Editing Inguinal hernia (section)

== '''Specific scenarios:''' ==

* Primary elective unilateral inguinal hernia repair in men
** Can use open, TAPP or TEP depending on surgeon preference
** Favour laparoscopic approaches in men <30yo
* Asymptomatic inguinal hernia in men (recommendations based on famous Fitzgibbons study)
** >70% will become symptomatic within 10 years and require surgery
** Only 2-3% will require emergency surgery in 10 years
** Overall, safe to wait until it becomes symptomatic, but just involve the patient in discussion. Might give some patients an extra 10 years of life without chronic post-op hernia pain by delaying!
* Primary elective unilateral IHR in women
** TAPP or TEP, to avoid missing a femoral hernia
* Femoral hernia
** Should generally be repaired expeditiously due to risk of strangulation
* Primary bilateral IHR (men and women)
** TAPP or TEP have better outcomes than open in terms of op time, recovery, complication rates
* Primary inguinoscrotal hernia
** Open approach favoured, especially if skin resection required due to large scrotal hernia
* Previous lower midline incision
** Open may be preferred due to adhesions/scarring
** TAPP is still ok
** TEP is difficult, worth trying, convert to open or maybe TAPP afterwards
* Previous pelvic or lower abdominal surgery
** Open preferred
* Elderly patients/comorbid patients
** Open Liechtenstein under LA for ASA III/IV
*** No difference in complication rates
* Recurrence
** Try to use a different approach to last time - e.g. if primary repair was open, do TAPP or TEP, and vice versa
* Emergency for symptomatic incarcerated or strangulated
** Any approach although it is preferable to visualise bowel to check for viability, meaning TAPP approach is ideal
** Many surgeons would prefer open for large incarcerated hernias, even if a bowel resection is likely to be required, this can be done through the open inguinal approach
*** If the incarceration point is the external ring, then it will likely spontaneously reduce when the EO fibres are opened, so try to grasp it for later inspection before it does so.
*** Hernia sac contains only fat: resect anything of doubtful viability with meticulous haemostasis
*** Spontaneous reduction of hernia before the bowel can be inspected:

***# Unlikely strangulated (no radiologic or clinical features of strangulation pre-op, the sac contains clear or serous fluid): repair the hernia and forget about the bowel.
***# Likely strangulated (pre-operative concern, or sac contains darker fluid): need to examine the bowel somehow, probably via laparoscopy, potentially via insertion of the scope through the hernia defect

*** Bowel resection required - can be hard to replace in abdomen; try steep Trendelenburg and gentle compression. May need to open EO laterally to internal ring, then IO/transversalis in the same way. May even need laparoscopy for further traction. If the IO defect is large enough, the simplest way to perform bowel resection is externally through the inguinal repair, then push the anastomosis back in. If unable to do that, will need a lower midline laparotomy.
** There is some (level 2a) evidence supporting nonabsorbable mesh in setting of bowel resection provided wound protectors are used along with saline lavage. However, standard practice is not to use mesh if resecting bowel or if tissues appear dusky/ischaemic.
*** If not doing it, perform Shouldice repair