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Overviewoftreatmentforinguinalandfemoralherniainadults
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Overviewoftreatmentforinguinalandfemoralherniainadults
Author
DavidCBrooks,MD

SectionEditor
MichaelRosen,MD

DeputyEditor
WenliangChen,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:May03,2016.
INTRODUCTIONThedefinitivetreatmentofallhernias,regardlessoforiginortype,issurgicalrepair[1].Groin
herniarepairisoneofthemostcommonlyperformedoperations.Over20millioninguinalorfemoralherniasare
repairedeveryyearworldwide[2],includingover700,000intheUnitedStates[3].
Aninguinalorfemoralherniarepairisperformedurgentlyinpatientswhodevelopcomplicationssuchasincarceration
orstrangulation.Forpatientswithoutacomplication,theoptimaltimingofrepair(watchfulwaitingversusearlyrepair)
andtheoptimalsurgicaltechnique(openversuslaparoscopic)arecontroversialandarethefocusofthistopic.
Theclinicalfeaturesanddiagnosisofaninguinalorfemoralhernia,thetechnicaldetailsofperforminganinguinalor
femoralherniarepair,thecomplicationsofherniarepair,andthetreatmentofrecurrentherniasarediscussed
separatelyinothertopics.(See"Classification,clinicalfeaturesanddiagnosisofinguinalandfemoralherniasinadults"
and"Opensurgicalrepairofinguinalandfemoralherniainadults"and"Laparoscopicinguinalandfemoralherniarepair
inadults"and"Overviewofcomplicationsofinguinalandfemoralherniarepair"and"Recurrentinguinalandfemoral
hernia".)
INDICATIONSFORSURGICALREPAIRTherewasatimewhenthemerepresenceofagroinherniawasa
sufficientindicationforsurgicalrepair.Contemporarypractice,however,triagespatientstosurgeryversuswatchful
waitingaccordingtotheseverityofsymptoms,sex,andthetypeofhernia(inguinalversusfemoral).
ComplicatedherniaPatientswhodevelopstrangulationorbowelobstructionshouldundergourgentsurgicalrepair.
Surgeryperformedwithinfourtosixhoursfromtheonsetofsymptomsmaypreventbowellossduetooneofthese
complications.
Patientswithanacutelyincarceratedinguinalherniabutwithoutsignsofstrangulation(eg,skinchanges,peritonitis)
shouldbeofferedurgentsurgicalrepair.However,herniareductioncanbeattemptedinpatientswhowishtodelay
surgery.Ifherniareductionissuccessful,thepatientshouldfollowupwiththeirsurgeonwithinonetotwodaysto
excluderecurrentincarcerationandarrangeforelectiverepair.Thosewhofailherniareductionshouldproceedurgently
tosurgery.
Theclinicalmanifestationsanddiagnosisofincarcerated/strangulatedinguinalorfemoralherniascanbefound
elsewhere.(See"Classification,clinicalfeaturesanddiagnosisofinguinalandfemoralherniasinadults".)
UncomplicatedherniasInpatientswithuncomplicatedinguinalorfemoralhernias,surgicalrepairisintendedto
relievesymptomsandtopreventfuturecomplications.Theindicationsforsurgicalrepairofuncomplicatedherniasare
lessrigidthancomplicatedhernias,anddependuponthetypeofhernias(inguinalversusfemoral)involved,the
severityofsymptoms,patientsex,andpatientpreference.Inselectpatients,watchfulwaitingisanalternativeto
surgery.(See'Asymptomatichernia'below.)
FemoralherniaForallpatientswithanewlydiagnosedfemoralhernia,wesuggestelectivesurgicalrepair,
ratherthanwatchfulwaiting,regardlessofthepatientssexandsymptoms.Femoralherniasareassociatedwithahigh
riskofcomplicationsandthereforeurgentsurgicalrepair.
Femoralherniasareassociatedwithahigherriskofdevelopingcomplicationsthaninguinalhernias.Inonestudy,the
ratesofstrangulationwere22and45percentat3and21months,respectively,forfemoralhernias,comparedwith2.8
and4.5percentforinguinalhernias[4].
Thus,earlyelectiverepairisadvisedforpatientswithanewlydiagnosedfemoralherniatoavoidcomplicationsthat
maynecessitateurgentsurgery.Urgentsurgeryforcomplicatedherniasismorelikelytoinvolvebowelresection,
whichisassociatedwithahighermortalityrate.Inonestudy,forexample,bowelresectionwasrequiredin23percent
ofurgent,comparedwith0.6percentofelectivefemoralherniarepairs,andurgentfemoralherniarepairswere
associatedwitha10foldincreaseinmortality[5].
Forpatientswhohavealongstanding(>3months)femoralherniathatisasymptomatic,surgeryispreferredbut
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observationisareasonableoption.
InguinalherniaForfemalepatientswithanewlydiagnosedinguinalhernia,wesuggestelectivesurgicalrepair,
ratherthanwatchfulwaiting,regardlessofsymptoms.Formalepatients,thedecisionisindividualizeddependingupon
thepatientssymptomsandpreference.
FemalepatientsFemalepatientswithaninguinalherniahaveahigherriskofdevelopingcomplicationsthan
malepatients[6].Thus,femalepatientsshouldundergoinguinalherniorrhaphyonceadiagnosisisestablished
regardlessofsymptoms,ratherthanwatchfulwaiting.
MalepatientsFormalepatientswithmoderatetoseveresymptomsfromaninguinalhernia,surgicalrepairis
indicated.Inaddition,surgeryisindicatedformenwithminimalornosymptomsiftheyhavescrotalorrecurrent
hernias,oriftheyareolderthan70years.However,forothermalepatientswithminimalornosymptomsfroman
inguinalhernia,watchfulwaitinguntilsignificantsymptomsdevelopisanoption.
Theonlynonsurgicaltherapyforgroinherniainmenisatruss.Atrussisastrapsimilartoanathleticsupporterwitha
metalorhardplasticplugpositionedtolieovertheherniadefect.Whenappliedappropriately,theharddiscorplug
exertspressuretokeeptheherniacontentsintheabdomen.Althoughtheuseofatrussmaybehelpfulincertain
situations,wegenerallydiscouragetheirusebecausethereisinsufficientevidencetoprovetheirefficacy[7,8].In
addition,inappropriateuseofatrussmayharmabdominalcontentsinaherniasacorcomplicatesubsequentsurgical
repair[9].
SymptomaticherniaMalepatientswithsignificantsymptomsattributabletoaninguinalherniashould
undergoelectivesurgicalrepair[1].Typicalsymptomsinclude:
Groinpainwithexertion(eg,lifting)
Inabilitytoperformdailyactivitiesduetopainordiscomfortfromthehernia
