Abdominal Hernias Treatment & Management: Approach Considerations, Hernia Reduction, Topical Therapy (2025)

The fundamentals of indirect inguinal hernia repair are basically the same, regardless of the age at presentation. Reduction or excision of the sac and closure of the defect with minimal tension are the essential steps in any hernia repair. If tissue is sufficiently attenuated as to preclude following these precepts, many techniques involving the release of tension by flaps, prosthetic materials, or a simple relaxing incision in adjacent tissue will fulfill the requirements. Overlay, underlay, and sandwiching of the edges with plastic meshes constitute most techniques today.

Return to work is dictated by the approach and the amount of physical activity involved with the job. Accurate postoperative instruction and easy access to care (if problems arise) are as effective as a full postoperative visit following routine inguinal hernia repairs.

Basic repair techniques

Bassini and Shouldice repairs

The essence of the Bassini repair is apposition of the transversus abdominis, transversalis fascia, and lateral rectus sheath to the inguinal ligament. This is usually performed by imbrication (see the image below). The Shouldice technique usestwo layers of continuous suture in a similar fashion.

Cooper repair

The Cooper repair approximates the conjoint area, transversus abdominis, and transversalis fascia to the pectineal (Cooper) ligament. Overlying the vein, these structures are sewn to the iliopubic tract. This technique also provides a good approach for the repair of femoral hernias.

Tension-free mesh repairs

The standard adult hernia repair now uses prostheses to reinforce the floor, usually polypropylene mesh. The material can overlay, underlay, or sandwich the area or can be used as a plug. This provides a tension-free repair and excellent results, but it carries a slightly increased risk of wound infection. The Lichtenstein hernioplasty is currently one of the most commonly performed mesh-based tension-free repairs (see Open Inguinal Hernia Repair).

The preperitoneal approach has advocates who claim that this approach makes it easier to identify the sac, reduce the contents, and dissect the cord structures. Mechanical advantages include the use of natural intra-abdominal pressure to keep the mesh in place over all potential hernia sites. The best uses are in the repair of hernias incidentally encountered during other abdominal procedures, recurrent hernias, and femoral hernias.

A Pfannenstiel, lower midline, or other incision is used to reach the preperitoneal plane. The internal inguinal ring and the hernia sac are identified lateral to the inferior epigastric vessels. After the sac is dissected from the testicular vessels and vas deferens, it is divided and the peritoneum closed. The repair follows the pectineal approach and often has mesh applied.

Simple repair for pediatric hernias

A simple inguinal hernia repair is possible in children because of the smaller size, better muscle tone in the canal, and rapid recuperation. Excision of the hernial sac (processus vaginalis) is usually sufficient, with little need for prosthetic repair of an attenuated internal ring or posterior wall of the inguinal canal. Either preincisional injection of the incision site or a caudal block is preferable to no preincisional therapy. ^[34]

A small incision is made just superior and lateral to the pubic tubercle in the suprapubic skin crease, centering the operative field near the internal ring. The external oblique aponeurosis is incised in the direction of its fibers, or the internal and external rings are transposed by laterally retracting the latter. Tugging on the testis helps visualize cord structures. The glistening white hernia sac often bulges up amid the cord. The sac, located anteromedial to the cord, is elevated from the floor and carefully dissected free from the vas deferens and testicular vessels.

Short hernia sacs are freed to the internal ring, but long sacs are often best divided. Proximal dissection to the internal ring should extend until preperitoneal fat is visible circumferentially. Twisting the sac before ligation provides strength and narrows the internal ring. The sac is ligated at its base. Because of occasional postoperative “spitting” of a nonabsorbable (eg, silk) suture, synthetic sutures are used for sac ligation.

If fascial repair seems necessary, the transversalis fascia is sutured to the shelving margin of the ilioinguinal ligament. The incision is closed in layers, and a single adhesive strip is placed. The testis must be pulled into the scrotum to prevent iatrogenic cryptorchidism (see the image below).

