What is the recommended management for a patient with a left inguinal hernia and previous surgery in the area, experiencing pain that worsens with Valsalva maneuver?

Management of Recurrent Left Inguinal Hernia with Pain

This patient requires elective surgical repair with mesh using a posterior approach (laparoscopic TEP or TAPP), as the symptomatic hernia with previous anterior surgery mandates definitive repair to prevent progression to incarceration while the posterior approach addresses the recurrent nature of the hernia. 1

Immediate Assessment Required

Determine urgency of repair based on reducibility and signs of complications:

• Assess for incarceration/strangulation: Pain increasing with Valsalva maneuver at 6/10 intensity requires evaluation for whether the hernia is fully reducible or shows signs of incarceration (inability to reduce, severe pain, nausea/vomiting, bowel obstruction symptoms) 1
• If signs of strangulation are present (severe pain, systemic symptoms, peritonitis), this becomes an emergency requiring immediate surgical intervention to prevent bowel necrosis, as delayed diagnosis beyond 24 hours significantly increases mortality 1
• Predictors of strangulation include SIRS criteria, elevated lactate, CPK, D-dimer levels, and contrast-enhanced CT findings showing bowel wall ischemia 1

Surgical Approach for Recurrent Hernia

Since this is a recurrent hernia after previous surgery in the area (presumed anterior repair):

• Posterior approach (laparoscopic TEP or TAPP) is recommended as the standard for recurrent hernias following anterior repair 1
• Laparoscopic repair offers significantly lower wound infection rates, no increase in recurrence rates, shorter hospital stay, and ability to identify contralateral hernias (present in 11.2-50% of cases) 1
• Mesh repair is mandatory - mesh repair shows 0% recurrence versus 19% with tissue repair in clean surgical fields 1
• TAPP may be easier in recurrent cases when TEP proves technically difficult 1

Mesh Selection and Fixation

• Standard synthetic mesh is recommended in clean surgical fields, with significantly lower recurrence rates without increased infection risk 1, 2
• In TEP repair, mesh fixation is unnecessary in most cases; however, mesh should be fixed in large medial hernias (M3) to reduce recurrence risk 3
• Biosynthetic, biologic, or composite meshes are only suggested when contamination is present 4

Anesthesia Considerations

• General anesthesia is required for laparoscopic approach 1
• Local anesthesia is only an option for open repairs in emergency settings without bowel compromise 1

Special Considerations for This Case

Given the previous surgery and current symptoms:

• The posterior laparoscopic approach avoids the previously operated anterior field, reducing risk of nerve injury and chronic pain 1
• Examine the contralateral side during TAPP to identify occult hernias present in up to 50% of cases 1
• Day surgery is appropriate for elective repair provided aftercare is organized 3

Postoperative Pain Management

• Prioritize acetaminophen and NSAIDs as primary pain control 1
• Limit opioid prescribing to 10 tablets of oxycodone 5mg for laparoscopic repair to minimize dependence risk 1
• Patients should resume normal activities without restrictions as soon as comfortable 3

Critical Pitfalls to Avoid

• Do not delay repair if signs of strangulation develop - this leads to bowel necrosis and increased morbidity/mortality 1
• Do not perform anterior repair for this recurrent hernia - after failed anterior repair, posterior approach is the recommended strategy 1
• Do not use tissue repair without mesh - this carries a 19% recurrence rate versus 0% with mesh 1
• Risk of chronic postoperative inguinal pain ranges from 10-12% overall, with debilitating pain affecting daily activities in 0.5-6% of cases 3