Inabilitytomanuallyreducethehernia(ie,chronicincarceration)
AsymptomaticherniaFormalepatientswithminimalornosymptomsfromaninguinalhernia,we
suggestelectiveherniarepair.However,thosewhowishtoavoidsurgerycanbemanagedwithwatchfulwaiting,
providedthattheyarecounseledoftherisksofdevelopingherniacomplications(eg,incarceration,strangulation,or
bowelobstruction).Patientswhochoosenottohaveherniarepairshouldrefrainfromheavyliftingandunderstandthe
needforpromptmedicalattentionshouldsymptomsdeveloporcomplicationsoccur.
Historically,groinherniaswererepairedoncedetected,undertheassumptionthatcomplicationsfromunrepaired
herniaswerecommonandcouldincreaseoperativemorbidity.Randomizedtrialscomparingwatchfulwaitingwith
surgicalrepairofinguinalhernias,however,demonstratedthatdelayingsurgicalrepairinasymptomaticpatientswas
safe,asacutecomplicationsrarelyoccurred.However,formostpatients,surgicalrepairwasrequiredeventually
becausesymptomsgraduallyincreasedovertime.
Thelargesttrial(theWWtrial)randomlyassigned720menwithanuncomplicatedinguinalherniatowatchfulwaitingor
opensurgicalrepair[10,11].Thepatients,whoweremenmostlybetweentheagesof40and65,wereasymptomatic
orminimallysymptomatic,andtheherniasremainedeasilyreduciblewithinsixweeksoftheinitialscreening.The
followingresultswerereported:
Attwoyears,similarnumbersofpatientsineachgroupreportedpainsufficienttolimitactivities(5.1with
watchfulwaitingversus2.1percentwithsurgery).Although23and31percentofpatientsinthewatchfulwaiting
grouprequiredsurgeryattwoandfouryears,respectively,onlytwopatientsrequiredurgentsurgeryduetoacute
complications,atarateof0.0018eventsperpatientyear[10].
Afteranadditionalsevenyearsoffollowup,atotalof68percentofmeninthewatchfulwaitinggrouphad
surgery,mostcommonlyforpain(54percent).Menolderthan65yearsweremorelikelytorequiresurgerythan
youngermen(79versus62percent).However,onlyoneadditionalpatientrequiredurgentsurgery[11].
Asubsequenttrialof160menalsofoundnodifferencesineithertherateofherniacomplicationsorpainscores
betweenthesurgeryandwatchfulwaitinggroups[12].However,atsixandtwelvemonths,patientsinthesurgery
groupreportedimprovementintheirgeneralhealth,whereaspatientsinthewatchfulwaitinggroupreportedadecline.
At15months,26percentofmeninthewatchfulwaitinggrouprequiredsurgery,includingthreeurgentoperations.
Mostlargetrialsonlyenrolledmiddleagedmenwithprimary(ratherthanrecurrent)hernias.Thus,datafromsuchtrials
maynotbeapplicabletootherpatientgroups.Asexamples:
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Menolderthan70yearsaremorelikelytorequireurgentsurgeryfortheiringuinalhernias,andthereforewould
benefitfromearlyelectivesurgicalrepair[13,14].
Patientswithaninguinalherniawithascrotalextensionorarecurrentinguinalherniaaremorelikelytorequire
urgentsurgeryandthereforeshouldbeofferedearlyelectivesurgery.Inaretrospectivereviewof1034
consecutivepatientswithagroinhernia,thosewithascrotalhernia(32.4versus16.2percent)orrecurrenthernia
(30.9versus16.7percent)weresignificantlymorelikelytorequireurgentrepairthanothers[13].
CONTRAINDICATIONSTOSURGICALREPAIRInguinalorfemoralherniarepaircanbeperformedwithminimal
morbidityandmortalityinalmostallpatients,includingthosewhoareolderand/orhavemedicalcomorbidities(eg,
advancedliverdisease[15,16])mostpatientsenjoyarapidrecoverytopresurgicalhealthshortlyaftersurgery.Thus,
thereisnocontraindicationtourgentrepairofcomplicatedhernias.However,pregnantwomenshouldnothaveelective
repairofaninguinalorfemoralherniauntilatleastfourweeksafterdelivery.
Forpatientswhocannottolerategeneralanesthesia,inguinalorfemoralherniascanberepairedunderlocalanesthesia.
Forpatientswithanactivegroininfectionorsystemicsepsis,meshplacementiscontraindicated,butgroinhernias
canberepairedusingnonmeshtechniqueswhennecessary.(See"Woundinfectionfollowingrepairofabdominalwall
hernia".)
PregnancyTheprevalenceofinguinalherniasduringpregnancyislowandestimatedtobe1:2000[17].Elective
repairofagroinherniaduringpregnancyisgenerallycontraindicated.Expectantmanagementduringtheperipartum
periodhasbeenassociatedwithfewseriousherniarelatedcomplications.Inonestudy,sevenwomenwithgroin
herniasweremanagednonoperatively,andeachhadtheirherniasrepairedafterdelivery[18].Althoughcombined
cesareandeliveryandherniarepairhavebeenreported[17,19],electiveherniarepairshouldgenerallybedeferredforat
leastfourweekspostpartumtoallowthelaxabdominalwalltoreturntoitsbaseline.
Urgentherniarepairduringpregnancymayberequiredifthepatientdevelopsseverediscomfortoroneofthe
complications,suchasacuteincarceration,strangulation,orbowelobstruction.Inonestudy,suchcomplicationswere
rareandonlyaccountedfor<5percentofintestinalobstructionsobservedduringpregnancy[20].
CHOOSINGASURGICALAPPROACHWhileallsurgeonsperformopengroinherniarepairs,somealsoperform
laparoscopicrepairs.Ingeneral,surgeonsshouldchoosetheapproachwithwhichtheyaremostcomfortableandmost
experienced.Forsurgeonswhoareequallyfacilewithbothrepairs,thechoiceofasurgicalapproachdependsupon
herniaandpatientcharacteristics.Theprocessdescribedbelowandoutlinedintheaccompanyingalgorithmreflects
theauthorspreferenceandshouldnotberegardedastheonlyapproach(algorithm1).
PatientsprecludedfromlaparoscopicrepairWhileopenrepairofaninguinalorfemoralherniaisfeasiblein
almostallpatients,laparoscopicrepaircannotbesafelyperformedincertainpatientsduetopatientortechnical
reasons.
PatientswithpriorsurgeryinvolvingthepreperitonealspaceLaparoscopicrepair,especiallywiththetotally
extraperitoneal(TEP)technique,requiresthedevelopmentandmaintenanceofthepreperitonealspace.Adhesions
formedafterprevioussurgery,incision,ormeshplacementcouldrenderthatspaceinaccessible.
Thus,weperformanopenherniarepairforpatientswhohavehadoneormoreprevioussurgeriesinvolvingthe
