients with mesh (hernioplasty) [50]. Overall, there was a significantly decreased risk for surgical site infection (SSI) in the treated group compared with control (3.1 versus 4.5 percent; odds ratio [OR] 0.64, 95% CI 0.50-0.82). In the herniorrhaphy (ie, no mesh) subgroup, the statistical significance was borderline, whereas in the hernioplasty (ie, with mesh) subgroup, antibiotic prophylaxis showed a significant reduction of SSI compared with the control group (2.4 versus 4.2 percent; OR 0.56; 95% CI 0.38-0.81). These results, and the low incidence of SSI and increasing problems with antibiotic resistance, argue against routine antibiotic prophylaxis for hernias that will be repaired primarily (ie, without mesh). It is important to note that most hernia surgical site infections are minor and generally respond to a brief course of antibiotics. (See "Overview of complications of inguinal and femoral hernia repair", section on 'Superficial wound infection'.)

Patients undergoing urgent or emergent inguinal or femoral hernia repair should be treated according to the nature of the complication (eg, bowel perforation, bowel ischemia). For inguinal or femoral hernia complicated by bowel obstruction or perforation, broad empiric antimicrobial coverage should be initiated (table 2) and narrowed based on intraoperative culture results, as soon as feasible, according to antibiotic sensitivity analysis.

When surgical site infection does occur, skin flora is most commonly isolated (ie, aerobic gram-positive organisms; aerobic streptococci, staphylococci, and enterococci) [53]. Thus, when antibiotic prophylaxis is given, we use a single dose of a cephalosporin administered within hour one of the incision. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Complicated hernias — Patients with complications related to inguinal and femoral hernia should be treated to manage symptoms and other problems associated with bowel obstruction, or perforation. This may include fluid therapy, nasogastric decompression, and antimicrobial therapy, which are discussed in detail elsewhere. (See "Overview of management of mechanical small bowel obstruction in adults".)

APPROACH TO REPAIR — A controversial aspect of inguinal hernia repair is the debate between proponents of open repair versus those who favor laparoscopic repair [18,54]. The repair approach differs relative to the hernia defect. With the open approach, the repair is anterior to the hernia defect (except Kugel repair and plug and patch repair), whereas laparoscopic repair is posterior to the hernia defect. Most modern techniques (open or laparoscopic) incorporate prosthetic mesh as a component of a tension-free repair. Important advantages of tension-free mesh repair are less short-term pain and discomfort, allowing the patient to return to normal activities more rapidly, and a lower hernia recurrence rate [55]. Regardless of the approach chosen (open or laparoscopic), we agree with various hernia society guidelines that recommend tension-free hernia repair [1,18,19,54].

Open repair techniques — Open techniques for inguinal hernia repair include tension-free mesh repairs such as the Lichtenstein, plug and patch, and Kugel (preperitoneal) repairs, and non-mesh primary tissue approximation repairs such as the Shouldice, Bassini, and McVay repairs [56-61]. Specific techniques used to perform open groin hernia repair, outcomes, and the choice of open technique are discussed in detail elsewhere. (See "Open surgical repair of inguinal and femoral hernia in adults".)

Inguinal hernias should be repaired using a tension-free, mesh repair [1]. When performed by surgeons experienced with each technique, no significant differences have been identified in randomized trials in the incidence of recurrent hernia when mesh is used [41,55,61-63]. Non-mesh repair, which is less likely to produce a tension-free repair, is thought to be the leading cause of failed hernia repair [64]. However, there are limited data comparing the outcomes of open tension-free mesh versus open non-mesh, primary approximation repair techniques [42].

One systematic review found that tension-free mesh repair was associated with fewer recurrences, although a formal metaanalysis was limited by the lack of data [55]. A systematic review of 13 trials comparing open hernia repair with mesh versus without mesh found a significantly lower risk of recurrent hernia when mesh was used (odds ratio [OR] 0.37, CI 0.26-0.51) [55]. No significant differences in recurrence rates were seen if the repair used a flat mesh repair (eg, Lichtenstein repair) versus a mesh plug.

The recurrence rate for primary hernia repair among 142,578 inguinal hernia repairs from the Swedish Hernia Registry was 4.3 percent [65]. Non-mesh repair, which was performed in 16 percent of the patients, was associated with an increased risk for recurrent hernia (hazard Ratio [HR] 1.27, 95% CI 1.14-1.43).

