Inguinal Hernia Repair
Lawrence H. Knott Jr., MD, FACS

Although inguinal hernia repairs constitute one of the most common operations performed by surgeons, there remains debate about many points ranging from etiology to proper management. Children and young adults are usually said to have “congenital” or indirect hernias representing failure of closure of the processus vaginalis. These however may not occur until middle or old age, when they become clinically manifest. “Direct” hernias are said to be acquired secondary to weakness of muscle layers, possibly related to defects in collagen synthesis or turnover. The clinical distinction between indirect and direct hernias is largely academic because the operative repair is much the same. That is fortuitous since the physical exam often precludes an accurate distinction.

Most hernias produce no symptoms until the patient notices a lump in the groin associated with some degree of discomfort. Not uncommonly, however, inguinal hernias are diagnosed in the course of routine physical examinations and are asymptomatic at the time of diagnosis.

Inguinal hernias should be repaired with rare exceptions. The complications of incarceration, obstruction, and strangulation are much greater threats than are risks of elective repair. Even elderly patients tolerate elective repair very well when other medical conditions are optimally controlled. Emergency repair carries a much greater risk for the elderly than carefully planned elective surgery.

The socioeconomic forces impacting the practice of surgery are no where more apparent than in the management of inguinal hernias. Approximately 800,000 cases per year are done in hospitals and "freestanding" surgical facilities. Inguinal hernia repair was one of the hallmark procedures leading to concepts of “ambulatory” or “come and go” surgery. Operative repairs have changed in recent years from historically based attempts at reapproximating inguinal anatomy to concepts of “tension-free” prosthetic repair of the inguinal anatomy.

The newest innovation is laparoscopic hernia repair. This remains a procedure in evolution as evidence by a number of different methods of performing laparoscopic hernia repair. A laparoscopic cholecystectomy is now widely established and has proven to be better for patients and certainly cost effective. The role of laparoscopic hernia repair is not yet so well established. It must compete against conventional repairs, which are already ambulatory and well established. Currently laparoscopic repair is more expensive than conventional repairs and most would agree that it is technically more difficult to perform. Issues of cost, return to work,and recurrence rates remain controversial.

Currently, some surgeons do only laparoscopic repairs, others only conventional repairs, and still others offer both procedures to their patients. Laparoscopic repair may be a of specific benefit in the management of recurrent and/or bilateral inguinal hernias. For unilateral repairs, both conventional and laparoscopic repairs are certainly acceptable choices pending patient and surgeon preferences.

In summary, inguinal hernias remain one of the most common afflictions of mankind. With rare exceptions, they should be referred for surgical repair. The method of repair chosen remains an evolving process.

Arregui, Surgical Clinics of North America 1993,73:513-527 Gilbert, Problems in General Surgery 12.2:209-214