preperitonealspace(eg,prostatectomy,hysterectomy,cesareansection,orlaparotomyvialowermidlineincision).
Althoughlaparoscopicsurgeryisfeasibleinsuchpatients(especiallywiththetransabdominalpreperitonealpatch
[TAPP]technique),itistechnicallychallenging,requiresalongeroperativetime,andisassociatedmorecomplications
thanopensurgeryinsuchpatients[21,22].
PatientswithcomplicatedherniaWerepairallincarceratedorstrangulatedgroinherniaswithanopen
approachtominimizetheriskofbowelinjury.Alaparoscopicapproachistheoreticallypossiblebutdifficulttoperform
[2325].
Furthermore,incaseswherebowelperforationhasoccurredduetobowelischemiaornecrosis,theplacementofmesh
iscontraindicated,therebyprecludingalaparoscopicrepair.Openrepaircanbeperformedwithorwithoutmesh,and
thereforeisthepreferredtreatmentforcomplicatedherniasinwhichtheriskofactiveinfectionorcontamination(from
perforation)ishigh.(See'Opentechniques'belowand"Woundinfectionfollowingrepairofabdominalwallhernia".)
Wealsoprefertorepairlargescrotalhernias(>3cm)withanopenapproachbecauseofthetechnicaldifficulty
associatedwithmanagingandreducingalargeherniasaclaparoscopically[26].
PatientswithascitesInpatientswithascites,wepreferanopenapproachtolaparoscopicapproaches.In
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particular,thelaparoscopicTAPPapproach(whichistransperitoneal)shouldbeavoided.Priortosurgery,ascites
shouldbeminimizedasmuchaspossiblewithmedicaltreatment.Atthetimeofsurgery,theherniasacshouldbeleft
intacttoavoidcomplicationssuchaspersistentleakageofasciticfluid.(See"Opensurgicalrepairofinguinaland
femoralherniainadults"and"Laparoscopicinguinalandfemoralherniarepairinadults".)
PatientseligibleforbothopenandlaparoscopicrepairPatientswhodonothaveahistoryofpriorpreperitoneal
surgery,ascites,oracomplicatedherniaareeligibleforbothopenandlaparoscopicrepairsofagroinhernia.The
choiceofthesurgicalprocedurethendependsuponwhethertheherniaisprimaryorrecurrent,unilateralorbilateral,
andfemoraloringuinal.
PrimaryherniaAprimary,unilateralinguinalherniacanberepairedopenorlaparoscopicallybasedupon
surgeonandpatientpreference.Aprimary,unilateralfemoralhernia,andallbilateralhernias(bothinguinaland
femoral),shouldberepairedlaparoscopically.
Unilateralhernia
InguinalherniaThereisnoconsensusastowhethertheoptimalapproachtoinguinalherniarepairis
openorlaparoscopic[2729].Somesurgeonsprefertorepairaprimary,unilateralinguinalherniawithanopen
technique,whileotherspreferalaparoscopicapproach.(See'Opentensionfreemeshrepairs'below.)
Openandlaparoscopicapproacheshavebeendirectlycomparedmostoftenininguinalherniarepairs.Ingeneral,
laparoscopicrepairhasbeenassociatedwithlesspostoperativepainandquickerrecovery,butlongeroperativetime
andhigherrecurrencerates[24,3042].Laparoscopicrepaircouldalsoresultinseriouscomplications(eg,massive
pelvicbleeding)thatwouldrarelyoccurduringopenrepairs.
Thelargesttrialrandomlyassigned1983menwithinguinalherniastoreceiveopenorlaparoscopicmeshrepairat1of
14UnitedStatesveteransaffairsmedicalcenters[43].Patientstreatedlaparoscopicallyhadlesspainonthedayof
surgeryandattwoweeks,andreturnedtoworkonedayearlier.However,theysufferedmorepostoperative
complications(39versus33.4percent),lifethreateningcomplications(1.1versus0.1percent),andherniarecurrences
(10.1versus4.9percentattwoyears).Insubgroupanalysis,thedifferenceinrecurrenceratewassignificantfor
primary(10.1versus4percent),butnotrecurrenthernias(10versus14percent).Thistrialhasbeencriticizedfor
higherthanaverageratesofrecurrencesinbothgroupsduetosurgeoninexperience,aswellasforapatientpopulation
thatisolder(averageage58)andlesshealthy(only34percentwereAmericanSocietyofAnesthesiologistsclassI)
thantheaveragepatientwhoneedsinguinalherniarepair.
Asubsequenttrialrandomlyassigned389patientswithaprimaryunilateralinguinalherniatoreceiveeitheropen
Lichtensteinrepairunderlocalanesthesiaorlaparoscopictotalextraperitoneal(TEP)repairundergeneralanesthesia
[44].Fewerpatientsinthelaparoscopicgroupreportedhavingpersistentgroinpainatoneyear(21versus33percent).
However,thisdifferencemaynotbeclinicallyrelevant,asmostpatientsreportedmildpain(describedascanbe
easilyignoredonthequestionnaire)onlyafewpatientsineachgroup(2percentinthelaparoscopicversus3percent
inopengroup)reportedseverepain.Inaddition,fewerpatientsinthelaparoscopicgroupreportedhavinggroinpainthat
limitedtheirabilitytoperformphysicalexercise(3versus8percent).Therecurrenceratesatoneyearweresimilarly
lowinbothgroups(1percentlaparoscopicversus2percentopen).
FemoralherniaWeprefertorepairafemoralhernialaparoscopicallybecauseofitseaseofaccess.
Anteriorfemoralherniarepairsrequireabreachoftheinguinalcanaltogainaccesstothefemoralherniaposteriorly
posteriorrepairshavedirectaccesstothefemoralherniawithoutgoingthroughtheinguinalcanal.Inonestudy,
posteriorrepairoffemoralherniaswasassociatedwithalowerrecurrenceratethananteriorrepair[5].Posteriorrepairs
aremostlydonelaparoscopically,astheonlyopenposteriorrepair(Kugel)israrelyperformed.
Inaddition,laparoscopicfemoralherniarepairisalsobetteratidentifyingocculthernias[45].Inonestudyof250men
undergoinglaparoscopicrepairofpresumedinguinalhernias,femoralherniasweredetectedinadditionalto(29)orin
lieuof(4)inguinalherniasin33patients(13.2percent)[46].Ofthe33patientswithafemoralhernia,61percenthad
undergoneapreviousopeninguinalherniarepair,reflectingeitherthefailuretorecognizeaconcomitantfemoralhernia
duringtheirinitialopensurgery,ortheintervaldevelopmentofafemoralhernia.
BilateralherniasWeprefertorepairbilateralgroinherniaslaparoscopicallybecause:
Bothherniascanberepairedthroughthesameincisions,whichimprovescosmesis.
AsinglelargepieceofmeshcanbeusedwithalaparoscopicTEPrepair,reducingcostsandpotentiallytherisk
ofdirectherniarecurrencemedially[47].

