Perioperative management - Inguinal hernia repair, Rutkow Plug

The repair of inguinal hernia represents the most common operation in visceral and general surgery. The lifetime risk for men is 27% (women 3%).

The incidence increases with age, and patients with a positive family history are significantly more affected.

Risk factors include:

• COPD
• Nicotine abuse
• Reduced BMI
• Collagen diseases

Indirect inguinal hernias occur twice as often as direct ones. Femoral hernias account for only 5% of inguinal hernias. Right-sided hernias are more common than left-sided ones.

There is no general recommendation for surgical therapy in the case of discretely symptomatic or asymptomatic, non-progressive inguinal hernia in men. Since most patients develop symptoms over time, it is recommended to discuss the indication for surgery and the timing with the patient, taking into account health status and social circumstances; "watchful waiting" may be an option.

The data situation for recurrent hernia is not as clear, so surgery would also be advised for asymptomatic, non-progressive hernia.

In women, femoral hernias occur more frequently than in men. Since no diagnostic procedure can reliably distinguish between inguinal and femoral hernias, and femoral hernias incarcerate significantly more often than inguinal hernias, the indication for surgical treatment of their hernia should be made promptly in women.

In principle, a mesh-based surgical procedure is required for the treatment of inguinal hernia!

A mesh-free method should only be chosen if the patient refuses a mesh or if no mesh is available.

The Lichtenstein operation is recommended in the guidelines as the currently best open procedure for the treatment of primary unilateral inguinal hernias in adults.

Another open technique presented here is the plug and patch technique. This involves a special mesh system that covers both the anterior and posterior planes via the classic open approach.

Although comparable results of plug and patch techniques and bilayer (double mesh) methods can be found in the literature compared to the Lichtenstein procedure, their use is not recommended. However, the principle of therapeutic freedom applies.

With comparable rates of recurrence and chronic pain in "plug and patch," the introduction of alloplastic material into both the anterior and preperitoneal space is seen as a disadvantage. Since both access routes to the groin are then compromised by scar tissue and foreign material, recurrent operations can be significantly complicated.

Several randomized studies compared "plug and patch" with the standard Lichtenstein procedure and were able to demonstrate the equivalence of this procedure regarding recurrence rate and frequency of chronic pain with a follow-up period of 1-4 years.

• Hernias in women and bilateral hernias should preferably be operated on laparoscopically/endoscopically.
• In cases of severe preoperative pain, preference should be given to minimally invasive procedures.
• Skin infection in the area of access
• Uncorrectable coagulation disorders
• Incurable intra-abdominal diseases with a poor prognosis (peritoneal carcinomatosis)

For the diagnosis of inguinal hernia, a clinical examination alone is sufficient. It includes inspection, palpation of the groin in both standing and lying positions, including digital exploration of the inguinal canal. A reducible bulge in the groin area is a clear indication of a hernia.

In cases of so-called occult hernia or recurrence, diagnostic certainty can be increased by ultrasound. If the ultrasound findings are unclear, diagnostics should be expanded to include magnetic resonance imaging or computed tomography.

The clinical confirmation of recurrent hernia is often complicated by scar tissue.

Non-reducible tissue structures must be subjected to further diagnostics even in the absence of symptoms.

In cases of incarceration or anamnesis abnormalities (irregular bowel movements, urinary complaints), the diagnostic concept may need to be expanded: colonoscopy, abdominal CT.

• Clear site marking on the skin in the awake patient before possibly taking premedication.
• Perioperative antibiotic prophylaxis is recommended in open procedures with mesh, especially with an increased risk profile.