What is the best course of action for a 60-year-old man with a reducible inguinal hernia that causes mild discomfort, especially when coughing or standing?

Surgical Repair is Recommended

For a 60-year-old man with a reducible inguinal hernia causing mild discomfort, surgical repair with mesh is the recommended approach, as all symptomatic inguinal hernias should be repaired electively to prevent the significantly higher morbidity and mortality associated with emergency repair if incarceration or strangulation develops. 1, 2

Rationale for Surgical Intervention

The evidence strongly supports elective repair over watchful waiting in this clinical scenario for several critical reasons:

• Emergency repair carries 10% mortality in elderly patients (>65 years) compared to 0% mortality with elective repair, making prophylactic surgery the safer option 3

• Emergency hernia repair has 58% complication rate versus 22% for elective repair in elderly patients, representing a nearly 3-fold increase in morbidity 3

• Emergency repair is required in 16.4% of elderly patients with inguinal hernias compared to only 4.4% in younger patients, demonstrating age-related increased risk 3

• Mesh repair is the standard of care with 0% recurrence rate versus 19% with tissue repair, without increased infection risk in clean surgical fields 1, 2

Why Other Options Are Inappropriate

Watchful waiting (Option D) is explicitly contraindicated in this case because:

• The hernia is already symptomatic with mild discomfort, and symptomatic groin hernias should be treated surgically 2
• The patient is 60 years old, placing him at higher risk for emergency complications if incarceration develops 3, 4
• All inguinal hernias should be repaired electively in elderly patients unless there is an overwhelming contraindication to surgical intervention 3

Lifestyle and activity modifications (Options B and C) do not address the underlying anatomical defect:

• These measures cannot prevent progression to incarceration or strangulation 5
• The physical features of the hernia (size, ease of reduction) do not consistently predict the risk of incarceration 5
• Avoiding activities that increase intra-abdominal pressure is only a temporizing measure, not definitive management 5

Surgical Approach Selection

For this patient, either open (Lichtenstein) or laparoscopic approach (TEP/TAPP) is appropriate for a primary unilateral hernia 2:

• Open repair with local anesthesia offers fewer cardiac and respiratory complications, shorter hospital stays, and lower costs 1
• Laparoscopic repair provides reduced chronic postoperative pain, faster return to activities, and ability to identify occult contralateral hernias (present in 11-50% of cases) 1, 2

Common Pitfalls to Avoid

• Delaying surgery in elderly patients significantly increases the risk of emergency presentation with incarceration/strangulation, which carries substantially higher mortality and morbidity 3, 4
• Assuming watchful waiting is safe in symptomatic patients ignores the evidence that symptomatic hernias warrant surgical intervention 2, 6
• Failing to examine the contralateral side may miss occult hernias present in up to 50% of cases 1, 2

The answer is A: Surgical repair.