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Alaparoscopicapproachpermitsexplorationofthecontralateralgroininpatientswithsymptomssuggestivebut
notdiagnosticofacontralateralhernia[48].
Threerandomizedtrialshaveindependentlyconcludedthatlaparoscopiccomparedwithopenrepairofbilateralinguinal
herniascausedlesspostoperativepain,fasterrecovery,andsimilarratesofrecurrence[4951].TheNationalInstitute
forHealthandClinicalExcellence(NICE)intheUnitedKingdomadvocateslaparoscopicrepairforpatientswith
bilateralhernias[52].
Whenlaparoscopicrepairisnotavailable,thealternativeforpatientswithbilateralherniasisbilateralopentensionfree
meshrepair,whichcanbeperformedasasingleoperation,ratherthantwoseparateprocedures[53].
RecurrentherniaWeprefertorepairarecurrentgroinherniawithalaparoscopicapproachiftheinitialrepair
wasopen,butwithanopenapproachiftheinitialrepairwaslaparoscopic.Therationaleisthatrecurrentherniarepair
isoptimalifperformedinapreviouslyundissectedtissueplane.
PatientswithprioropenrepairManysurgeonsfeelthatrecurrenthernias,particularlythosethatrecurafter
ananteriormeshrepair,arebestaddressedviaalaparoscopictechnique[32,36].Aswithprimaryrepairs,a
laparoscopicrepairofrecurrentherniaswasalsoassociatedwithfasterrecovery,lesspostoperativepain,andfewer
complications[36,51,5456].TheNationalInstituteforHealthandClinicalExcellence(NICE)intheUnitedKingdom
alsoadvocateslaparoscopicrepairforrecurrenthernias[52].
PatientswithpriorlaparoscopicrepairAnopenrepairisrequiredforpatientswitharecurrentherniaifthey
havehadapreviouslaparoscopicherniarepair(usuallywithmeshplacement)orothersurgeriesinvolvingthe
preperitonealspace(eg,prostatectomy,hysterectomy,cesareansection,orlaparotomyvialowermidlineincision).In
suchpatients,thepreperitonealspacemaybedifficulttoaccess.(See'Patientswithpriorsurgeryinvolvingthe
preperitonealspace'above.)
Specialconsiderations
CosteffectivenessStudieshavegenerallyfoundanoverallcostbenefitforopen,asopposedtolaparoscopic,
herniarepair[5761].Factorsconsideredinsuchstudiesincludedthecostofoperatingroomtimeandequipment
(especiallysingleuseitems),lengthofhospitalstay,andthecostoftreatingpotentialcomplications.Variationsinone
ormoreofthesefactors(eg,byusingreusableequipment)couldmakelaparoscopicsurgerymorecosteffective[57].
FemalepatientsGroinherniasareuncommoninfemaleslessthan8percentofherniarepairsareperformedin
women[5,6,62,63].Comparedwithmen,womenaremorelikelytohavefemoralhernias,complicatedhernias
(incarcerationorstrangulation),orrecurrenthernias[6].(See"Classification,clinicalfeaturesanddiagnosisofinguinal
andfemoralherniasinadults",sectionon'Epidemiology'and"Classification,clinicalfeaturesanddiagnosisofinguinal
andfemoralherniasinadults",sectionon'Femoralhernia'.)
Allwomenwithanewlydiagnosedgroinherniawhoarenotpregnantshouldundergoearlysurgicalrepairofthehernia.
Forwomenwhohavehadapriorsurgeryinvolvingthepreperitonealspace(eg,cesareansectionorhysterectomy),an
openanteriormeshrepairisthebestoption.Inothers,alaparoscopicapproachispreferredbecauseitallows
identificationandrepairofocculthernias(especiallyfemoralhernias).
SURGICALTECHNIQUESSpecifictechniquesofinguinalorfemoralherniarepairarebrieflydiscussedbelow.
Detailedinformationcanbefoundinothertopics.(See"Opensurgicalrepairofinguinalandfemoralherniainadults"
and"Laparoscopicinguinalandfemoralherniarepairinadults".)
OpentechniquesOpentechniquesapproachtheherniadefectanteriorly,andincludetensionfreemeshrepairsas
wellasprimarytissueapproximationnonmeshrepairs.Forpatientsinwhommeshplacementisnotcontraindicated,
werecommendusingameshrepairtechniquetoachieveatensionfreerepairratherthananonmeshrepairtechnique.
Nonmeshrepairtechniquesmayberequiredforpatientswithactivegroininfectionorcontamination(eg,asaresultof
bowelperforationfromastrangulatedhernia).
OpentensionfreemeshrepairsSuccessfulherniarepairdependsuponatensionfreeclosure,whichis
typicallyachievedwithplacementofamesh.Multiplestudieshavedemonstratedthattensionfreemeshrepairof
inguinalherniasreducespostoperativegroinpain,expeditesrecovery,andreducesrecurrencerate[1,2,26,6467].
Thus,thetensionfreemeshtechniquesaremostwidelyusedandendorsedbyvariousherniasocieties[1,27,28].
TensionfreerepairsthatusemeshincludeLichtenstein(ourpreferredmethodofopenrepair),plugandpatch,and
Kugel(preperitonealrepair).(See"Opensurgicalrepairofinguinalandfemoralherniainadults",sectionon'Mesh
versusnonmeshrepair'and"Opensurgicalrepairofinguinalandfemoralherniainadults",sectionon'Herniarepair
techniques'.)
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OpenprimarytissueapproximationnonmeshrepairsShouldice,Bassini,andMcVayrepairsareopen
techniquesthatachieveprimarytissueapproximationwithouttheuseofmesh[66,6872].AlthoughtheShouldice
repairdoesnotincorporatemesh,someregarditasatensionfreetechnique.Nonmeshrepairtechniquesareprimarily
usedwhenmeshplacementiscontraindicated,suchaswhenthereisactiveinfectionorcontaminationofthegroin,or
whentheuseofameshiscostprohibitive(eg,inresourcelimitedsettings).(See"Opensurgicalrepairofinguinaland
femoralherniainadults",sectionon'Herniarepairtechniques'.)
LaparoscopictechniquesLaparoscopicrepairsapproachtheherniadefectposteriorly.Thetwomaintechniques
aretotallyextraperitoneal(TEP)repairandtransabdominalpreperitonealpatch(TAPP)repair,bothofwhichrequirethe
useofmeshandareconsideredtensionfreerepairs[73].(See"Laparoscopicinguinalandfemoralherniarepairin
adults",sectionon'Laparoscopicrepairapproaches'.)
PREOPERATIVEPREPARATIONInguinalandfemoralherniascanusuallyberepairedwithminimalmorbidityand
mortality.Weusethefollowingpreoperativeroutinetooptimizepatientoutcomesandexperience.
ConfirmpresenceandlocationofherniaThediagnosisofaninguinalorfemoralherniaisclinicalformost
patients.Immediatelypriortosurgery,thepatientshouldbereexaminedtoconfirmthepresenceofaherniaandmark
itslaterality.(See"Classification,clinicalfeaturesanddiagnosisofinguinalandfemoralherniasinadults".)
ObtaininformedconsentTherisksandbenefitsofherniarepairversuswatchfulwaiting,includingpotential
complicationsofeachapproach,shouldbereviewedwiththepatient.Ifsurgicalrepairiselected,therisksandbenefits
ofanopenversuslaparoscopicapproachshouldalsobediscussedwiththepatient.(See'Choosingasurgical
approach'above.)
MedicalriskassessmentMuchofthepreoperativemedicalevaluationisdirectedtowardensuringthatthepatient
cantolerateanesthesia,especiallyifgeneralanesthesiaisplanned.(See"Preoperativemedicalevaluationoftheadult
healthypatient"and"Evaluationofcardiacriskpriortononcardiacsurgery"and"Evaluationofpreoperativepulmonary
