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Asian J Endosc Surg ISSN 1758-5902

GUIDELINE

Inguinal hernia repair: Toward Asian guidelines

Davide Lomanto,1 Wei-Keat Cheah,2 Jose Macario Faylona,3 Ching Shui Huang,4 Darin Lohsiriwat,5
Andy Maleachi,6 George Pei Cheung Yang,7 Michael Ka-Wai Li,7 Sathien Tumtavitikul,8 Anil Sharma,9
Rolf Ulrich Hartung,10 Young Bai Choi11 & Barlian Sutedja12
1 Minimally Invasive Surgery Centre, Department of Surgery, Yong Loo Lin School of Medicine, National University Health System, National University
Singapore, Singapore
2 Department of Surgery, Jurong General Hospital, Singapore
3 Department of Surgery, Philippines General Hospital, University of Philippines, Manila, Philippines
4 Department of Surgery, Taipei University, Taipei, Taiwan
5 Department of Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
6 Department of Digestive Surgery, Karyadi Hospital, Semarang, Indonesia
7 Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong
8 Department of Surgery, Vichaiyut Hospital, Bangkok, Thailand
9 Minimal Access and Bariatric Surgery Centre, Max Healthcare Hospital, New Delhi, India
10 Surgery, BR Medical Suites, Mediclinic City Hospital, Dubai, UAE
11 Department of Surgery, Assan University, Seoul, Korea
12 Department of Surgery, Gading Pluit Hospital, Jakarta, Indonesia

Keywords Abstract
Guidelines; hernia; inguinal hernia
Groin hernias are very common, and surgical treatment is usually recom-
Correspondence mended. In fact, hernia repair is the most common surgical procedure per-
Davide Lomanto, Minimally Invasive Surgical formed worldwide. In countries such as the USA, China, and India, there may
Centre, Department of Surgery, Yong Loo Lin
easily be over 1 million repairs every year. The need for this surgery has
School of Medicine, National University of
become an important socioeconomic problem and may affect health-care
Singapore, 5 Lower Kent Ridge Road,
119074 Singapore. providers, especially in aging societies. Surgical repair using mesh is recom-
Tel: +65 6772 2897 mended and widely employed in Western countries, but in many developing
Fax: +65 6774 6077 countries, tissue-to-tissue repair is still the preferred surgical procedure due to
Email: surdl@nus.edu.sg economic constraints. For these reason, the development and implementation
of guidelines, consensus, or recommendations may aim to clarify issues
Received 11 August 2014; accepted 20
related to best practices in inguinal hernia repair in Asia. A group of Asian
August 2014
experts in hernia repair gathered together to debate inguinal hernia treat-
DOI:10.1111/ases.12141 ments in Asia in an attempt to reach some consensus or develop recommen-
dations on best practices in the region. The need for recommendations or
guidelines was unanimously confirmed to help overcome the discrepancy in
clinical practice between countries; the experts decided to focus mainly on the
technical aspects of open repair, which is the most common surgery for hernia
in our region. After the identification of 12 main topics for discussion (indi-
cation, age, and sex; symptomatic and asymptomatic hernia: type of hernia;
type of treatment; hospital admission; preoperative care; anesthesia; surgical
technique; perioperative care; postoperative care; early complications; and
long-term complications), a search of the literature was carried out according
to the five levels of the Oxford Classification of Evidence and the four grades
of recommendation.

Introduction repair is the most common surgical procedure performed

worldwide. In countries such as the USA, China, and
Groin hernias are very common, and surgical treatment India, there may be as many as a million repairs every
is recommended for the majority of patients. Hernia year, with significant impact on the cost of health care

Asian J Endosc Surg 8 (2015) 16–23

16 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
D Lomanto et al. Inguinal hernia repair: Asian guidelines

Fig. 1. (a) Annual incidence of inguinal hernia in Asian countries. (b) Annual incidence of inguinal hernia in China and India. Data extrapolated based
on the assumption that hernia affects 15%–20% of the population.

