Surgical Repair is Recommended
For an elderly patient with a reducible inguinal hernia causing mild discomfort, surgical repair (Option A) is the recommended management approach, as hernias should always be managed surgically to prevent the life-threatening complication of incarceration and strangulation. 1
Rationale for Surgical Intervention
The principle that drives hernia management is clear: all inguinal hernias should be repaired surgically because the risk of incarceration—which can lead to bowel necrosis and death—makes conservative management unacceptably dangerous. 1 While this patient currently has a reducible hernia with only mild symptoms, the natural history of inguinal hernias involves progressive enlargement and eventual risk of acute incarceration, which becomes a surgical emergency. 2, 3
Key Clinical Considerations:
Strangulation risk is unpredictable: Even minimally symptomatic hernias can suddenly incarcerate, and delayed diagnosis beyond 24 hours significantly increases mortality rates 2, 3
Emergency surgery carries higher risks: If this patient develops incarceration later, he would require urgent/emergency surgery with significantly higher complication rates compared to elective repair 3, 4
Mesh repair is the standard approach: For elective repair, mesh techniques (such as Lichtenstein or laparoscopic approaches) offer significantly lower recurrence rates without increased infection risk 2, 4, 5
Why Not Watchful Waiting?
While recent evidence suggests watchful waiting may be acceptable for truly asymptomatic or minimally symptomatic hernias, this approach comes with important caveats 6:
Conversion rates from watchful waiting to surgery range from 35-57.8%, meaning most patients eventually require surgery anyway 6
The patient is already experiencing symptoms (bulging with coughing/standing and mild discomfort), which moves him beyond the "asymptomatic" category where watchful waiting might be considered 6
The elderly population may have reduced physiologic reserve to tolerate emergency surgery if acute incarceration occurs, making elective repair the safer option
Recommended Surgical Approach
Mesh repair is strongly recommended as the standard approach with significantly lower recurrence rates 2, 4, 5
Laparoscopic approaches (TAPP or TEP) offer advantages including reduced postoperative pain, lower wound infection rates, and faster return to activities 2, 4
Open Lichtenstein repair remains an excellent option, particularly for elderly patients, and can be performed under local anesthesia on an outpatient basis 1, 5, 7
Critical Pitfall to Avoid
Never delay definitive surgical repair in favor of prolonged observation once a hernia is diagnosed, as the transition from reducible to incarcerated hernia can occur suddenly and unpredictably, leading to emergency surgery with substantially higher morbidity and mortality. 2, 3, 4