risk"and"Perioperativemanagementofbloodglucoseinadultswithdiabetesmellitus".)
TreatherniacomplicationsifpresentPatientswithcomplicatedherniasshouldreceivecomplicationspecific
treatmentpriortoherniarepair.Asexamples,patientswithbowelobstructionrequirefluidresuscitationandnasogastric
decompressionpatientswithbowelischemiaorperforationrequireantimicrobialcoverage.(See"Overviewof
managementofmechanicalsmallbowelobstructioninadults"and"Overviewofgastrointestinaltractperforation",
sectionon'Initialmanagement'.)
PreoperativeprophylaxisMostinguinalandfemoralherniarepairsareelectiveproceduresperformedinan
outpatientsetting.Thromboprophylaxisand/orprophylacticantibioticsmayberequiredinselectedpatientstoprevent
complicationssuchasvenousthromboembolism(VTE)orsurgicalsiteinfection(SSI).
ThromboprophylaxisThromboprophylaxisisadministeredaccordingtothepatientsrisksofdevelopingVTE
perioperatively(table1).Patientswhoareyoung(<40yearsofage),otherwisehealthy,andhavenootherriskfactors
forVTEdonotrequirepharmacologicthromboprophylaxis.Mechanicalthromboprophylaxismaybeappliedtopatients
undergoinggeneralanesthesia,oratthesurgeonsdiscretion.(See"Preventionofvenousthromboembolicdiseasein
surgicalpatients".)
AntibioticsForpatientsundergoinguncomplicatedinguinalorfemoralherniarepairwithplannedmesh
placement,werecommendadministeringprophylacticantibioticsratherthannoantibiotics.Patientswithcomplicated
herniasrequirebroaderantimicrobialcoveragethanprophylacticantibiotics.Forpatientsundergoinguncomplicated
inguinalorfemoralherniarepairwithoutplannedmeshplacement,prophylacticantibioticsmaybeomittedbasedupon
surgeonpreference.
Theroleofprophylacticantibioticsgivenpriortoinguinalorfemoralherniarepairremainscontroversial[7479].
Uncomplicatedherniasurgeryisconsideredcleansurgery,forwhichprophylacticantibioticsarenotindicated.Some
surgeons,however,prefertoadministerantibioticstopatientsundergoinghernioplasty(ie,herniarepairwithmesh)to
preventpotentialmeshinfection[79,80].OthersomitroutineprophylacticantibioticsbecausetheriskofSSIaftergroin
herniasurgeryislow,andmostSSIsthatoccuraresuperficialandcanbeeasilytreatedwithoralantibiotics.(See
"Overviewofcomplicationsofinguinalandfemoralherniarepair",sectionon'Superficialwoundinfection'.)
A2012Cochranereviewof17randomizedtrialsdemonstratedalowerrateofSSIinpatientswhoreceived,compared
withthosewhodidnotreceive,prophylacticantibiotics(3.1versus4.5percent,oddsratio0.64,95%CI0.500.82)
[80].Insubgroupanalyses,however,thedifferencewassmallerinpatientswithoutmeshplacement(3.5versus4.9
percent,oddsratio0.71,95%CI0.511.00)thaninthosewithmeshplacement(2.4versus4.2percent,oddsratio
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0.56,95%CI0.380.81).
Prophylacticantibioticsshouldcovertheusualskinflora,includingaerobicgrampositiveorganisms,aerobic
streptococci,staphylococci,andenterococci[81](table2).Tobeeffective,prophylacticantibioticsmustbe
administeredwithinonehourbeforethetimeofincision[82,83].(See"Antimicrobialprophylaxisforpreventionof
surgicalsiteinfectioninadults"and"Controlmeasurestopreventsurgicalsiteinfectionfollowinggastrointestinal
proceduresinadults".)
Patientsundergoingurgentinguinalorfemoralherniarepairsshouldreceiveantibioticsaccordingtothecomplication
(eg,bowelperforation,bowelischemia,orobstruction).Forthosepatients,antibioticsareconsideredtherapeuticrather
thanprophylactic,andtheinitialcoverageshouldbebroad(table2).Onceanintraoperativeculturehasbeenobtained,
furtherantibiotictherapyshouldbeguidedbymicrobiologydata.(See"Overviewofgastrointestinaltractperforation".)
ChoiceofanesthesiaInguinalorfemoralherniarepaircanbeperformedusinggeneral,neuraxial(spinalor
epidural),orregionalanesthesia(peripheralnerveblock,local)[84,85].Thechoiceofanesthesiadependsuponthe
typeandsizeofthehernia,surgicalapproach,andpatient/surgeonpreferences.(See"Overviewofanesthesiaand
anestheticchoices".)
AnesthesiaforopenrepairWeprefertoperformopengroinherniarepairwithlocalanesthesia,especiallyin
patientswithcomorbidities(eg,advancedliverdisease).
Inarandomizedtrialof616patientsundergoingopeninguinalherniarepairs,theuseoflocalanesthesiaresultedin
lesspostoperativepainandnausea,ashorterrecoveryroomstay(3.1versus6.2and6.2hours),andfewerunplanned
overnightadmissions(3versus14and22percent),comparedwiththeuseofregionalandgeneralanesthesia,
respectively[84].Anotherrandomizedtrialofopeninguinalherniarepairsalsofoundthatlocalanesthesiaresultedin
lesspostoperativepain,ashorteroperatingtime,andfewerovernightstaysthanspinalanesthesia[86].
Localanesthesiacanbeadministeredasanerveblockoftheilioinguinalandiliohypogastricnerves,orasdirect
infiltrationintotheincisionsite(s).Nerveblockmaybemoredifficulttoadminister,butcauseslesssofttissueedema
thandirectinfiltration.(See"Nerveblocksofthescalp,neck,andtrunk:Techniques",sectionon'Ilioinguinaland
iliohypogastricnerveblock'.)
Themaindisadvantageoflocalanesthesiaisthatitmaynotprovideadequateanesthesiaduringtherepairoflarge
hernias,particularlyinpatientswhohavealossofabdominaldomain.Insuchpatients,generalanesthesiaispreferred.
Generalanesthesiacanalsobeusedinopenherniarepairbypatientorsurgeonpreference.
AnesthesiaforlaparoscopicrepairAnesthesiarequirementsforlaparoscopicinguinalorfemoralherniarepairs
varydependinguponthetechniqueused:
Transabdominalpreperitonealpatch(TAPP)repairrequiresgeneralanesthesia.
Intraperitonealonlaymesh(IPOM)repairrequiresgeneralanesthesia.
Totallyextraperitoneal(TEP)repairsareoftenperformedundergeneralanesthesia,butcanalsobeperformed
underspinalorepiduralanesthesia.
MORBIDITYANDMORTALITY
MortalityThe30daymortalityrateforinguinalorfemoralherniarepairis0.1percentafterelectivesurgery,and2.8
to3.1percentafterurgentsurgery[6,13,87].Themortalityrateishigherwhenbowelresectionisperformedwithhernia
repair[88].Otherriskfactorsassociatedwithahighermortalityrateinclude:
OlderageOlderpatientshavehighermortalityratesafteremergencyherniarepair.Inonestudy,themortality
rateswere1,5,and16percent,respectively,forpatientswhowereintheirsixties,seventies,andeighties[87].
FemoralherniaFemoralherniarepairsareassociatedwithhighermortalitythaninguinalherniarepairs[5].In
onestudy,the30daystandardizedmortalityratioswerehigherforfemoralthaninguinalherniarepairsinboth
men(6.81and1.29)andwomen(7.16versus2.82)[88].
WomenWomenhavehighermortalityaftergroinherniarepairthanmen[5].However,itisnotcleariffemale
sexisanindependentriskfactor,aswomenwhorequiregroinherniasurgeriestendtobeolder,havemore
