What are the next steps in managing a patient with multiple hernias, including a left inguinal hernia, causing pain, as shown on a CT abdomen/pelvis with contrast?

Management of Patient with Multiple Hernias and Left Inguinal Pain

This patient requires urgent surgical consultation for evaluation and likely repair of the symptomatic left inguinal hernia, with concurrent assessment of the indeterminate right inguinal soft tissue mass to exclude abscess or incarceration.

Immediate Next Steps

Clinical Assessment Priority

• Examine specifically for signs of incarceration or strangulation of the left inguinal hernia: assess for irreducibility, severe tenderness, overlying skin changes, fever, or systemic signs 1
• Evaluate the indeterminate right inguinal mass (2.2 x 1.9 cm) for signs of infection (warmth, erythema, fluctuance) versus recurrent hernia versus other pathology 1
• Assess pain characteristics: burning, gurgling, aching sensation that worsens with activity suggests symptomatic hernia requiring intervention 1

Diagnostic Workup for the Indeterminate Right Inguinal Mass

• Obtain ultrasound of the right inguinal region to differentiate between post-surgical changes, abscess, recurrent hernia, or mass 2, 1
• Point-of-care ultrasound is useful for evaluating suspected hernias and can help characterize the soft tissue density 2
• If ultrasound is inconclusive and clinical concern persists, MRI may be warranted 1

Surgical Management Algorithm

For the Symptomatic Left Inguinal Hernia

Surgical repair is indicated for all symptomatic inguinal hernias 1, 3

• The patient has documented pain localized to the left inguinal region where the hernia is identified—this constitutes a clear indication for repair 1, 3
• Watchful waiting is NOT appropriate for symptomatic hernias, only for minimally symptomatic or asymptomatic hernias in men 4

Surgical Approach Selection

Laparoscopic/endoscopic repair is preferred for this patient given multiple hernias 3

• For bilateral hernias or multiple hernias, laparoscopic or endoscopic procedures are preferable to open procedures 3
• Laparoscopic approach results in less chronic postoperative pain compared to open surgery 3
• Mesh-based repair is generally recommended given the pathophysiology involving extracellular matrix abnormalities 3

Addressing Multiple Concurrent Hernias

• The supraumbilical hernias (both paramidline and midline) should be evaluated for symptoms; the reticulation in adjacent soft tissues suggests possible inflammation or fat necrosis that could be contributing to pain 1
• If the patient is undergoing surgery for the symptomatic left inguinal hernia, consider concurrent repair of other hernias if technically feasible and patient condition permits 3
• The transverse colon-containing supraumbilical hernia warrants attention due to risk of obstruction, even if currently asymptomatic 1

Critical Management Considerations

The Right Inguinal Indeterminate Mass

This requires definitive characterization before or during surgery 2, 1

• If ultrasound reveals abscess: drainage and antibiotics before elective hernia repair
• If recurrent hernia: may require different surgical approach or mesh type
• If mass of unclear etiology: may require biopsy or excision

Timing of Intervention

• Urgent surgical consultation (within 24-48 hours) if no signs of strangulation 1
• Emergency surgery if any signs of incarceration, strangulation, or bowel obstruction develop 1
• The absence of bowel obstruction on current CT is reassuring but does not eliminate urgency for symptomatic hernia 1

Common Pitfalls to Avoid

• Do not delay surgical referral for symptomatic inguinal hernias—the risk of complications increases with time 1, 4
• Do not assume the right inguinal soft tissue density is benign post-surgical change without imaging confirmation; abscess or recurrent hernia requires different management 2, 1
• Do not treat with conservative measures (trusses are no longer recommended and are ineffective) 4
• Do not perform isolated repair of only the symptomatic hernia without addressing the indeterminate right inguinal finding 1