Table 1 Prevalence of inguinal hernia by age group (1)

Age groups examined (years) 25–34 35–44 45–54 55–64 65–74 75 plus Total
Number of men examined 620 438 300 322 156 47 1883
Current prevalence (excluding successful repairs) 11.9% 15.1% 19.7% 26.1% 29.5% 34.1% 18.3%
Lifetime prevalence (including successful repairs) 15.2% 19.4% 28.0% 34.5% 39.7% 46.8% 24.3%

Table 2 Number and type of procedures for inguinal hernia repair in
Western countries
USA (2010)
Total inguinal hernia repair 842 000
Tension repair 41 000 (4.8%)
Tension-free repair 801 000 (95.2%)
Open 635 000 (80.3%)
Laparoscopic 207 000 (19.7%)
Source: Millennium Research Group. http://www.mrg.net
(Figure 1). There have not been many studies on the
incidence and prevalence of hernia, especially in devel-
oping countries. Scientific references show that preva-
lence increases with age, making hernia repair an
important socioeconomic problem that raises costs for
health-care providers, especially in aging societies
(Table 1) (1). Surgery is recommended for all groin
hernias not only to relieve symptoms but also to reduce
the risk of serious complications. In the USA and Europe,
the use of mesh material as reinforcement of the groin
region is very popular and is applied in up to 90% of
procedures (Table 2) (2,3). In contrast, in many develop-
ing countries, tissue-to-tissue repair is still the preferred
surgical procedure because of economic constraints; this
type of repair is used in the majority of total inguinal
hernia repairs.
Several randomized controlled trials have compared
surgical techniques using suture and mesh repair, open
and laparoscopic techniques, and techniques with and
without the use of prosthesis, and there is still a debate
Europe (2010) over the best treatment today (4). The randomized con-
703 000 trolled trials have indicated the superiority of a tension-
92 000 (13%) free mesh repair, performed either with the open method
611 000 (87%) or laparoscopically, over a tissue repair. However, meta-
491 000 (69.8%) analyses have shown that a tension-free repair using
120 000 (17%)
mesh must be performed routinely for it to have an
advantage over tissue repair. Regardless, modern
tension-free repair methods enable patients to return to
normal activity following surgery (5–7). Similarly, lapa-
roscopic surgery offers benefits in terms of early recovery,
but it requires an experienced surgeon to avoid compli-
cations and recurrences. The technique also costs more
than open methods for health services, and the proce-
dure takes longer (8,9). Controversy extends as well to
the best prosthetic material to implant, with debates over
the merits of polypropylene compared to polyester and
lightweight mesh.
For these reasons, the development and implementa-
tion of guidelines, a consensus, or recommendations may
clarify issues related to the best practice in inguinal
hernia repair. Under the auspices of the Asia Pacific
Hernia Society, a group of Asian surgeons, experts in the
repair of hernia, recently gathered to debate inguinal
hernia treatments in Asia in an attempt to reach some
consensus or develop recommendations on best practices
in the region. The need for recommendations and