femoralhernias,andaremorelikelytorequireemergencyoperations.
MorbidityMinorcomplicationsofinguinalorfemoralherniarepair,includingsuperficialwoundinfectionand
seroma/hematomaformation,arecommonandeasilymanaged.Othercomplications,suchaspostherniorrhaphy
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neuralgiaandherniarecurrence,arelessfrequentlyseenbutmoredebilitating.Complicationsofgroinherniarepairsare
discussedseparatelyinothertopics.(See"Postherniorrhaphygroinpain"and"Overviewofcomplicationsofinguinal
andfemoralherniarepair".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereading
level,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesare
bestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopics
toyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfo
andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Inguinalandfemoral(groin)hernias(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Thedefinitivetreatmentofallhernias,regardlessoforiginortype,issurgicalrepair.Inguinal/femoralherniarepair
isoneofthemostcommonlyperformedoperationsintheworld.(See'Introduction'above.)
Patientswhodevelopstrangulationorbowelobstructionfromaninguinalorfemoralherniashouldundergourgent
surgicalrepair.Patientswithanacutelyincarceratedinguinalherniabutwithoutsignsofstrangulationor
obstructionalsorequiresurgery,typicallyurgently.However,forthosewhowishtodelaysurgery,nonsurgical
herniareductioncanbeattemptedand,ifsuccessful,electiveherniarepaircanbeperformedatalatertime.(See
'Complicatedhernia'above.)
Patientswithanuncomplicatedinguinalorfemoralherniamayundergosurgicalrepairorbemanagedwith
watchfulwaitingdependingupontheherniatype,severityofsymptoms,aswellasthesexandpreferencesof
thepatient,asfollows:
Forallpatientswithnewlydiagnosedfemoralhernia,werecommendelectiverepair,ratherthanwatchful
waiting,regardlessofthepatientssexorwhetherornots/hehassymptoms(Grade1B).Inpatientswith
longstandingfemoralhernias(>3months),surgeryispreferredbutobservationisareasonableoption.(See
'Femoralhernia'above.)
Forfemalepatientswithanewlydiagnosedinguinalhernia,werecommendelectiverepairratherthan
watchfulwaitingregardlessofwhetherornotshehassymptoms(Grade1B).(See'Femalepatients'
above.)
Formalepatientswithsymptomsattributabletoaninguinalhernia,werecommendelectiverepairrather
thanwatchfulwaiting(Grade1B).(See'Symptomatichernia'above.)
Formalepatientswithminimalornosymptomsattributabletoaninguinalhernia,wesuggestelectivehernia
repairratherthanwatchfulwaiting(Grade2B).Althoughthereisevidencethatdelayingsurgicalrepairis
safe,mostpatientseventuallyrequiresurgerybecauseofworseningsymptoms.(See'Asymptomatic
hernia'above.)
Patientswithaninguinalherniawithminimalornosymptoms,whowishtoavoidsurgery,canbemanaged
withwatchfulwaitingprovidedthattheyarecounseledoftheriskofdevelopingherniacomplications
(incarcerationandstrangulation)andunderstandtheneedforpromptmedicalattentionshouldsuch
complicationsoccur.Trussesareassociatedwithnegativeconsequencesandshouldnotbeusedto
managesymptomsrelatedtoinguinalhernias.(See'Asymptomatichernia'above.)
Thesurgicalapproachtogroinherniarepairshouldbetheonethatthesurgeonismostcomfortablewithand
mostexperiencedinperforming.Forsurgeonswhoareequallyfacilewithbothopenandlaparoscopicrepairs,the
choiceofasurgicalapproachdependsuponherniaandpatientcharacteristicsasfollows(algorithm1):
Wepreferanopenapproachforpatientswithpriorsurgeryinvolvingthepreperitonealspace(including
laparoscopicgroinherniarepair,prostatectomy,hysterectomy,cesareansection,andlaparotomyvialower
midlineincision),complicatedinguinalhernias(infected,incarcerated,strangulated,largescrotal),or
ascites.Laparoscopicrepairisrelativelycontraindicatedinthesepatients.(See'Patientsprecludedfrom
laparoscopicrepair'above.)
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Aprimary,unilateralinguinalherniacanberepairedopenorlaparoscopicallybaseduponsurgeonand
patientpreference.(See'Inguinalhernia'above.)
Weprefertorepairafemoralhernialaparoscopically.(See'Femoralhernia'above.)
Weprefertorepairbilateralinguinalorfemoralherniaslaparoscopically.(See'Bilateralhernias'above.)
Weprefertorepairarecurrentgroinherniawithalaparoscopicapproachiftheinitialrepairwasopen,but
withanopenapproachiftheinitialrepairwaslaparoscopic.(See'Recurrenthernia'above.)
Forpatientswithuncomplicatedinguinalandfemoralhernias,werecommendperformingatensionfreerepair,
whichtypicallyrequirestheuseofmesh,ratherthanarepairthatproducestension(ie,mostnonmeshprimary
tissueapproximationrepairsexceptShouldice)(Grade1B).Nonmeshrepairtechniquesmayberequiredfor
patientswithactivegroininfectionorcontamination(eg,asaresultofbowelperforationfromastrangulated
hernia),orwhentheuseofameshiscostprohibitive.(See'Surgicaltechniques'above.)
Forpatientsundergoingelectiveinguinalorfemoralherniarepairrequiringmeshplacement(eg,laparoscopic,
Lichtenstein),wesuggestusingpreoperativeprophylacticantibiotics(Grade2B).(See'Antibiotics'above.)
Weprefertoperformopengroinherniarepairunderlocalanesthesia,especiallyinpatientswithcomorbidities(eg,
advancedliverdisease).Mostlaparoscopicrepairsrequiregeneralanesthesia.(See'Choiceofanesthesia'
above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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80.SanchezManuelFJ,LozanoGarcaJ,SecoGilJL.Antibioticprophylaxisforherniarepair.CochraneDatabase
SystRev2012:CD003769.
81.SanchezVM,AbiHaidarYE,ItaniKM.Meshinfectioninventralincisionalherniarepair:incidence,contributing
factors,andtreatment.SurgInfect(Larchmt)201112:205.
82.FryDE.Surgicalsiteinfectionsandthesurgicalcareimprovementproject(SCIP):evolutionofnationalquality
measures.SurgInfect(Larchmt)20089:579.
83.BratzlerDW,HouckPM,SurgicalInfectionPreventionGuidelinesWritersWorkgroup,etal.Antimicrobial
prophylaxisforsurgery:anadvisorystatementfromtheNationalSurgicalInfectionPreventionProject.Clin
InfectDis200438:1706.
84.NordinP,ZetterstrmH,GunnarssonU,NilssonE.Local,regional,orgeneralanaesthesiaingroinherniarepair:
multicentrerandomisedtrial.Lancet2003362:853.
85.YoungDV.Comparisonoflocal,spinal,andgeneralanesthesiaforinguinalherniorrhaphy.AmJSurg1987
153:560.
86.vanVeenRN,MahabierC,DawsonI,etal.Spinalorlocalanesthesiainlichtensteinherniarepair:arandomized
controlledtrial.AnnSurg2008247:428.
87.ArenalJJ,RodrguezVielbaP,GalloE,TinocoC.Herniasoftheabdominalwallinpatientsovertheageof70
years.EurJSurg2002168:460.
88.NilssonH,StylianidisG,HaapamkiM,etal.Mortalityaftergroinherniasurgery.AnnSurg2007245:656.
Topic3687Version18.0

