In a young, healthy male builder with a reducible inguinal hernia extending into the scrotum who is concerned about the swelling, what is the most appropriate management: herniotomy, tension‑free mesh repair, herniorrhaphy, or observation?

Management of Reducible Inguinal Hernia in Young Builder

For a young, healthy male builder with a reducible inguinal hernia extending into the scrotum, tension-free mesh repair (Option B) is the definitive treatment of choice, offering significantly lower recurrence rates compared to tissue repair without increased infection risk. 1

Rationale Against Observation

Observation (Option D) is not appropriate for this patient because:

• All symptomatic inguinal hernias require surgical repair to prevent life-threatening complications including bowel incarceration and strangulation 1, 2
• The patient is already concerned about the swelling, indicating symptomatic disease that warrants intervention 3
• His occupation as a builder involves activities that increase intra-abdominal pressure, which elevates the risk of incarceration and strangulation 4
• Delaying repair increases the risk of emergency surgery with significantly higher complication rates and mortality 1, 2

Why Tension-Free Mesh Repair is Superior

Mesh repair demonstrates a dramatic reduction in recurrence rates:

• In young men (18-30 years), mesh repair shows a 1.6% recurrence rate at 5 years versus 3.9% with sutured repair 5
• The overall reoperation rate is three-fold lower with mesh (1.2%) compared to sutured repair (3.5%) 5
• Large-scale data from 3,019 primary inguinal hernias treated with mesh showed only 0.2% recurrence rate with no mesh rejections 6
• Prosthetic mesh repair is strongly recommended (Grade 1A) for clean surgical fields, with studies showing 0% recurrence versus 19% with tissue repair 1

Herniotomy vs Herniorrhaphy vs Mesh Repair

Herniotomy (Option A) is primarily a pediatric procedure involving simple excision of the hernia sac without repair of the floor, which is inadequate for adult inguinal hernias 4

Herniorrhaphy (Option C) refers to traditional tissue repair techniques (such as Bassini or Shouldice):

• While these techniques may be considered in resource-limited settings 7, they are not the standard of care in developed countries for young, active patients
• The significantly higher recurrence rates make this approach suboptimal for a builder who will return to physically demanding work 5

Surgical Approach Selection

For this young, healthy patient, laparoscopic approaches (TEP or TAPP) offer specific advantages:

• Reduced chronic postoperative pain and numbness compared to open repair 1, 2
• Faster return to normal activities, which is crucial for a builder 2
• Lower wound infection rates (P<0.018) without increased recurrence (P<0.815) 8, 1
• Ability to identify occult contralateral hernias, present in 11.2-50% of cases 1, 2

Open mesh repair (Lichtenstein) remains an excellent alternative:

• Can be performed under local anesthesia, offering fewer cardiac and respiratory complications, shorter hospital stays, and lower costs 1
• Provides comparable recurrence rates to laparoscopic approaches 1

Critical Considerations for This Patient

The scrotal extension requires specific attention:

• Large inguinoscrotal hernias may contain significant bowel content, presenting unique surgical challenges 4
• Both laparoscopic and open mesh approaches can effectively manage scrotal hernias 1

Chronic pain risk must be balanced:

• While mesh repair reduces recurrence, the risk of chronic pain exists with any repair technique 5
• Laparoscopic approaches may reduce chronic pain compared to open repair 9
• Preperitoneal mesh positioning (via TEP, TAPP, or open preperitoneal approaches) shows promising results for reducing postoperative chronic pain 9

Common Pitfalls to Avoid

• Do not delay surgery in symptomatic patients, as this increases emergency presentation risk with higher morbidity and mortality 1, 2
• Do not use tissue repair alone in young, active patients given the substantially higher recurrence rates 5
• Examine both groins to avoid missing occult contralateral hernias, which occur in up to 50% of cases 1, 4
• Ensure the patient understands that returning to heavy lifting too soon postoperatively can compromise repair integrity 1