Asian J Endosc Surg 8 (2015) 16–23

© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd. 17
Inguinal hernia repair: Asian guidelines
guidelines was unanimously confirmed because of the
discrepancy in clinical practice from country to country.
The experts decided to focus mainly on technical aspects
of open repair, which is the most common surgery for
hernia in our region.
Material and Methods
A brief questionnaire was sent by mail to collect initial
data and to ask about willingness to participate in devel-
oping guidelines. As a first step, the committee of experts
identified the objectives and topics for discussion. Then, a
search of the literature was carried out according to the
five levels of the Oxford Classification of Evidence and
the four grades of recommendation.
The 12 main topics for discussion were as follows: (i)
indication, age, and sex; (ii) symptomatic and asymptom-
atic hernia; (iii) type of hernia; (iv) type of treatment; (v)
hospital admission; (vi) preoperative care; (vii) anesthe-
sia; (viii) surgical technique; (ix) perioperative care; (x)
postoperative care; (xi) early complications; and (xii)
long-term complications.
The consensus meeting occurred in Singapore in April
2011, and a subsequent meeting was held in Hong Kong
in November 2013. The recommendations that follow,
which were the result of these meetings, do not contrast
or compete with the published European Hernia Society
guidelines on the treatment of inguinal hernia in adults
(10). Instead, these recommendations are meant to
reflect the socioeconomic situation and clinical practice
in the Asia–Pacific region.
Discussion, Results, and Recommendations
Indications, age, and sex
Adult hernia surgery should be performed as an elective
procedure to minimize surgical risk. There are no age
restrictions if a patient’s general condition do not affect
operative risk. Based on several studies, mesh repair
seems to have better long-term clinical outcomes, espe-
cially in terms of recurrence. There are no differences
with regard to gender, except that women seem to have
a higher reoperation rate due to high frequency of
femoral recurrence (11). Mesh should be used in adult
patients (10,12).
Conclusions (Level 2B–C)
Mesh should be used in patients age 18 years and older
(18–21 debated) if 60%–70% of natural growth has been
achieved. In cases where patients younger than 18 years
have very large defects, multiple recurrences, and weak
tissues, mesh should also be used. Synthetic is preferred
over biological mesh.
18 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
D Lomanto et al.
Recommendation (Grade B)
Mesh should be used in all adult patients. There is no
difference in treatment between men and women.
However when a femoral hernia is detected in a female
patient, the endo-laparoscopic approach is a better
option.
No consensus could be reached on the resection or
preservation of the round ligament because preservation
is sometimes difficult and resection can lead to pain and
risk of prolapse.
Symptomatic and asymptomatic hernia
Conclusions (Level 1B)
Watchful waiting may be an option for asymptomatic
patients, but this depends on a variety of factors, includ-
ing an individual’s lifestyle, socioeconomic background,
and access to health-care facilities (13–17). However, in
most patients, symptoms will progress and surgical repair
will be required eventually.
Conclusions (Level 4)
There was some debate about the definition of “asymp-
tomatic.” Hernia was defined by Sir Astley Cooper (1804)
as a protrusion of a viscus from its proper cavity (18).
Even if a patient is asymptomatic, there is a very real
chance that he or she will develop a symptomatic hernia
in the future. The committee agreed that if hernia is
present, even without discomfort or pain, and protrud-
ing, it requires treatment, although treatment need not
necessarily be immediate (Grade D).
If a hernia is discovered during concomitant surgery,
the local medico-legal regulations should be considered
before the hernia is addressed (Grade D).
Recommendation (Grade D)
Symptomatic hernia should be repaired.
We suggest that all symptomatic patients be treated.
Surgical treatment may be recommended for asymptom-
atic patients, as most will develop symptoms over time.
Type of hernia
Conclusions (Level 1B)
For primary unilateral hernia, tension-free mesh repair is
the treatment of choice. However, tissue/suture repair is
still widely used in many Asian countries, and depending
on a country’s socioeconomic conditions, it should be
considered as an option. Mesh repair is significantly
superior because of lower recurrence rate, but socioeco-
nomic aspects (e.g. cost, availability, and training) limit its
usage.
Asian J Endosc Surg 8 (2015) 16–23
D Lomanto et al.
Suture repair remains an acceptable option for indirect
hernias smaller than 2 cm, young patients, and when
surrounding tissue quality is good (19).
Conclusions (Level 1A)
For bilateral and recurrent hernias, tissue repair is not
suitable; the endo-laparoscopic approach is suggested.
For recurrent hernia with previous open suture repair, a
mesh repair is recommended. In cases of recurrent
hernia, the suggested approach depends on whether the
primary procedure is an anterior or posterior operation;
the hernia should be approached from the opposite site of
the previous surgical repair (5,20,21).
Recommendation (Grade A)
For bilateral and recurrent hernias, endo-laparoscopic
repair is suggested, but open anterior mesh repair is an
acceptable option.
Strangulated or obstructed hernia
For these complicated hernias, the open approach is sug-
gested. However, the laparoscopic approach may have
superior diagnostic value for conditions such as ischemic
bowel and serosal tear (21,22). In a grossly contaminated
surgical field, the use of mesh should be avoided.
Hernia classification
There are many classifications for inguinal hernia, but no
worldwide consensus exists on the use of classification
for clinical purposes (23–25). The classification is mainly
for scientific purposes (e.g. publications, studies, and
clinical outcomes). The European Hernia Society Classi-
fication may be preferred (26).
Recommendation (Grade D)
Clinical data should include all parameters to identify the
hernia (e.g. type, size, location, and presentation).
Hospital admission
Conclusions (Level 2A)
Hernia repair can mostly be done as an ambulatory
surgery except in selected patients (27–29).
Recommendation (Grade A)
For ASA I and II patients, hernia repair should generally
be performed as a day surgery, although this should be
assessed based on the type of anesthesia (30).
For ASA ≥ III patients, if surgery is performed under
local or general anesthesia, an overnight stay should be
required.
Asian J Endosc Surg 8 (2015) 16–23
© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Inguinal hernia repair: Asian guidelines
Preoperative care
Preoperative care should include the following: (i) the
positioning of a urinary catheter; (ii) antibiotic prophy-
laxis; and (iii) deep vein thrombosis prophylaxis.
Conclusions (Level 2B)
A urinary catheter is not required in most patients. Pre-
operative voiding is recommended.
Conclusions (Level 1B)
Routine antibiotic prophylaxis is not suggested except in
selected patients (31–36).
Recommendation (Grade B)
Routine antibiotic prophylaxis is not recommended.
Antibiotic prophylaxis may be suggested depending on
increased risk for infection.
Anesthesia
Conclusions (Level 1B)
Hernia repair can be performed with the patient under
general, regional, or local anesthesia (37). The choice of
anesthesia should be made according to the patient’s
choice, age, comorbidities, and operative risk. However,
in open repair, local anesthesia may be preferred.
Local anesthesia is the most cost-effective (38–42).
Recommendation (Grade B)
All types of anesthesia are valid and accepted options.
The choice of anesthesia depends on the patient’s
condition.
Surgical technique
Patient position: conclusions (Level 1B)
The supine position is recommended for all cases.
Type of incision: conclusions (Level 4)
The committee of experts suggests a lower lateral inci-
sion, about two fingers above and lateral to the pubis, to
allow direct access to the pubic area for fixation. An
adequate incision should be made; this may help reduce
the amount of pain because the retractors can stretch less
during the procedure.
Incision length depends on the patient’s body size and
hernia size. However, a 5–7-cm incision should be suffi-
cient with horizontal incision for a small hernia and with
oblique incision for a large hernia.
For an external oblique incision, a 6–7-cm medial inci-
sion should be made in the direction opposite to the
fibers in order to preserve a wider inguinal ligament.
19
Inguinal hernia repair: Asian guidelines D Lomanto et al.

