Perioperative management - Inguinal hernia repair, Shouldice

The repair of inguinal hernia is the most common operation in visceral and general surgery. The lifetime risk for men is 27%, for 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 hernias. 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 mildly 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 the health condition and social circumstances; "watchful waiting" may be an option.

Approach for Primary Inguinal Hernia

The data situation for recurrent hernia is not as clear, so even with asymptomatic, non-progressive hernia, surgery would be more likely recommended.

Approach for Recurrent Inguinal Hernia

? = adequate expertise in laparoscopic hernia surgery required

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 repair of their hernia should be made promptly in women.

EHS Classification of Inguinal Hernias

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

A weak recommendation to use a suture technique exists for patients who refuse mesh implantation or prefer a suture technique.

Among the suture techniques, the Shouldice technique is recommended as the best technique. Data from the German Herniamed Register show that a comparably good outcome exists for the Shouldice technique with appropriate indication (small lateral hernia in young men). Another international publication confirms that centers specialized in Shouldice repair also achieve good results with suture techniques.

In emergency procedures with incarceration, the diagnostic superiority of laparoscopy should be utilized. Its advantage is the possibility of repositioning the incarcerated content with assessment of organ perfusion afterward. The repair of the inguinal hernia can be performed immediately or at a later time, depending on the local infection situation.

The Shouldice technique is demonstrated in the teaching contribution on a direct hernia.

• 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.

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 of the patient, while still awake, possibly before taking premedication.

• Information about alternative procedures or so-called "watchful waiting"
• Handling of nerves, possibly neurectomy
• Injury to the vas deferens and testicular vessels
• Persistent sensory disturbance
• Severe chronic pain risk depending on the preoperative symptomatology
• Recurrence

 General complications:

• Seroma
• Hematoma
• Wound healing disorder
• Infection
• Vascular and nerve injury
• (Post-)Bleeding
• Follow-up surgery
• Bowel injury
• Lethality