Approximately 2% of girls with inguinal hernias have an intersex differentiation syndrome. Each girl should have the fallopian tubes and ovaries examined directly or via peritoneoscopy. The hernia sac of a female patient must be scrupulously examined for signs of testicular tissue if it contains an ovary.

The most common cause of this is testicular feminization (androgen insensitivity) syndrome, which results from end-androgen resistance and leads to a small testis and a rudimentary vagina (persistent genitourinary sinus) without fallopian tubes or a uterus. If a girl with a hernia has testicular feminization, a gonadectomy on one side and isolation of the other gonad in a superficial position until puberty permits secondary sexual characteristics to develop. Hermaphrodites have an asymmetric ovotestis, which should not be removed.

An incarcerated object within an inguinal hernia in a girl, especially in an infant, is usually an ovary. An incarcerated ovary is not usually reducible, but strangulation is infrequent, making surgical reduction of the irreducible ovary less urgent than reduction of an incarcerated intestine would be. A child with an incarcerated hernia containing the intestine that successfully is reduced should be admitted for 1 day to allow resolution of edema before repair.

A child with tachycardia, fever, or signs of obstruction must be operated on immediately. Fluid and electrolyte correction and antibiotic administration precede the operation. Testicular atrophy occurs with incarcerated pediatric hernias, and the parents should be warned of the possibility.

Exposing and opening the sac before dividing the external ring permits the contained intestine to be controlled with a clamp, preventing unintentional release of the bowel into the abdomen. Once the viability of the incarcerated intestine is ensured, dividing the external ring (and sometimes the internal oblique muscles) laterally will reduce it.

Laparoscopy through the hernia sac can be used to assess visceral viability if incarcerated intestinal contents reduce before visualization. The gangrenous bowel is resected, an end-to-end anastomosis is performed, and the intestine is returned to the abdomen. Repair of the contralateral side, if required, is deferred. An apparently infarcted testis is left in place after a capsulotomy is performed.

Laparoscopic repair techniques

Laparoscopic techniques are increasingly being used to repair both primary hernias and recurrent hernias (see Laparoscopic Inguinal Hernia Repair). The totally extraperitoneal (TEP) approach is usually favored over the transabdominal preperitoneal (TAPP) approach because of the complications that arise from exposed intraperitoneal mesh in the latter. Postoperative pain, time to full recovery, and return to work are improved with the laparoscopic approach, but it is more expensive. Short-term recurrence data are comparable so far.

For most abdominal wall hernias, laparoscopic repair probably represents the future. ^[35] As the cost of instrumentation decreases, procedure-specific instrument design improves, and the laparoscopic learning curve is obliterated, the saying “if all else is equal, less pain and better cosmesis win out” will hold true. For example, prospective studies out of Europe found laparoscopic repair of pediatric hernias to be comparable to the results of open surgery. ^[36] The use of new materials or techniques may alter the approach. ^[37]

In a retrospective cohort study of 79 patients who underwent laparoscopic repair of primary ventral hernias and 79 who underwent open hernia repair, patients with a laparoscopic ventral hernia repair were significantly less likely to develop a surgical site infection (7.6% vs 34.1%). However, patients who underwent laparoscopic repair were more likely to develop a postoperative ileus (10.1% vs 1.3%), to have a persistent bulge at the operative site (21.5% vs 1.3%), and to have a longer hospital stay. ^{[38, 39]}

Treatment approach

Adults

After a diagnosis is established, the signs, symptoms, and risks of incarceration, as well as the timing, conduct, and risk of the repair procedure, should be explained to the patient or caregiver. Most repairs proceed within several weeks, with the precise timing dependent on multiple factors (eg, employment and insurance).

With massive hernias, prosthetic material is usually needed to aid closure, and appropriate materials should be available in the operating room before incision. Progressive pneumoperitoneum, using increasing volumes of air over time, may allow accommodation to increased intra-abdominal pressure but probably does little to increase the size of the abdominal cavity.