There is no need to provide recommendations for space seem to improve the clinical outcome, but instead seems
dissection. to increase the risk for postoperative pain (45,46).
Sealant or glue may be considered for fixation (47–49).
Nerve identification The fixation of flat mesh should be over the pubic
tubercle with 1–2-cm overlap. Non-absorbable sutures
Conclusions (Level 2A)
should be used. For lateral fixation, either a running or
The dissection of the ilio-hypogastric nerve may be nec-
interrupted suture is suggested. If the mesh is slit around
essary to gain elasticity on the spermatic cord.
the spermatic cord, it should be closed adequately around
it to avoid recurrence and/or ischemia of the testicular
Recommendation (Grade B)
vessels (50,51).
The identification and isolation of the nerves are not
If posterior repair is performed, the mesh should be
strictly required. However, it is necessary to identify the
fixed using either sutures or sealant.
genital branch of ilio-inguinal and ilio-hypogastric nerve,
If self-gripping mesh is applied, a simple fixation over
but isolating the nerves are not required.
the pubic tubercle is required without lateral fixation.
This may reduce the risk of postoperative pain (52,53).
Hernia sac management
Conclusions (Level 2A) Recommendation (Grade B)
The transection of the hernia sac may increase postop- Mesh should be fixed, and the slit closed around the
erative pain. spermatic cord to avoid ischemia.
Self-gripping mesh should be fixed only to the pubic
Recommendation (Grade B) tubercle.
There is no need for transection except in cases of com- Either glue or sealant is an acceptable choice for
plicated hernias. fixation.