The EU Hernia Trialists Collaboration reviewed 58 trials (8221 patients) and also found a significantly higher recurrence rate for hernias repaired without mesh versus those performed with mesh using either open or laparoscopic techniques [41,61].

A subsequent prospective study of 26,304 herniorrhaphies performed in Denmark (Danish hernia database) found that reoperation rates using anterior open mesh and laparoscopic (mesh) techniques were significantly lower compared with a sutured posterior wall (open, non-mesh) technique 30 months after primary inguinal hernia repair (2.2 and 2.6 versus 4.4 percent, respectively), and recurrent inguinal hernia repair (6.1 and 3.4 versus 10.6 percent, respectively) [2].

Laparoscopic repair techniques — The two main laparoscopic inguinal hernia repairs are the totally extraperitoneal (TEP) and transabdominal properitoneal patch (TAPP) repairs [19], and each require the use of mesh. The intraperitoneal onlay mesh technique (IPOM) is another uncommonly used technique that has fallen out of favor. Laparoscopic techniques, outcomes, and the choice of laparoscopic technique are discussed in detail elsewhere. (See "Laparoscopic inguinal and femoral hernia repair in adults".)

TEP repair is performed by gaining access to the preperitoneal space using an anterior approach [66,67]. The surgeon develops the space between the peritoneum and the anterior abdominal wall without entering the abdomen.

TAPP repair enters the peritoneal cavity to access the preperitoneal space, which is a disadvantage since this can result in injury to adjacent abdominal organs, adhesions resulting in intestinal obstruction, or bowel herniation [68,69].

Open versus laparoscopic inguinal hernia repair — There is no strong consensus as to whether the optimal approach for inguinal and femoral hernia repair should be open or laparoscopic, and the issue continues to be debated [70]. An open approach may be the best approach for primary, unilateral inguinal hernia repair, but in general, the approach used to repair groin hernia should be the one the surgeon is most comfortable with and most experienced performing. In certain clinical situations, an open or laparoscopic approach may be preferred. (See 'Favoring open approach' below and 'Favoring a laparoscopic approach' below.)  

Multiple systematic reviews of randomized trials have generally agreed that although laparoscopic repair is associated with less postoperative pain and quicker return to normal activities (including work), it can take longer to perform and may be associated with a higher recurrence rate and other rare, but serious complications [71-85]. The largest, multicenter trial randomly assigned 1983 patients to open mesh or laparoscopic mesh repair [86]. Patients treated laparoscopically had less pain on the day of surgery and at two weeks, and returned to work one day earlier. However, laparoscopic repair resulted in significantly more recurrences at two years (10.1 versus 4.9 percent) and complications (39 versus 33.4 percent) including more life-threatening complications (1.1 versus 0.1 percent). A significantly higher incidence of recurrence was found for laparoscopic repair of primary hernia compared with open repair (10.1 versus 4.0 percent) but similar recurrence rates were found for the treatment of recurrent hernias (10.0 versus 14.1 percent). Patients were older (average age 58) and less healthy (only 34 percent were ASA class I) than the general population. Some earlier trials found lower recurrence rates for laparoscopic repair compared with open repair [87]; however, open repairs in these studies were not necessarily tension-free repairs (ie, with mesh) as was performed in the large multicenter trial [88].

Favoring open approach — The following may favor an open approach to groin hernia repair.

Prior pelvic surgery – For those with an abdominal incision or surgery in the preperitoneal space (eg, prostatectomy), an open approach may be favored. Prior mesh placement in the preperitoneal space also makes a laparoscopic approach much more difficult. Although TAPP repair is feasible, TEP repair is more difficult. TAPP or TEP repair has been performed after prostatectomy, but laparoscopic repair was found in observational studies to have a higher incidence of morbidity and longer operative time compared with open repair [89,90].

Infection – Active infection is a contraindication to mesh placement. An open repair may be an option for patients with remote infection in whom repair cannot be deferred, or in those with an infected mesh graft. The management of infected or recurrent hernia is discussed elsewhere. (See "Wound infections following abdominal wall hernia repair: Epidemiology, pathogenesis, and prevention".)

