Inguinal Hernia Repair Medical Slides

Present the HerniaSurge 2018 recommendations: Unilateral primary hernia — open Lichtenstein OR laparoscopic (TEP/TAPP) both recommended (surgeon expertise is the primary determinant). Bilateral hernias — laparoscopic preferred (single incision set, same mesh placement bilaterally). Recurrent hernia after open repair — laparoscopic preferred (avoids scar tissue from prior anterior approach). Recurrent after laparoscopic — open Lichtenstein preferred. Key outcome data: recurrence rates equivalent (1-2%), laparoscopic has less acute pain and faster return to activity, but longer operative time and learning curve (~100 cases for TEP). Chronic pain rates similar at 10-12%.

Present the evidence from two landmark trials: (1) Fitzgibbons 2006 (JAMA): minimally symptomatic men randomized to watchful waiting vs surgery — 23% crossed to surgery within 2 years due to increasing pain, with NO increased risk of acute incarceration or strangulation (0.2% per year). (2) 10-year follow-up showed 68% eventually underwent repair, mostly for pain. HerniaSurge recommendation: watchful waiting is acceptable for men with asymptomatic or minimally symptomatic inguinal hernias after shared decision-making. NOT recommended for: women (higher risk of femoral hernia requiring emergent repair), incarcerated hernias, or significantly symptomatic patients.

Present the scope: chronic pain (>3 months post-op) affects 10-12% of hernia repairs, with 1-3% experiencing severe debilitating pain. Risk factors: young age, female sex, high preoperative pain, open technique, heavyweight mesh. The three inguinal nerves at risk: iliohypogastric, ilioinguinal, and genital branch of genitofemoral. Prevention: careful nerve identification (pragmatic nerve preservation — identify and protect when visualized, divide if at risk), lightweight mesh (less inflammatory response), adequate surgeon experience. Treatment of established chronic pain: pain management (gabapentinoids, nerve blocks), mesh removal if meshoma identified, triple neurectomy (removes all three nerves — success rate 60-80%).