Adults with very large chronic hernias should be admitted postoperatively because of the combination of ileus from extensive manipulation and loss of domain with the attendant problems of increased pressure on the diaphragm, vena cava, kidneys, and hernia closure. Adults who present with bilateral hernias without the need for formal reconstruction can undergo simultaneous repair; more complex procedures require the repairs to be separated by at least 1 month.

Local anesthesia is sufficient for most repairs in adults; however, prolonged procedures, repair of hernias with a large intraperitoneal component, including laparoscopy, and repair of recurrent hernias are best managed with spinal, epidural, or general anesthesia.

Routine preoperative antibiotic prophylaxis is not currently recommended for low-risk adults undergoing a standard tension-free mesh-based repair; multiple studies have shown this practice to be of no benefit in decreasing postoperative wound infection.

Patients undergoing a neurectomy have a significantly lower prevalence of neuralgia without increased paresthesia.

Children

In healthy full-term infant boys with asymptomatic reducible inguinal hernias, regardless of age or weight, pediatric surgeons typically carry out repair soon after diagnosis. ^[20] In full-term girls with a reducible ovary, most surgeons operate at a close elective date, but more urgent scheduling of surgery is preferred if the ovary is not reducible but asymptomatic.

Premature infants with inguinal hernias usually undergo repair before being discharged from the neonatal intensive care unit (NICU), but this practice is changing, and infants are now being discharged home at much lower weights. Some surgeons prefer to postpone the surgery in these very small babies for 1-2 months to allow further growth.

All children with a bilateral presentation should undergo bilateral inguinal hernia repair under a single anesthesia. However, there remains some controversy regarding the correct approach to exploration of the contralateral side in pediatric inguinal hernias. ^[40] The potential damage to the spermatic cord structures in boys and the low incidence of contralateral hernia development in infants (< 1 year) and older children argue against routine contralateral groin exploration. ^{[41, 42]}

The previous practice of routinely exploring the opposite side in all boys younger than 2 years and all girls younger than 4-5 years is no longer popular. Most surgeons do not routinely perform open exploration of the contralateral groin, except in cases of high anesthetic risk, significant risk for developing contralateral hernia secondary to increased intra-abdominal pressure, or limited access of the child to appropriate medical care should an incarceration occur on the opposite side.

Current practice in many pediatric centers uses peritoneoscopy through the ipsilateral inguinal sac to identify contralateral patent processes and hernias. ^[43] Long-term follow-up is needed because only 20% of the patent processes identified become clinically apparent hernias in the short term.

A surgeon who is unfamiliar with the tissue characteristics and metabolic and psychological needs of children or who does not have a skilled pediatric anesthesiologist available should not attempt a hernia operation in a young child. Older children usually have general inhalation anesthesia, whereas some anesthesia providers use spinal or continuous caudal anesthesia with preterm infants. Preemptive regional anesthesia, by ilioinguinal and iliohypogastric nerve block or by caudal block, decreases postoperative discomfort.

Routine use of perioperative antibiotics for uncomplicated inguinal hernia repairs in children is not generally indicated. Some cardiologists advise prophylactic antibiotic use to lower the risk of endocarditis in children with associated cardiac defects; patients with ventriculoperitoneal shunts may also benefit.

Postoperative apnea is common in premature infants. ^[44] Those younger than 50 weeks’ gestational age should be admitted for 24 hours postoperatively and placed on a cardiorespiratory monitor. ^{[45, 46, 47]}

Sliding hernia

In about 40% of girls with an inguinal hernia, the fallopian tube (or, occasionally, the ovary or uterus) is a sliding component of the hernia that cannot be easily reduced into the abdominal cavity. The sac wall may seem too thick in the medial or lateral quadrants, or the contained viscus (particularly the fallopian tube and ovary) may not be reducible into the peritoneum. The walls must then be inspected for a sliding component.

To repair a sliding hernia, the sac is ligated distal to the fallopian tube and divided. The proximal sac is ligated and then invaginated into the peritoneal cavity. A purse-string suture inside the opened hernia sac may be used to aid in visualization during sac closure. The internal ring is closed with sutures from the transversalis fascia to the iliopubic tract.