Complicated inguinal or femoral hernia – Although a laparoscopic approach is theoretically possible for nearly all inguinal hernias, including incarcerated or strangulated hernias [91], laparoscopic repair of complicated hernias may be fraught with technical difficulties [80,92]. We repair all strangulated hernias using an open approach, and in spite of several case series documenting successful laparoscopic repairs of acutely incarcerated inguinal hernia [91], we also use an open approach for incarcerated hernias to minimize the risk of bowel injury. If bowel perforation has occurred due to strangulation and necrosis, the placement of mesh is contraindicated, precluding laparoscopic repair.

Large scrotal hernia – Large scrotal hernia (>3 cm) represents a relative contraindication for laparoscopic repair because of the difficulty in managing and reducing a large indirect inguinal hernia sac [63].

Favoring a laparoscopic approach — The following may favor a laparoscopic approach to groin hernia repair:

Bilateral hernias – Three small, randomized trials have compared the laparoscopic with open approach for bilateral inguinal hernia [93-95]. Each study showed less postoperative pain and a more rapid recovery to normal activities with a laparoscopic approach and a similar recurrence rate for both techniques. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom advocates laparoscopic repair for bilateral hernia repair [96]. The advantages of bilateral hernia repair by a laparoscopic approach may include:

Both hernias can be accessed through the same incision, which improves the cosmetic result.

A single large piece of mesh can be used with a laparoscopic TEP repair, reducing costs and potentially reducing the risk of direct recurrence medially [97].

A laparoscopic approach allows exploration of the contralateral groin in patients with contralateral groin pain but where there remains uncertainty regarding the presence of a contralateral hernia [98].

It is important to note, however, that bilateral open tension-free mesh repairs can be also be performed simultaneously [99]. Prior to the development of tension-free open hernia repair, bilateral inguinal hernias were repaired one side at a time, which has led some surgeons to conclude that bilaterality should be an absolute indication to laparoscopic repair.

Recurrent hernia – Many surgeons feel that recurrent hernias, particularly those that recur after an anterior mesh repair, are best addressed via a laparoscopic technique [73,74]. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom also advocates laparoscopic repair for recurrent hernias [96]. The rationale for this argument is that recurrent hernia repair is optimal if performed in a previously undissected tissue plane. As with primary repair, a laparoscopic approach is associated with faster recovery, less postoperative pain, and fewer complications [95,100-102]. A meta-analysis of four small randomized trials found no significant differences between the laparoscopic and open approach for recurrence, chronic pain, or complications [73].

Femoral hernia – For open repair of femoral hernia, the floor of the inguinal canal must be opened to gain access to a femoral canal. The laparoscopic approach (TEP or TAPP) is more direct and is better for identifying occult femoral hernia. In an audit of patients undergoing laparoscopic recurrent hernia repair following initial open Shouldice or Lichtenstein repair, 10 percent of recurrent hernias that were presumed to be inguinal were femoral [103]. In a Swedish Registry study of emergency femoral hernia repair, a preperitoneal approach (laparoscopic or open) was associated with a lower rate of recurrence [8].

Prevention of post-herniorrhaphy neuralgia – Laparoscopic repair appears to be associated with less chronic groin pain [104-110]. A metaanalysis of 14 trials found a significantly decreased risk of chronic groin pain following laparoscopic inguinal hernia repair versus open inguinal hernia (relative risk [RR] 0.66, 95% CI 0.51-0.97) [110]. When comparing different types of laparoscopic hernia repair, the difference was attributable to repairs performed using transabdominal preperitoneal (TAPP) laparoscopic repair (RR 0.66, 95% CI 0.50-0.97). There was no significant difference in the occurrence of chronic groin pain between totally extraperitoneal (TEP) laparoscopic repair and open inguinal hernia repair (RR 0.81, 95% CI 0.45-1.44). Other measures to limit the potential for post-herniorrhaphy neuralgia are discussed above. (See 'Measures to prevent post-herniorrhaphy neuralgia' above.)

Laparoscopic hernia repair may be particularly beneficial for patients with jobs that require physical activity (eg, manual labor), given advantages such as reduced postoperative pain, and early return to normal activity.

Cost considerations — Cost-effectiveness studies weighing the reduced cost of a shortened hospitalization versus the increased costs of operating time, equipment expenditures and complications have found an overall cost benefit for open hernia repair compared with laparoscopic repair [111-115]. However, a sensitivity analysis in one study showed that there are specific situations in which laparoscopic repair may be a viable alternative, such as when reusable equipment is employed [111].

