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n South African Journal of Surgery - Inguinal hernia guidelines 2015 : guideline
Background. Inguinal hernia repair is the most frequent general surgical procedure. These guidelines aim to improve and standardise practice. They apply to adult patients only. This is a summary of the key points in the document. The authors strongly recommend the guidelines be read thoroughly.
Clinical. The diagnosis is almost always a clinical one. Imaging is seldom required and should only be requested at specialist level.
Referral.Routine referral of men with uncomplicated, minimally symptomatic, reducible hernias. All hernias should be repaired wherever possible as most patients ultimately come to surgery. Urgent referral of all women and men with irreducible hernias is recommended and emergency referral is used for patients with obstruction or strangulation. Patients with hernia recurrences should be referred to a surgeon with an interest in hernia surgery.
Anticoagulation. It is recommended to continue aspirin, but stop clopidogrel 5 - 7 days before surgery. Warfarin should be stopped 5 days before, and bridging with low-molecular weight heparin (LMWH) should be done if the patient has a high thromboembolic risk.
Hair removal. Shaving should be avoided. If needed, clipping is recommended.
Antibiotic prophylaxis is not routinely recommended; however, it should be used in high-risk groups (recurrence, age >70, immunocompromised, obese, diabetes mellitus (DM), catheterised patients).
Anaesthesia. General anaesthetic (GA) is required for laparoscopic repair, although it is feasible to do a totally extraperitoneal (TEP) repair under spinal anaesthesia. Open repair could be performed under local anaesthesia in all patients with reducible unilateral hernias, especially ASA III/IV, the elderly and those with multiple comorbidities. Patients with morbid obesity, incarcerated hernias, and very anxious patients should have a GA. Spinal anaesthesia is not recommended. Day-case surgery should be offered to all patients, where feasible.
Surgery. Laparoscopic repair is the treatment of choice for all inguinal hernias including primary unilateral hernias. The contralateral side should always be inspected for an occult hernia, but repair should only be performed if a defect exists. Prophylactic repair is not advised. There are no data to recommend transabdominal preperitoneal (TAPP) over TEP repairs or vice versa. The Lichtenstein repair is the preferred technique for open repairs. The Shouldice repair may be considered if there is gangrenous bowel and resection is required. All groin hernias must be repaired with a mesh. A regular polypropylene or polyester mesh is adequate for all open and laparoscopic hernia repairs.
Special circumstances. If the initial operation was an open repair, then the operation for a recurrence should be laparoscopic, and vice versa. Strangulated hernias may be repaired with open or laparoscopic methods but the bowel should always be inspected. A femoral hernia should always be excluded in women with a groin hernia. Patients presenting with hernias in pregnancy should be managed conservatively, with a planned postpartum repair.
Complications. Include seroma (which is common but often insignificant clinically), haematoma (which should be managed conservatively unless causing tension of skin), urinary retention, ischaemic orchitis, infection, and chronic groin pain. In patients with mesh infection it is not always essential to remove the mesh.
Aftercare. Patients may return to work and driving after 1 week.
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