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GRAPHICS
Choosingasurgicalapproach(openversuslaparoscopic)forgroinhernia
repair

*Herniaswithactiveinfectionorcontaminationrequireanopenrepairwithouttheuseofmeshatensionfreemesh
repairisrecommendedforallotherhernias.
Graphic107556Version1.0

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ModifiedCapriniriskassessmentmodelforVTEingeneralsurgical
patients
Riskscore
1point

2points

3points

5points

Age41to60years

Age61to74years

Age75years

Stroke(<1month)

Minorsurgery

Arthroscopicsurgery

HistoryofVTE

Electivearthroplasty

BMI>25kg/m 2

Majoropensurgery
(>45minutes)

FamilyhistoryofVTE

Hip,pelvis,orleg
fracture

Swollenlegs

Laparoscopicsurgery

FactorVLeiden

Acutespinalcordinjury

(>45minutes)

(<1month)

Varicoseveins

Malignancy

Prothrombin20210A

Pregnancyor
postpartum

Confinedtobed(>72
hours)

Lupusanticoagulant

Historyofunexplained

Immobilizingplaster

Anticardiolipin

orrecurrent
spontaneousabortion

cast

antibodies

Oralcontraceptivesor

Centralvenousaccess

Elevatedserum

hormonereplacement
Sepsis(<1month)

homocysteine

Heparininduced

thrombocytopenia
Seriouslungdisease,

Othercongenitalor

includingpneumonia

acquiredthrombophilia

(<1month)
Abnormalpulmonary
function

Acutemyocardial

Congestiveheartfailure
(<1month)

Historyofinflammatory

infarction

boweldisease
Medicalpatientatbed
rest

Interpretation
EstimatedVTEriskin
theabsenceof
Surgicalrisk
category*

Score

pharmacologicor
mechanical
prophylaxis
(percent)

Verylow(seetextfor

<0.5

Low

1to2

1.5

Moderate

3to4

3.0

definition)

