What is the best management approach for a 67-year-old man with a left hydrocele and a history of left inguinal hernia repair?

Management of Left Hydrocele Following Left Inguinal Hernia Repair

Surgical intervention is recommended for a 67-year-old man with a left hydrocele that developed after a previous left inguinal hernia repair, as this likely represents a postoperative complication requiring correction.

Pathophysiology and Diagnosis

A hydrocele following inguinal hernia repair can develop due to:

• Disruption of lymphatic drainage during the previous surgery
• Incomplete closure of the processus vaginalis
• Inflammatory response to mesh placement
• Recurrent hernia with fluid accumulation

Diagnostic Approach

• Physical examination to confirm the presence and extent of the hydrocele
• Ultrasonography is indicated to:
  • Differentiate between simple hydrocele and recurrent hernia
  • Evaluate for mesh displacement or migration
  • Assess for other complications 1, 2
• CT scan with contrast enhancement may be necessary if ultrasonography is inconclusive 1

Treatment Algorithm

1. Conservative Management

• Generally not recommended for post-hernia repair hydroceles in adults, as these rarely resolve spontaneously
• Unlike congenital hydroceles in infants that often resolve within 18-24 months 3

2. Surgical Management

• Scrotal approach is preferred for isolated hydrocele repair when:

  • Ultrasound confirms no recurrent inguinal hernia
  • The previous repair site appears intact
  • Benefits include shorter operative time and excellent cosmetic results 4

• Inguinal approach is indicated when:

  • Recurrent hernia is suspected or confirmed
  • Previous mesh requires evaluation or revision
  • Complex anatomy or adhesions are anticipated 5

• Surgical technique considerations:

  • Tension-free repair with non-absorbable sutures should be attempted 3
  • If a large defect is identified (>8 cm or area >20 cm²), mesh reinforcement is recommended 1
  • For clean surgical fields, prosthetic mesh is preferred; for contaminated fields, primary suture repair is recommended 1
  • Biosynthetic or biological meshes may be considered due to their higher resistance to infections 3, 1

Postoperative Care

• Pain management:

  • Acetaminophen 500-1000 mg every 6 hours (maximum 4000 mg/day) as first-line treatment
  • Tramadol 50-100 mg every 6-8 hours (maximum 400 mg/day) if additional pain control is needed
  • Avoid NSAIDs due to increased bleeding risk 1

• Monitoring for complications:

  • Wound infection (occurs in 4-12% of cases)
  • Recurrence (5-year recurrence rates approximately 10-12% with mesh repair)
  • Bleeding or hematoma formation 1

Follow-up Recommendations

• Initial follow-up within 1-2 weeks to assess wound healing
• If pain persists beyond 1 month, CT scan of abdomen and pelvis is recommended to evaluate for complications 1
• Long-term follow-up to monitor for recurrence, with typical follow-up periods of 6-12 months 4, 5

Special Considerations

• Minimally invasive approaches (laparoscopic) may be considered in stable patients without evidence of complications, offering lower morbidity (5-6%) compared to open approaches (17-18%) 1
• If the hydrocele is very large or recurrent after previous repair attempts, referral to a specialist with experience in complex hernia/hydrocele repair is recommended 5

The management of post-hernia repair hydrocele requires careful evaluation and appropriate surgical intervention to prevent recurrence and ensure optimal outcomes.