Any indirect inguinal hernia should be repaired electively unless contraindicated by the large size of the hernia or by the age or poor physical condition of the patient. The appearance of indirect inguinal hernia in middle-aged or elderly patients requires thorough medical investigation. Before repair is advised, it is wise to rule out any other source of pathology as a cause for the patient’s complaint rather than ascribe it to the presence of an indirect inguinal hernia. Patients who have straining from symptomatic gastrointestinal tract obstruction, chronic pulmonary disease, or prostatism need appropriate diagnostic studies.
Repair of an inguinal hernia in an infant or child is indicated as soon as practical after the diagnosis is made. In the presence of an undescended testicle, the repair, which includes an orchiopexy, should be delayed until 3 to 5 years of age to permit maximum spontaneous descent. The orchiopexy is indicated at any age if there is strong indication for repairing the hernia due to incarceration.
Obese persons should be refused repair until their weight has been substantially reduced to a point within the range of their calculated ideal weight in order to ensure a low recurrence rate. Repair should also be delayed in patients with acute upper respiratory infections or a chronic cough until these conditions have been remedied. Smoking is curtailed or stopped and frequent intermittent positive pressure breathing, with appropriate drugs added, should be instituted several days before surgery.
In the presence of strangulation, the operation is delayed only long enough for fluid and electrolyte balance to be established by the intravenous administration of Ringer’s lactate solution. Systemic antibiotic therapy is instituted. Colloid solutions or blood products may be needed, especially if gangrenous bowel is suspected. A small nasogastric tube is passed, and constant gastric suction is maintained before, during, and for several days after operation. Sufficient time must be taken to ensure a satisfactory urine output of at least 30 to 50 mL per hour, a pulse under 100 per minute, and an appropriate blood pressure with a normal central venous pressure. Repeated electrolyte values should be approaching normal. Adequate resuscitation may require from several hours to a much longer period for the administration of several liters of fluids and electrolytes, especially potassium and blood, in the patient who has had intestinal obstruction for several days. Operative intervention before stabilization may have disastrous results.
A child 2 years or older should be prepared psychologically in advance for the hospital experience. Booklets that describe in simple narrative style the various details of hospitalization and operation can be read to the child before operation. Such preparation undoubtedly serves to diminish the incidence of emotional trauma as a complication of elective surgery.
Uncomplicated inguinal hernias in patients of any age may be repaired as ambulatory surgical procedures using local, regional, or general anesthesia.