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High

6.0

VTE:venousthromboembolismBMI:bodymassindex.
*Thistableisapplicableonlytogeneral,abdominalpelvic,bariatric,vascular,andplasticandreconstructive
surgery.Seetextforothertypesofsurgery(eg,cancersurgery).
From:GouldMK,GarciaDA,WrenSM,etal.PreventionofVTEinnonorthopedicsurgicalpatients:
antithrombotictherapyandpreventionofthrombosis,9thed:AmericanCollegeofChestPhysiciansevidence
basedclinicalpracticalguidelines.Chest2012141:e227S.Copyright2012.Reproducedwithpermission
fromtheAmericanCollegeofChestPhysicians.
Graphic83739Version13.0

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Antimicrobialprophylaxisforgastrointestinalsurgeryinadults
Natureof
operation

Common
pathogens

Recommended
antimicrobials

Usualadult
dose*

Redose
interval

Gastroduodenalsurgery
Procedures

Entericgram

involvingentry
intolumenof

negativebacilli,
grampositive

gastrointestinal

cocci

Cefazolin

<120kg:2gIV

Fourhours

120kg:3gIV

tract
Proceduresnot
involvingentry

Entericgram
negativebacilli,

intolumenof

grampositive

gastrointestinal
tract(selective

cocci

Highrisk only:
cefazolin

<120kg:2gIV

Fourhours

120kg:3gIV

vagotomy,
antireflux)
Biliarytractsurgery(includingpancreaticprocedures)
Open
procedureor

Entericgram
negativebacilli,

laparoscopic

enterococci,

procedure
(highrisk)

clostridia

Laparoscopic

Cefazolin

<120kg:2gIV

Fourhours

120kg:3gIV
ORcefotetan

2gIV

Sixhours

ORcefoxitin

2gIV

Twohours

ORampicillin
sulbactam

3gIV

Twohours

N/A

None

None

None

Entericgram

Cefoxitin

2gIV

Twohours

negativebacilli,

ORcefotetan

2gIV

Sixhours

ORcefazolin

<120kg:2gIV

Fourhours

procedure(low
risk)
Appendectomy

anaerobes,
enterococci

120kg:3gIV
PLUSmetronidazole

500mgIV

N/A

Cefazolin

<120kg:2gIV

Fourhours

Smallintestinesurgery
Nonobstructed

Entericgram
negativebacilli,

120kg:3gIV

grampositive
cocci
Obstructed

Entericgram

Cefoxitin

2gIV

Twohours

negativebacilli,

ORcefotetan

2gIV

Sixhours

ORcefazolin

<120kg:2gIV

Fourhours

anaerobes,
enterococci

120kg:3gIV
PLUSmetronidazole

500mgIV

N/A

Cefazolin

<120kg:2gIV

Fourhours

Herniarepair

Aerobicgram
positive

120kg:3gIV

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organisms
Colorectalsurgery

Entericgram
negativebacilli,
anaerobes,
enterococci

Parenteral:
Cefoxitin

2gIV

Twohours

ORcefotetan

2gIV

Sixhours

ORcefazolin

<120kg:2gIV

Fourhours

120kg:3gIV
PLUS

500mgIV

N/A

3gIV(basedon

Twohours

metronidazole
ORampicillin

sulbactam ,**

combination)

Oral(usedinconjunctionwithmechanicalbowel
preparation):
NeomycinPLUS

erythromycin
baseor
metronidazole
IV:intravenous.
*ParenteralprophylacticantimicrobialscanbegivenasasingleIVdosebegunwithin60minutesbeforethe
procedure.Ifvancomycinorafluoroquinoloneisused,theinfusionshouldbestartedwithin60to120
minutesbeforetheinitialincisiontohaveadequatetissuelevelsatthetimeofincisionandtominimizethe
possibilityofaninfusionreactionclosetothetimeofinductionofanesthesia.
Forprolongedprocedures(>3hours)orthosewithmajorbloodlossorinpatientswithextensiveburns,
additionalintraoperativedosesshouldbegivenatintervalsonetotwotimesthehalflifeofthedrug.
Forpatientsallergictopenicillinsandcephalosporins,clindamycin(900mg)orvancomycin(15mg/kgIV
nottoexceed2g)witheithergentamicin(5mg/kgIV),ciprofloxacin(400mgIV),levofloxacin(500mgIV),
oraztreonam(2gIV)isareasonablealternative.Metronidazole(500mgIV)plusanaminoglycosideor
fluoroquinolonearealsoacceptablealternativeregimens,althoughmetronidazoleplusaztreonamshouldnot
beusedsincethisregimendoesnothaveaerobicgrampositiveactivity.
Morbidobesity,gastrointestinal(GI)obstruction,decreasedgastricacidityorGImotility,gastricbleeding,
malignancyorperforation,orimmunosuppression.
Factorsthatindicatehighriskmayinclude:Age>70years,pregnancy,acutecholecystitis,nonfunctioning
gallbladder,obstructivejaundice,commonbileductstones,immunosuppression.
Cefotetan,cefoxitin,andampicillinsulbactamarereasonablealternatives.
Forarupturedviscus,therapyisoftencontinuedforapproximatelyfivedays.
Useofertapenemorothercarbapenemsnotrecommendedduetoconcernsofresistance.
**DuetoincreasingresistanceofEscherichiacolitofluoroquinolonesandampicillinsulbactam,local
sensitivityprofilesshouldbereviewedpriortouse.
Inadditiontomechanicalbowelpreparation,thefollowingoralantibioticregimenisadministered.1gof
neomycinplus1goferythromycinbaseat1PM,2PM,and11PM,or2gofneomycinplus2gof
metronidazoleat7PMand11PMthedaybeforean8AMoperation.Issuesrelatedtomechanicalbowel
preparationarediscussedfurtherseparately.RefertoUpToDatetopiconoverviewofcolonresection.
Datafrom:
1.Antimicrobialprophylaxisforsurgery.TreatGuidelMedLett201210:73.
2.BratzlerDW,DellingerEP,OlsenKM,etal.Clinicalpracticeguidelinesforantimicrobialprophylaxisin
surgery.SurgInfec(Larchmt)201314:73.
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ContributorDisclosures
DavidCBrooks,MDNothingtodisclose.MichaelRosen,MDGrant/Research/ClinicalTrialSupport:WLGore
Miromatrix[Mesh(Mesh)].Speaker'sBureau:WLGoreBard[Mesh(Mesh)].Consultant/AdvisoryBoards:Artiste
Medical[Mesh(Mesh)].WenliangChen,MD,PhDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
evidence.
Conflictofinterestpolicy

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