What is the best course of management for a 28-year-old male patient with intermittent hernia pain, able to reduce the hernia, and currently using a hernia belt (hernia truss) and Tylenol (Acetaminophen) 325 mg?

From the Guidelines

The best course of management for this 28-year-old male patient with intermittent hernia pain, able to reduce the hernia, and currently using a hernia belt, is surgical repair, as it provides a definitive treatment with high success rates and relatively quick recovery, minimizing the risk of complications such as bowel obstruction and strangulation. While the patient's current approach using a hernia belt and acetaminophen provides temporary symptom relief, it does not address the underlying anatomical defect. The use of mesh in clean surgical fields is associated with a lower recurrence rate, as stated in the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1.

The patient should be referred to a general surgeon for evaluation and elective hernia repair, which is typically performed as an outpatient laparoscopic or open procedure depending on the hernia type and surgeon preference. Prior to surgery, the patient can continue using the hernia belt and acetaminophen for pain management, but should seek immediate medical attention if the hernia becomes irreducible or if he develops severe pain, nausea, vomiting, or skin changes over the hernia site, as these may indicate incarceration or strangulation requiring emergency surgery.

Some key points to consider in the management of this patient include:

• The patient's ability to reduce the hernia suggests that it is not currently incarcerated or strangulated, but this can change, and the patient should be aware of the signs and symptoms that require immediate medical attention.
• The use of a hernia belt can provide temporary relief, but it is not a long-term solution, especially for young, healthy patients, as hernias typically enlarge over time and carry risks of complications.
• Surgical repair offers a definitive treatment with high success rates and relatively quick recovery, typically allowing return to normal activities within 1-2 weeks and full physical activity within 4-6 weeks.
• The choice of surgical approach, including the use of mesh, should be individualized based on the patient's specific condition and the surgeon's preference, as outlined in the guidelines 1.

It is essential to prioritize the patient's safety and well-being, and surgical repair is the most effective way to achieve this, as it minimizes the risk of complications and provides a long-term solution for the patient's condition.

From the Research

Management of Intermittent Hernia Pain

• The patient's complaint of intermittent hernia pain, ability to reduce the hernia, and current use of a hernia belt (hernia truss) and Tylenol (Acetaminophen) 325 mg can be managed through a combination of watchful waiting and surgical treatment 2, 3.
• Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias, but it is not recommended in patients with symptomatic hernias or in nonpregnant women 2, 3.
• Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics, and local/national resources 3.
• Mesh repair is recommended as the first choice, either by an open procedure or a laparo-endoscopic repair technique 3, 4.

Diagnostic Imaging

• Ultrasonography is often needed in women and is helpful when a recurrent hernia, surgical complication after repair, or other cause of groin pain is suspected 2, 5.
• Magnetic resonance imaging has higher sensitivity and specificity than ultrasonography and is useful for diagnosing occult hernias if clinical suspicion is high despite negative ultrasound findings 2.
• CT is the imaging modality of choice for the assessment of a known adult abdominal hernia in both elective and acute circumstances 5.

Pain Management

• The use of Tylenol (Acetaminophen) 325 mg is a common approach for managing hernia pain, but other options such as ultrasound-guided transversus abdominis plane catheters and ambulatory perineural infusions may also be considered for outpatient inguinal hernia repair 6.
• Chronic postoperative inguinal pain (CPIP) is a potential complication of hernia repair, and its management should be performed by multi-disciplinary teams using a combination of pharmacological and interventional measures 3.