Repair of an inguinal hernia should be considered in patients with symptoms ascribable to the hernia. Typically, this includes pain and/or functional limitations due to the hernia itself. Watchful waiting can be considered in asymptomatic patients, especially if surgical risk is high or other comorbidities may impact the durability of repair (e.g., morbid obesity, poor functional status). The appearance of an 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 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 because of the increased risk of incarceration. In the presence of an undescended testicle, the repair, which includes an orchiopexy, should not be delayed. The orchiopexy is performed at any age if there is an associated inguinal hernia. Hernia repairs are routinely performed on an outpatient basis. Premature infants must be 60 weeks postconceptual age and term babies should be 44 weeks to be considered appropriate candidates for outpatient surgery. Infants that have not achieved the 60- or 44-week limit are done as inpatients so that postoperative apnea monitoring can be performed.
Patients with obesity should be counseled on preoperative weight loss. This should be considered in light of the acuity and severity of presentation. Repair also should be delayed in patients with acute upper respiratory infections or a chronic cough until the condition has been remedied. Smoking is curtailed or stopped, especially if associated with chronic coughing.
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 isotonic crystalloid solution. Systemic antibiotic therapy is instituted. A small nasogastric tube is passed, and constant gastric suction is maintained before, during, and after operation as warranted. Sufficient time must be taken to ensure adequate preoperative resuscitation. In the setting of prolonged intestinal obstruction, additional care should be taken to ensure appropriate resuscitation and correction of electrolyte imbalance to minimize the risk of cardiovascular collapse on induction of anesthesia. Operative intervention before stabilization may have disastrous results.
A child 2 years of age 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 surgery. 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, ...