What is the best approach for managing a 72-year-old man with intermittent perinumbilical pain, vascular dementia, and hypertension, who has a supraumbilical hernia and is in a fragile state with gait abnormalities?

From the Guidelines

The best approach for managing this 72-year-old man with a supraumbilical hernia and multiple comorbidities would be conservative management rather than surgical intervention. Given his vascular dementia, hypertension, fragile state, and gait abnormalities, the risks of surgery likely outweigh the benefits. Conservative management should include pain control with acetaminophen 500-1000 mg every 6 hours as needed (avoiding NSAIDs due to hypertension), and application of a hernia support belt or abdominal binder to reduce discomfort. The patient should be educated to avoid heavy lifting and straining, maintain regular bowel movements with stool softeners like docusate sodium 100 mg twice daily if needed, and seek immediate medical attention if the hernia becomes painful, firm, or irreducible, which could indicate incarceration or strangulation requiring emergency surgery. Regular follow-up every 3-6 months is recommended to monitor the hernia. This conservative approach is justified because elderly patients with significant comorbidities face higher perioperative risks, and the patient's dementia may complicate postoperative recovery and rehabilitation. Additionally, his gait abnormalities increase the risk of falls during the recovery period, which could lead to complications such as wound dehiscence or hernia recurrence.

Some key considerations in managing this patient include:

• Monitoring and controlling his hypertension, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1
• Ensuring adequate hydration, with a daily fluid intake of 1.6 L for women and 2.0 L for men, as recommended for individuals with dementia and frailty 1
• Avoiding heavy lifting and straining, and maintaining regular bowel movements to reduce the risk of hernia complications
• Regular follow-up to monitor the hernia and adjust the management plan as needed

It's also important to note that the patient's vascular dementia and fragile state require careful consideration in any management plan, and a multidisciplinary team approach may be beneficial in ensuring comprehensive care. However, the most recent and highest quality study, 1, supports a conservative approach to managing the supraumbilical hernia in this patient.

From the Research

Management Approach

The management of a 72-year-old man with intermittent perinumbilical pain, vascular dementia, and hypertension, who has a supraumbilical hernia and is in a fragile state with gait abnormalities, requires careful consideration of his overall health and the risks associated with surgical intervention.

• The patient's age and frailty, combined with his vascular dementia and hypertension, increase the risk of complications from surgery 2.
• The presence of a supraumbilical hernia, as diagnosed by abdominal ultrasound, necessitates a decision on whether to proceed with surgical repair or adopt a watchful waiting approach.
• Studies have shown that watchful waiting can be a reasonable option for older adults with hernias, especially if they are asymptomatic or have significant comorbidities that increase surgical risk 2.
• However, the patient's symptoms of intermittent perinumbilical pain may indicate the need for surgical intervention to alleviate discomfort and prevent potential complications such as obstruction or strangulation.

Surgical Considerations

If surgical repair is deemed necessary, the approach should take into account the patient's fragile state and the potential for increased risk of mortality and morbidity.

• A study on umbilical hernia repair in patients with signs of portal hypertension found that elective repair was associated with lower morbidity and mortality rates compared to emergency surgery 3.
• The use of invagination with serosal closure, as described in a case report on Richter's hernia, may be a suitable approach for managing the supraumbilical hernia, especially if the patient's condition does not allow for more extensive surgery 4.
• The choice of anesthesia and the surgical technique should be carefully selected to minimize risks and optimize outcomes for the patient.

Individualized Care

Ultimately, the best approach for managing this patient's supraumbilical hernia will depend on a thorough evaluation of his individual needs and health status.

• A multidisciplinary team, including surgeons, primary care physicians, and geriatric specialists, should be involved in the decision-making process to ensure that all aspects of the patient's care are considered 2.
• The patient's quality of life, functional status, and personal preferences should be taken into account when determining the most appropriate management strategy.