Management of Incidentally Discovered, Reducible Inguinal Hernia in a 60-70 Year Old Man
For a 60-70 year old man with an incidentally discovered, reducible inguinal hernia causing only slight discomfort, surgical mesh repair is the most appropriate management, as watchful waiting is only considered safe in younger patients under 50 years old. 1, 2
Key Decision Factors
The critical age threshold fundamentally changes the management approach:
Watchful waiting is only safe and cost-effective for patients under 50 years old with asymptomatic or minimally symptomatic inguinal hernias, provided they have ASA class 1-2, an inguinal (not femoral) hernia, and duration of signs more than 3 months. 1
Patients over 60 years face significantly higher risk of incarceration and complications, with age above 60 years being a specific risk factor for hernia incarceration (approximately 4 per 1,000 patients per year). 1
Emergency repair in older patients carries substantially higher morbidity and mortality, particularly in those over 49 years, making elective repair the safer strategy. 1
Recommended Surgical Approach
Mesh repair should be performed electively as the standard of care, with the following considerations:
Either open (Lichtenstein) or laparoscopic approach (TEP/TAPP) is appropriate for primary unilateral inguinal hernias in men, with mesh repair showing significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 3, 2
Local anesthesia for open repair is strongly recommended in this age group, as it provides effective anesthesia with fewer cardiac and respiratory complications, shorter hospital stays, and faster recovery compared to general anesthesia. 4, 2
Day-case surgery is feasible and recommended for elderly patients, even with significant comorbidities, as studies demonstrate excellent outcomes with no major complications in patients over 70 years. 5, 2
Why Not Observation?
The "watchful waiting" strategy has critical limitations in this age group:
The majority of patients on watchful waiting eventually require surgery anyway, making delayed repair inevitable rather than preventive. 2
Elderly patients (>70 years) actually tolerate elective hernia repair better than younger patients, with less postoperative discomfort, faster recovery (13 vs 21 days return to normal activities), and fewer days of analgesic use (3.4 vs 6.0 days). 5
Elective repair in elderly patients is safe and effective when performed under local anesthesia with mesh, even in the presence of significant cardiac comorbidities. 5, 6
Common Pitfalls to Avoid
Do not delay surgery based solely on age - age alone should not be a barrier to elective day-case inguinal hernia repair, as outcomes are excellent in the 70+ age group when surgery is performed electively. 5
Avoid emergency situations - the risk of emergency repair is substantially higher than elective repair in older patients, with increased morbidity when delay between symptom onset and surgery exceeds 12 hours. 1
Do not recommend increased physical activity - this is not a treatment for inguinal hernia and does not address the underlying defect or prevent progression. 2
Practical Implementation
Schedule elective mesh repair under local anesthesia as a day-case procedure, ensuring:
Preoperative assessment confirms ASA class and identifies cardiac comorbidities (present in 60% of patients >70 years). 5
Perioperative field blocks and/or subfascial/subcutaneous infiltrations are used for optimal pain control. 2
Postoperative pain management emphasizes acetaminophen and NSAIDs, with limited opioid prescribing (15 tablets hydrocodone/acetaminophen 5/325mg or 10 tablets oxycodone 5mg for open repair). 4
Patients are advised to resume normal activities without restrictions as soon as comfortable. 2