What is the best course of treatment for a 51-year-old male patient with a symptomatic 2.0 cm reducible ventral hernia, severe pain, and failed conservative management with Tylenol (acetaminophen) and ibuprofen, despite significant weight loss?

From the Guidelines

The best course of treatment for this 51-year-old male patient with a symptomatic, reducible ventral hernia is surgical repair, specifically with a laparoscopic approach and mesh reinforcement, as recommended by the most recent guidelines 1. Given the patient's severe pain, failed conservative management with Tylenol and ibuprofen, and the 2.0 cm hernia size, a surgical approach is indicated. The procedure would involve reducing the hernia contents back into the abdominal cavity and repairing the defect, typically using a synthetic or biologic mesh to strengthen the abdominal wall and prevent recurrence. Some key points to consider in the management of this patient include:

• Preoperative pain management with acetaminophen and ibuprofen as needed until surgery
• Post-operative care with pain management using medications such as acetaminophen 650 mg every 6 hours and possibly short-term opioids like oxycodone 5-10 mg every 4-6 hours as needed for severe pain
• Activity restrictions for 4-6 weeks, including no heavy lifting (over 10 pounds)
• Continued weight management efforts, as obesity increases recurrence risk The use of mesh in clean surgical fields is associated with a lower recurrence rate, without an increase in wound infection rate, as supported by the guidelines 1. Additionally, laparoscopic approach may be a useful tool for assessing bowel viability after spontaneous reduction of strangulated hernias, and can be used for repair of incarcerated hernias in the absence of strangulation and suspicion of bowel resection 1. It is essential to note that symptomatic hernias with severe pain that have failed conservative management rarely improve without intervention, and there is a risk of incarceration or strangulation if left untreated, which would require emergency surgery with higher complication rates. Therefore, surgical repair is the recommended course of treatment for this patient, with careful consideration of the approach and mesh type to minimize complications and optimize outcomes.

From the Research

Treatment Options for Symptomatic Ventral Hernia

The patient presents with a symptomatic 2.0 cm reducible ventral hernia, severe pain, and failed conservative management with Tylenol (acetaminophen) and ibuprofen, despite significant weight loss. Considering the patient's condition, the following treatment options can be explored:

• Surgical repair: The study by 2 suggests that generalized pain is a common indication for elective repair of ventral hernias, with 68.7% of surgeons considering it a primary reason for surgery.
• Physical therapy: The study by 3 highlights the importance of physical therapy in ventral hernia repair, drawing parallels with musculoskeletal tendon reconstruction, where physical therapy is a crucial component of rehabilitation.
• Pain management: The study by 4 explores the use of a lidocaine patch for postoperative pain control after laparoscopic ventral hernia repair, showing promising results in reducing postoperative pain.

Considerations for Surgical Repair

When considering surgical repair, the following factors should be taken into account:

• Recurrence rates: The study by 5 notes that previous ventral hernia repair increases the complication profile of subsequent repairs, with higher recurrence rates observed in patients with multiple repairs.
• Operative duration and surgical site infection: The study by 5 also highlights the increased risk of operative duration and surgical site infection in patients with multiple repairs.
• Patient satisfaction: The study by 2 suggests that most patients experience resolution of pain and improved cosmesis after surgery, with the majority of surgeons reporting high patient satisfaction rates.

Alternative Approaches

In addition to surgical repair, alternative approaches can be considered, such as:

• Prevention of incisional hernias: The study by 6 discusses the importance of preventing incisional hernias, particularly in high-risk patient subgroups, and explores various modalities to decrease the incidence of incisional hernia.
• Conservative management: The patient's significant weight loss may have contributed to the reduction of hernia symptoms, and continued conservative management may be explored, although the patient's severe pain and failed previous management may indicate the need for more invasive interventions.