Should an elderly male with a reducible right inguinal hernia, confirmed by ultrasound showing a 1.8cm fat-containing hernia with a break in the muscle wall, undergo computed tomography (CT) scan or be referred for surgical evaluation?

Direct Surgical Referral Without CT

This elderly male with a reducible inguinal hernia confirmed by ultrasound should be referred directly to surgery without obtaining a CT scan. The ultrasound has already provided definitive diagnosis showing a 1.8cm fat-containing hernia with a clear defect in the muscle wall, and CT imaging would not change management in this uncomplicated, reducible hernia 1.

Why CT is Not Indicated

• CT scanning is reserved for emergency settings when complications like bowel obstruction, strangulation, or incarceration are suspected 2
• In this case, the hernia is reducible (meaning it can be pushed back), which rules out the emergency complications that would warrant CT imaging 1
• CT is useful for predicting bowel strangulation with contrast enhancement findings, but this patient has no signs of strangulation 2
• The ultrasound has already confirmed the diagnosis and characterized the hernia adequately for surgical planning 3

Why Surgical Referral is Appropriate

Surgical repair is indicated for this patient based on several factors:

• The 1.8cm defect represents a significant risk for future complications including incarceration and strangulation 4
• Delaying repair of inguinal hernias can lead to complications such as incarceration and strangulation, which significantly increase morbidity and mortality 4, 1
• All symptomatic inguinal hernias (this patient has pain) should be repaired, as watchful waiting is only reasonable for asymptomatic or minimally symptomatic hernias 3
• The hernia is currently reducible, making this an elective repair in a clean surgical field, which allows for optimal outcomes with mesh repair 1

Surgical Approach Considerations

The surgeon will likely recommend:

• Mesh repair as the standard approach, which has significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk in clean surgical fields 1
• Laparoscopic repair (TEP or TAPP) offers advantages including reduced postoperative pain, lower wound infection rates, faster recovery, and the ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 2
• Open repair remains an option, particularly if the patient has significant comorbidities or if local anesthesia is preferred 1

Common Pitfall to Avoid

Do not delay surgical referral to obtain unnecessary imaging. The ultrasound diagnosis is sufficient, and the reducible nature of the hernia means this is an appropriate elective surgical case. Delaying increases the risk that the hernia will become incarcerated or strangulated, converting an elective procedure into an emergency with higher complication rates 4, 1.