What is the recommended treatment for an adult male with an inguinal hernia?

Treatment of Inguinal Hernia in Adult Males

Surgical repair with mesh is the recommended treatment for symptomatic inguinal hernias in adult males, with laparoscopic approaches preferred when expertise is available due to lower chronic pain risk and faster recovery. 1

Diagnosis and Assessment

• Inguinal hernias can typically be diagnosed by physical examination alone in most patients with appropriate signs and symptoms 2
• Ultrasonography may be needed when:
  • A recurrent hernia is suspected
  • Surgical complications after repair are suspected
  • Other causes of groin pain are being considered 2
• MRI has higher sensitivity and specificity than ultrasound and is useful for diagnosing occult hernias when clinical suspicion remains high despite negative ultrasound findings 2

Treatment Decision Algorithm

1. For symptomatic inguinal hernias:

   • Surgical repair is strongly recommended 2, 1
   • Delaying treatment has few advantages as most patients eventually require surgery 3

2. For asymptomatic or minimally symptomatic hernias:

   • Watchful waiting is a reasonable option in men with asymptomatic or minimally symptomatic inguinal hernias 2, 1
   • However, most of these patients will eventually require surgery, so surgical risks and watchful waiting strategy should be discussed 1
   • Asymptomatic inguinal hernias should be repaired in patients who desire treatment after being informed of risks, sequelae, and expected results 3

3. For femoral hernias:

   • Immediate surgical repair is recommended due to high risk of strangulation 3

Surgical Approach Selection

1. Mesh repair is recommended as first choice, either by open or laparoscopic technique 1

2. Laparoscopic repair advantages:

   • Faster recovery time
   • Lower chronic pain risk (26-46% reduction compared to open repair)
   • Cost-effective when performed as day surgery with minimal disposables 4, 1
   • Recommended when expertise is available

3. Open repair (Lichtenstein technique):

   • Well-established technique with good outcomes
   • May be preferred when laparoscopic expertise is unavailable
   • Particularly suitable in low-resource settings 1

4. Tissue repair (Shouldice technique):

   • Can be offered after appropriate discussion with patients
   • Not first-line but an option for selected cases 1

Important Considerations

Mesh Selection and Fixation

• Surgeons should be aware of intrinsic characteristics of meshes they use
• Selection based on weight alone is not recommended
• Mesh fixation in TEP is generally unnecessary except in large medial (M3) hernias 1

Anesthesia

• Local anesthesia for open repair has advantages when surgeon is experienced with this technique
• General anesthesia is suggested over regional anesthesia in patients ≥65 years due to fewer complications like myocardial infarction, pneumonia, and thromboembolism 1, 5

Postoperative Care

• Day surgery is recommended for most patients with organized aftercare 1
• Patients should resume normal activities without restrictions as soon as they feel comfortable 1
• Acetaminophen is recommended as first-line treatment for pain management 6
• NSAIDs should be avoided due to increased bleeding risk 6

Complications to Monitor

• Chronic postoperative inguinal pain (CPIP) occurs in 10-12% of patients
• Debilitating chronic pain affecting daily activities ranges from 0.5-6% 1
• Risk factors for CPIP include young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia, and open repair 1
• Recurrence rates are approximately 10.6-12.3% with mesh repair compared to 17.1% without mesh 6

Special Considerations for Older Adults

• Watchful waiting may be more appropriate for elderly patients with serious comorbidities or short life expectancy 3, 5
• Increased risk of mortality after surgery has been demonstrated in patients ≥65 years 5
• Assessment of frailty is important in determining optimal management for older adults 5

Follow-up Care

• Patients should seek immediate medical attention for severe constant pain, redness over the hernia site, nausea, vomiting, inability to pass gas or stool, fever, or general malaise 6
• CT scan of abdomen and pelvis should be performed if pain persists beyond 1 month to detect potential complications 6