Management of Incidentally Discovered Reducible Inguinal Hernia in a 60-70 Year Old Male
For a 60-70 year old male with an incidentally discovered, reducible inguinal hernia causing only mild discomfort and no pain, surgical repair with mesh is the most appropriate management, as watchful waiting carries ongoing risk of incarceration/strangulation and all symptomatic hernias warrant definitive repair. 1, 2
Rationale for Surgical Repair
Mesh repair is the standard of care for symptomatic inguinal hernias, demonstrating significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk in clean surgical fields 1, 2
Even "mild discomfort" constitutes a symptom that warrants repair, as the European Hernia Society and American College of Surgeons recommend surgical intervention for symptomatic hernias to prevent progression and complications 1, 3
The distinction between asymptomatic and minimally symptomatic is critical: watchful waiting may be considered only for truly asymptomatic male patients, but once symptoms develop (even mild discomfort), repair becomes indicated 2
Why Observation Alone Is Inadequate
While watchful waiting has been studied as an option for asymptomatic hernias, the presence of discomfort—even if mild—changes the risk-benefit calculation toward surgical intervention 4, 5
Delayed repair increases the risk of emergency presentation with incarceration or strangulation, which carries significantly higher mortality rates, particularly when diagnosis is delayed beyond 24 hours 3
Femoral hernias (which can be misdiagnosed as inguinal hernias, especially in women) carry an 8-fold higher risk of requiring bowel resection, emphasizing the importance of definitive repair rather than observation 3, 2
Optimal Surgical Approach for This Patient
Choice Between Open and Laparoscopic Repair
For a primary unilateral hernia in a male patient, either open (Lichtenstein) or laparoscopic approach (TEP or TAPP) is appropriate, with the choice depending on surgeon expertise and patient factors 2
Laparoscopic approaches offer significant advantages including reduced chronic postoperative pain, faster return to normal activities, lower wound infection rates, and ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1, 3
Anesthesia Considerations
Local anesthesia for open repair is strongly recommended when feasible, providing effective anesthesia with fewer cardiac and respiratory complications, shorter hospital stays, lower costs, and faster recovery compared to general anesthesia 1
General anesthesia is required for laparoscopic approaches (TEP or TAPP) 1
Common Pitfalls to Avoid
Do not delay repair once symptoms develop, as progression to incarceration/strangulation significantly increases morbidity and mortality, particularly in older patients 3, 4
Do not dismiss "mild discomfort" as insignificant—this represents a symptomatic hernia warranting repair rather than observation 2, 5
Ensure accurate differentiation from femoral hernia, particularly given the higher complication risk with femoral hernias 3, 2
Consider laparoscopic approach to avoid overlooking contralateral hernias, which are present in up to 50% of cases and would require future operation if missed 1, 3