In a young healthy male builder with a reducible inguinal hernia extending into the scrotum, what is the recommended management?

Management of Reducible Inguinal Hernia in Young Builder

Tension-free mesh repair (Option B) is the recommended treatment for this young, healthy, physically active male with a reducible inguinal hernia extending to the scrotum. 1, 2

Why Surgical Repair is Indicated

• All symptomatic groin hernias should be treated surgically, even when reducible, to prevent complications that would necessitate emergency surgery with higher complication rates. 1, 2

• Observation (watchful waiting) is not appropriate for this patient because:

  • He is concerned about the hernia (making it symptomatic by definition) 2
  • His occupation as a builder involves activities that increase intra-abdominal pressure, which patients should avoid to prevent incarceration and strangulation 1
  • The physical demands of his work make conservative management impractical 1

Why Mesh Repair is Superior

• Mesh repair significantly reduces hernia recurrence compared to non-mesh techniques (RR 0.46,95% CI 0.26 to 0.80), preventing one recurrence for every 46 mesh repairs performed. 3

• Mesh repair results in fewer neurovascular and visceral injuries compared to non-mesh repair (RR 0.61,95% CI 0.49 to 0.76, NNTB = 22). 3

• Mesh repair allows faster return to normal activities (mean 2.87 days sooner) and shorter hospital stay (0.6 days shorter), which is particularly important for a young working individual. 3

Mesh Repair Approach Options

• Both open (Lichtenstein) and laparoscopic (TEP/TAPP) mesh repairs are appropriate, with the choice depending on available expertise and patient factors. 2

• Laparoscopic approaches offer advantages for young, active patients:

  • Faster recovery times 2
  • Lower chronic pain risk 2
  • Cost-effective when performed as day surgery with minimal disposables 2

• Open Lichtenstein repair remains an excellent option with well-established outcomes and can be performed under local anesthesia. 2

Why Other Options Are Not Recommended

• Herniotomy (Option A) is a pediatric procedure for patent processus vaginalis and is not appropriate for adult inguinal hernias. 1

• Herniorrhaphy without mesh (Option C) has significantly higher recurrence rates and is only considered when mesh cannot be used or after extensive patient discussion about inferior outcomes. 2, 3

• Observation (Option D) is contraindicated because the patient is symptomatic (concerned), young, and physically active with occupational demands that increase hernia complications risk. 1, 2

Important Considerations for This Patient

• Scrotal extension (large hernia) presents unique surgical challenges but does not change the recommendation for mesh repair. 1

• In young males, mesh repair may cause a slight increase in testicular resistive index postoperatively, but does not significantly affect sperm concentration or progressive motility. 4

• Day surgery is recommended for the majority of groin hernia repairs, allowing rapid return to work. 2

• The patient should be counseled that he can resume normal activities without restrictions as soon as comfortable postoperatively. 2

Critical Red Flags to Assess Before Elective Repair

• Ensure the hernia remains reducible without signs of incarceration (irreducibility, tenderness, erythema, warmth). 1, 5

• Rule out systemic signs of strangulation (fever, tachycardia, abdominal rigidity, vomiting) that would require emergency intervention. 1, 5

• Examine the contralateral groin as occult hernias occur in 11-50% of cases. 1, 2