Mesh size Cord positioning

Conclusions (Level 1B) Conclusions (Level 4)

Depending on the size of the defect, the mesh should The cord should be preferably positioned under the
allow for a large coverage and overlap the pubic bone by external oblique aponeurosis.
at least 1–2 cm.
Recommendation (Grade D)
In open repair, the size of the mesh should adequately
No recommendation
cover the hernia defects and overlap the surrounding
area by more than 3 cm in all directions. Management of the round ligament
It is recommended that a minimum of 8 × 12-cm cov-
Conclusions (Level 2A)
erage be used for anterior repair and 10 × 15 cm for pos-
No consensus could be reached on the resection or pres-
terior repair.
ervation of the round ligament. Preservation is not fea-
sible most of the time, and resection may increase
Mesh type
postoperative pain and the risk of prolapse.
Conclusions (Level 1B)
A synthetic mesh is preferred over biological or Recommendation (Grade D)
semisynthetic prosthesis (43,44). No recommendation
There is no evidence regarding the superiority of light-
weight or heavyweight mesh in relation to pain or recur- Fascia closure/skin closure
rence (44). Recommendation (Grade D)
No recommendation
Recommendation (Grade A)
The use of a synthetic mesh with large pores is recom- Perioperative care
mended to reduce the shrinkage rate (43,44). Postoperative pain control is an essential aspect of
perioperative care.
Mesh fixation
Conclusions (Level 2B)
Conclusions (Level 2A)
In an anterior repair, the mesh should be fixed over the Pre-emptive local analgesia may be helpful for reducing
pubic tubercle. Lateral fixation of the mesh does not immediate postoperative pain, and non-steroidal

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D Lomanto et al.
anti-inflammatory drugs are optimal for pain control
during early recovery. In case of severe pain, opioids may
be considered (54).
Recommendation (Grade D)
Non-steroidal anti-inflammatory drugs or
cyclooxygenase-2 and paracetamol (acetaminophen) are
recommended for postoperative pain control (55).
Postoperative care
Conclusions (Level 2B)
It is suggested that patients have an early return to
normal activities (e.g. walking, driving, and light duties)
(28,56–58).
It is also recommended that patients avoid heavy
lifting (i.e. more than 5 kg) for at least 2–3 weeks post-
operatively. They may resume heavy lifting after 4
weeks.
Recommendation (Grade D)
Patients may resume normal activities a few days after
surgery. However, they should wait 3–4 weeks to resume
participation in intensive sports.
Early complications
Possible postoperative complications include wound
infection or hematoma, scrotal hematoma, seroma, and
orchitis (59–62).
Draining a seroma may increase risks of infection (63).
If a seroma persists for 3–4 weeks, aspiration may be
performed under aseptic conditions. In cases of recurrent
hernia, patients should be informed of the increased risk
of injury to the vas deferens and vessels structures (i.e.
spermatic cord injury) and consent before any procedure
is performed (25).
The risk of mesh infection is increased as a result of
long operating time. Also, proper mesh handling is rec-
ommended to avoid contamination. Meticulous tissue
handling must be ensured to avoid hematoma formation
In case of mesh infection, the following steps should be
taken as needed:
• adequate drainage and culture
• targeted antibiotic therapy
• staged repair
• mesh removal if necessary.
Long-term complications
Possible long-term complications include:
• recurrences, the overall rate of which is 3%–15% (3%
is achievable in specialized centers) (4,6,19,60,64)
Asian J Endosc Surg 8 (2015) 16–23
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Inguinal hernia repair: Asian guidelines
• chronic pain, which may be very subjective and related
to social and/or psychological influences (50,51,62,65–
71)
• infertility
• sexual dysfunction
• testicular atrophy.
There are several causes and risk factors for patients to
develop long-term complications, and these may lead to
a higher risk for recurrent hernia. Risk factors include the
presence of preoperative chronic pain and early sexual
activity in women, as women are more sensitive to pain.
Mesh repair is superior to tissue repair in terms of pre-
venting chronic pain, but there is no consensus on the
potential influence of mesh material. Nerve identification
during the procedure may reduce the occurrence of post-
operative pain. A patient’s age does not appear to be a
risk factor.
Treatment for long-term complications should start as
early as possible after diagnosis. Nerve block may be
considered initially for pain relief. Surgical exploration
(e.g. triple neurectomy) may be considered after failure
of less invasive options. A multidisciplinary approach
with a pain team is also an option.
Acknowledgments
We are grateful to Dr Dino Halim Liem for his generous
support and coordination in drafting the final paper.
The authors have no conflicts of interest to declare and
received no financial support for this paper.
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