Gender differences — Groin hernias are uncommon in females, with less than 8 percent of the repairs performed in women [8,116-118]. Hernias are more likely to be femoral in location and to present with incarceration or strangulation in women compared with men [116]. Women also have a higher incidence of recurrent hernia than men [116]. (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'.)

For male patients with primary, unilateral or bilateral hernia, a tension-free mesh repair, either open (Lichtenstein repair, plug and patch) or laparoscopic is preferred.

In female patients, laparoscopic repair has important advantages such as allowing identification and repair of occult hernias; however, women are more likely to have had prior surgery in the preperitoneal space contraindicating a totally extraperitoneal (TEP) approach. For uncomplicated hernias, an open, anterior approach, particularly for small femoral hernias, is less invasive overall and provides excellent outcomes.

MORBIDITY AND MORTALITY — Minor complications of inguinal and femoral hernia repair are relatively common and include seroma/hematoma formation. More significant complications such as chronic postoperative pain, post-herniorrhaphy neuralgia, and hernia recurrence can occur and depend upon the site of the hernia and type of repair. (See "Persistent groin pain following hernia repair and post-herniorrhaphy neuralgia" and "Overview of complications of inguinal and femoral hernia repair".)

Mortality within 30 days of groin hernia surgery for both sexes is 0.1 percent in elective settings [7,116], but increases significantly when emergency operation is needed ranging from 2.8 to 3.1 percent [116,119], and are even higher when bowel resection is needed [120]. Significant factors associated with increased mortality factors in emergency settings are female gender and increasing age [8]. In one study, mortality after emergent hernia repair increased from 1 percent for those 60 to 69 years of age, to 5 percent in those 70 to 79 years of age, further increasing to 16 percent for those 80 to 89 years of age [119].

A study of the Swedish Hernia Registry found increased mortality rates for femoral hernia repair [8]. Mortality associated with femoral hernias was 0.16 percent in elective and 9.8 percent in emergency cases. Compared with inguinal hernia, femoral hernias showed an increased 30-day standardized mortality ratio (6.81 versus 1.29 in men and 7.16 versus 2.82 in women) [120]. The higher mortality rate in women is due to the greater proportion of femoral hernias, emergencies, and older age in women compared with men.

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 their origin or type, is surgical repair. Patients with complications (acute incarceration, ischemia, obstruction) related to inguinal or femoral hernia should undergo urgent/emergent hernia repair.

For male patients with moderate to severe symptoms related to inguinal hernia, we recommend repair rather than watchful waiting (Grade 1B). For minimally symptomatic patients with inguinal hernia, we suggest elective surgical repair (Grade 2A).

For female patients with groin hernia, we suggest repair once a diagnosis is established, regardless of symptoms, rather than watchful waiting (Grade 2C).

For patients with femoral hernia, regardless of gender or symptoms, we suggest elective repair rather than watchful waiting (Grade 2B). Femoral hernia is associated with an increased risk for complications and higher mortality following emergent repair.

Male patients with minimal or no symptoms who wish to avoid surgery can reasonably be treated with watchful waiting provided they are counseled of the very low risk of hernia complications (incarceration and strangulation) and understand the need for prompt medical attention should symptoms of these complications occur. Trusses are associated with negative consequences and should not be used to manage symptoms related to inguinal hernia.

An open approach may be the best approach for primary, unilateral inguinal hernia repair, but in general, the approach used to repair groin hernia should be the one the surgeon is most comfortable with and most experienced performing. In certain clinical situations, an open or laparoscopic approach may be preferred. (See 'Open versus laparoscopic inguinal hernia repair' above.)

A laparoscopic approach to hernia repair may be preferred over an open approach for bilateral hernia, recurrent hernia where prior repair was an open, anterior repair, and femoral hernia.

An open approach may be preferred over a laparoscopic approach for patients with prior surgery involving the preperitoneal space, primary inguinal hernia, large hernias, scrotal hernias, and when infection is a concern (ie, mesh contraindicated).

For patients undergoing elective inguinal or femoral hernia repair requiring mesh placement (eg, laparoscopic, Lichtenstein), we recommend prophylactic antibiotics (Grade 1B). Although prophylactic antibiotics may not be routinely needed for all patients undergoing elective inguinal or femoral hernia repair, a growing body of evidence supports antibiotic prophylaxis prior to elective hernia repairs that use mesh. (See 'Antibiotics' above.)

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