What is the recommended treatment for an adult male with a symptomatic inguinal hernia and a history of heavy lifting or straining?

Inguinal Hernia Repair in Adult Males with Symptomatic Hernias

For an adult male with a symptomatic inguinal hernia and history of heavy lifting, surgical repair with mesh is the definitive treatment and should be performed electively to prevent incarceration and strangulation. 1, 2

Immediate Assessment Required

First, determine if the hernia is reducible, incarcerated, or strangulated, as this dictates urgency 2, 3:

• Reducible hernia: Schedule elective repair within reasonable timeframe
• Incarcerated hernia: Urgent repair needed, assess for signs of strangulation
• Strangulated hernia: Emergency surgery mandatory—delayed diagnosis beyond 24 hours significantly increases mortality 4, 1, 3

Look for these red flags indicating strangulation 1, 3:

• Systemic inflammatory response syndrome (SIRS) criteria
• Elevated lactate, CPK, or D-dimer levels
• Contrast-enhanced CT showing bowel wall ischemia
• Peritoneal signs on examination

Surgical Approach Selection

Mesh repair is strongly recommended over tissue repair for all non-complicated inguinal hernias, with significantly lower recurrence rates (0% vs 19%) without increased infection risk 1, 2, 5.

Choose Laparoscopic Repair (TEP or TAPP) when 1, 2:

• Bilateral hernias present
• Patient desires reduced postoperative pain and faster return to activities
• Incarcerated hernia without strangulation or bowel compromise
• Recurrent hernia
• Surgeon has laparoscopic expertise

Laparoscopic advantages include 1, 2:

• Significantly lower wound infection rates (P<0.018)
• Reduced postoperative pain medication requirements
• Ability to identify occult contralateral hernias (present in 11.2-50% of cases)
• Faster return to normal activities including heavy lifting

Choose Open Repair (Lichtenstein) when 1, 2, 3:

• Strangulated hernia with suspected bowel compromise
• Patient cannot tolerate general anesthesia
• Local anesthesia preferred (feasible for open approach without bowel gangrene)
• Laparoscopic expertise unavailable
• Significant comorbidities present

Emergency/Incarcerated Hernia Management

For incarcerated hernias, the approach depends on clinical presentation 1, 3:

Without signs of strangulation 1:

• Prosthetic mesh repair strongly recommended (Grade 1A)
• Laparoscopic approach appropriate if no peritonitis
• Synthetic mesh safe in clean surgical fields

With strangulation or suspected bowel compromise 4, 1, 3:

• Emergency surgery mandatory immediately
• Open preperitoneal approach preferable when bowel resection may be needed
• Consider hernioscopy (laparoscopy through hernia sac) to assess bowel viability—decreases hospital stay and prevents unnecessary laparotomies 1, 3
• Local anesthesia acceptable for open repair if no bowel gangrene 4, 1

Risk factors predicting need for bowel resection 4, 1:

• Femoral hernia (8-fold higher risk)
• Obvious peritonitis
• Lack of health insurance (reflects delayed presentation)

Postoperative Pain Management

Prioritize non-opioid analgesia 1:

• First-line: Acetaminophen and NSAIDs
• Opioid prescribing limits:
  • Laparoscopic repair: 10 tablets oxycodone 5mg or 15 tablets hydrocodone/acetaminophen 5/325mg
  • Open repair: 15 tablets hydrocodone/acetaminophen 5/325mg

Critical Pitfalls to Avoid

Never delay repair of strangulated hernias—this leads to bowel necrosis, increased morbidity, and significantly higher mortality 4, 1, 2, 3. Emergency repair must be performed immediately when strangulation is suspected.

Do not overlook contralateral hernias—occult contralateral hernias are present in up to 50% of cases 1, 2. Laparoscopic approach allows examination of the opposite side during the same procedure.

Avoid attempting manual reduction if 3:

• Skin changes present (erythema, warmth, discoloration)
• Firm, tender, irreducible mass
• Peritoneal signs on examination
• Even if reduction successful, consider diagnostic laparoscopy to rule out occult bowel ischemia

Special Consideration for This Patient

Given the history of heavy lifting, counsel the patient that 1, 2:

• Laparoscopic repair offers faster return to normal activities including heavy work
• Mesh repair provides superior strength and lower recurrence rates essential for patients with ongoing physical demands
• Postoperative activity restrictions typically last 2-4 weeks before gradual return to heavy lifting