What is the best management approach for a 68-year-old male patient with bilateral inguinal hernias and obesity?

Management of Bilateral Inguinal Hernias in a 68-Year-Old Male with Obesity

For this 68-year-old male patient with bilateral inguinal hernias and obesity, elective surgical repair with a laparoscopic approach (TAPP or TEP) is recommended, though his age ≥65 years makes him statistically more likely to receive open repair, which remains an acceptable alternative with comparable outcomes. 1, 2

Surgical Approach Selection

Laparoscopic Repair (Preferred for Bilateral Hernias)

Laparoscopic repair offers significant advantages for bilateral inguinal hernias, including shorter convalescence (17.9 days vs 56.4 days return to work), lower wound infection rates, and the ability to address both hernias through the same access points. 1, 3

• Both TAPP (transabdominal preperitoneal) and TEP (totally extraperitoneal) approaches demonstrate comparable outcomes with low complication rates (5.7% minor complications, 0.4% major complications) 1, 4
• Laparoscopic bilateral repair shows recurrence rates as low as 0.2-1.3% with proper technique 4, 3
• The approach allows visualization of occult contralateral hernias, present in 11.2-50% of cases 1
• Hospital stay averages 4 days, similar to open repair 3

Age-Related Considerations

Patients aged ≥65 years are 4.2 times more likely to receive open repair compared to younger patients, likely due to age-related comorbidities and anesthetic considerations. 5

• Your patient's age of 68 years places him in this higher-risk category for receiving open rather than laparoscopic repair 5
• However, recent propensity-matched data shows no significant differences in 3-year outcomes (quality of life, recurrence rates, complications) between laparoscopic, robotic, and open approaches for bilateral hernias 2
• The choice should account for his specific comorbidities, anticoagulant use (if any), and surgical team expertise 5

Open Repair Considerations

If open repair is selected, a preperitoneal approach (rather than anterior Lichtenstein) may offer biomechanical advantages for bilateral repair, though both are acceptable. 2

• Open bilateral repair can be performed safely with recurrence rates of 5.1% 3
• Mean operative time for bilateral repair is approximately 68 minutes 4
• Open repair can be performed under local anesthesia if general anesthesia poses significant risk 1

Obesity Management

Weight optimization prior to surgery should be considered but should not indefinitely delay repair, as the long-standing right-sided hernia (>20 years) carries ongoing risk of complications. 6

• At 252 pounds, calculate BMI to determine if he meets criteria (BMI ≥30) for medical weight management 6
• Consider referral for obesity management with GLP-1 receptor agonists or other anti-obesity medications if BMI ≥30, which may reduce surgical risk 6
• Metabolic and bariatric surgery should be considered if BMI ≥35 or BMI 30-34.9 with metabolic comorbidities, though hernia repair should not be delayed for this 6

Timing of Repair

Semi-urgent elective repair should be scheduled within 2-4 weeks to minimize incarceration risk, particularly given the chronic nature of the right-sided hernia. 7

• The 20-year history of the right hernia increases risk of complications including incarceration and strangulation 7
• All inguinal hernias require surgical repair to prevent bowel incarceration, strangulation, and potential gonadal infarction 7, 1
• Delayed diagnosis beyond 24 hours in strangulated hernias significantly increases mortality 7, 1

Mesh Selection

Synthetic mesh repair is strongly recommended for both hernias, as it provides significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk in clean surgical fields. 1

• Prosthetic repair with synthetic mesh is the standard approach (Grade 1A recommendation) 1
• Mesh should overlap the defect edge by 1.5-2.5 cm 8
• For laparoscopic repair, mesh fixation can use tackers or transfascial sutures, avoiding tackers near the pericardium 6

Critical Pitfalls to Avoid

Do not delay repair until symptoms worsen—the chronic right-sided hernia poses ongoing risk of incarceration despite being asymptomatic for 20 years. 7, 1

• Anticoagulant use increases the odds of requiring open repair by 38-fold; if patient is on anticoagulants, coordinate perioperative management carefully 5
• Do not overlook the contralateral side during unilateral repair—laparoscopic approach allows simultaneous evaluation and repair 1
• Ensure adequate mesh coverage to prevent technical recurrence, which accounts for most failures 4

Postoperative Monitoring

Monitor for wound infection, chronic pain, recurrence, and testicular complications, with particular attention to the obesity-related increased risk of wound complications. 1

• Early mobilization and venous thromboembolism prophylaxis are essential given age and obesity 6
• Return to normal activities typically occurs within 2-3 weeks for laparoscopic repair vs 6-8 weeks for open repair 3