What are the considerations for a 58-year-old patient with hypertension, diabetes, and coronary artery disease with stents undergoing an open left inguinal hernia repair with mesh?

Open Left Inguinal Hernia Repair with Mesh in High-Risk Cardiac Patient

For this 58-year-old patient with coronary artery disease and stents, proceed with open mesh repair using synthetic mesh with appropriate perioperative antiplatelet management, as mesh repair significantly reduces recurrence rates (50-75% reduction) compared to non-mesh techniques, and the cardiovascular comorbidities do not contraindicate mesh placement in clean surgical fields. 1

Perioperative Antiplatelet Management

This patient's coronary stents require careful antiplatelet drug management to balance thrombotic and bleeding risks:

• Continue aspirin (75-100 mg daily) throughout the perioperative period without interruption, as this is a low-bleeding-risk procedure 2
• If on dual antiplatelet therapy (DAPT) with clopidogrel: Continue both aspirin and clopidogrel if stents were placed within the past 12 months, as interruption increases stent thrombosis risk 2
• If stents are >12 months old: Aspirin monotherapy is sufficient for this procedure 2
• Avoid prasugrel or ticagrelor substitution—clopidogrel is the P2Y12 inhibitor of choice for patients requiring anticoagulation or at bleeding risk 2

The key pitfall is stopping antiplatelet therapy unnecessarily, which dramatically increases cardiac event risk in patients with recent stents.

Cardiovascular Risk Optimization

Blood Pressure Control

• Target systolic BP 120-130 mmHg preoperatively (or 130-140 mmHg given age >65 years) 2
• Continue beta-blockers and ACE inhibitors/ARBs through the morning of surgery, as these reduce perioperative cardiac events 2

Glycemic Control

• Target HbA1c control to reduce surgical site infection risk, though specific targets are not defined for hernia surgery 2
• Avoid hypoglycemia perioperatively, which increases cardiac risk 2

Statin Therapy

• Continue statin therapy perioperatively without interruption 2

Surgical Technique Selection

Open mesh repair is the appropriate choice for this patient, offering several advantages:

• Mesh repair reduces recurrence by 50-75% compared to non-mesh techniques (Peto OR: 0.37,95% CI: 0.26-0.51) 1
• Operating time is comparable or slightly shorter than complex non-mesh repairs (7-10 minutes less than Shouldice) 1
• Return to activities is faster with mesh repair 1
• Chronic pain rates may be lower with mesh compared to non-mesh repair 1

Mesh Selection

• Use synthetic polypropylene mesh in this clean surgical field (CDC Class I), as it provides optimal durability with low infection risk 3, 4
• Large-pore synthetic mesh demonstrates superior infection resistance compared to small-pore designs 3
• Mesh infection risk is only 1.9-5% even in higher-risk patients 3

Risk Factor Mitigation

This patient has multiple factors that increase complication risk:

Hypertension

• Hypertension significantly increases acute postoperative complications (p=0.027) in inguinal hernioplasty 5
• Ensure BP is optimally controlled preoperatively with target <130/80 mmHg 2

Diabetes

• Diabetes increases wound complications and infection risk 5
• Optimize glucose control preoperatively 2
• Consider perioperative glucose monitoring 2

Coronary Artery Disease

• This patient is at very high cardiovascular risk requiring aggressive risk factor management 2
• Ensure cardiac medications (beta-blockers, ACE inhibitors, statins) are continued 2

Antibiotic Prophylaxis

Administer single-dose preoperative antibiotic prophylaxis (typically cefazolin 2g IV within 60 minutes of incision):

• Prophylaxis is particularly important given this patient's risk factors: diabetes, hypertension, and cardiovascular disease 4
• Emergency operations, ASA score ≥3, and longer operative duration increase mesh infection risk 3, 4
• This patient likely has ASA score ≥3 given multiple comorbidities 3

Proton Pump Inhibitor Therapy

Prescribe routine PPI therapy perioperatively:

• PPIs are recommended for patients on aspirin monotherapy or DAPT who are at high GI bleeding risk 2
• This patient's age, antiplatelet therapy, and comorbidities constitute high GI bleeding risk 2

Anesthetic Considerations

Local or regional anesthesia is preferred over general anesthesia when feasible:

• Reduces cardiac stress and allows faster recovery 6
• Open inguinal hernia repair can be performed safely under local anesthesia 6
• Discuss with anesthesia team given cardiac history 6

Expected Outcomes

With appropriate perioperative management:

• Recurrence rate with mesh: 0.8-2% at short-term follow-up 6, 1
• Mean operative time: approximately 40-45 minutes 6
• Hospital stay: typically 1-2 days or same-day discharge if no complications 6, 1
• Return to usual activities: faster than non-mesh repair 1

Critical Pitfalls to Avoid

• Never discontinue aspirin perioperatively in patients with coronary stents—the thrombotic risk far exceeds bleeding risk for this procedure 2
• Do not interrupt DAPT if stents are <12 months old without cardiology consultation 2
• Ensure BP is controlled preoperatively—uncontrolled hypertension significantly increases complications 5
• Do not omit antibiotic prophylaxis—this patient has multiple risk factors for infection 4
• Avoid rapid ascites removal if present—not applicable here but important consideration in similar patients 3