What is the optimal management for a young, physically active male builder with a reducible inguinal hernia extending into the scrotum?

Management of Reducible Inguinal Hernia in Young Builder

For a young, physically active male builder with a reducible inguinal hernia extending into the scrotum, tension-free mesh repair (Option B) is the definitive treatment of choice. 1

Rationale for Surgical Intervention

Observation (Option D) is not appropriate for this patient. All symptomatic inguinal hernias in adults require surgical repair to prevent life-threatening complications including incarceration, strangulation, and bowel necrosis. 1 The physical characteristics of the hernia—including size, amount of herniating contents, and ease of reduction—do not reliably predict incarceration risk, making watchful waiting unacceptably dangerous. 2 For a young, physically active builder whose occupation involves heavy lifting and increased intra-abdominal pressure, delaying repair significantly increases the risk of emergency presentation with strangulation. 1, 2

Choice of Surgical Technique

Why Mesh Repair is Superior

Tension-free mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias in adults. 1 The evidence overwhelmingly favors mesh over tissue repair:

• Recurrence rates: Mesh repair demonstrates 0% recurrence versus 19% with tissue repair in clean surgical fields 1
• Meta-analysis data: Mesh reduces recurrence risk by 50-75% compared to non-mesh techniques (Peto OR: 0.37,95% CI: 0.26 to 0.51) 3
• No increased infection risk: Synthetic mesh in clean fields does not increase wound infection rates 1

Why Not Herniotomy (Option A)

Herniotomy—simple high ligation of the hernia sac—is exclusively reserved for pediatric inguinal hernias caused by patent processus vaginalis. 4 This technique is inappropriate for adult hernias, which result from acquired weakness of the inguinal floor rather than congenital defects. 4

Why Not Simple Herniorrhaphy (Option C)

Traditional herniorrhaphy (tissue repair under tension, such as Bassini technique) violates the fundamental surgical principle that tissues should never be approximated under tension. 5 This accounts for the unacceptably high recurrence rates of 19% compared to mesh repair. 1 While one study from resource-limited settings reported acceptable short-term outcomes with Bassini repair for giant inguinoscrotal hernias, this was explicitly in an austere environment without mesh availability—not the standard of care. 6

Optimal Surgical Approach Selection

For this young, active patient with a scrotal hernia, you have two evidence-based options:

Laparoscopic Approach (TEP or TAPP)

This is the preferred method for primary unilateral inguinal hernias in young males due to:

• Lower postoperative pain and reduced analgesic requirements 1, 7
• Faster return to work and normal activities (critical for a builder) 1, 7
• Significantly lower wound infection rates 1
• Comparable recurrence rates to open repair 1, 7
• Ability to identify occult contralateral hernias (present in 11.2-50% of cases) 1

Open Lichtenstein Mesh Repair

This remains appropriate and may be preferred for scrotal hernias specifically because: 8

• Scrotal extension is listed as a relative indication for open approach over laparoscopic 8
• Can be performed under local anesthesia if general anesthesia is contraindicated 1
• Proven track record with 4,000 repairs showing only 4 recurrences over 5-year mean follow-up 5

Practical Algorithm for This Patient

1. Confirm the hernia is truly reducible and assess for any signs of incarceration (irreducibility, tenderness, erythema, systemic symptoms) 2

2. Examine both groins bilaterally to avoid missing occult contralateral hernias 2

3. Discuss surgical options with the patient:

   • If laparoscopic expertise is available and patient can tolerate general anesthesia: TEP or TAPP is preferred 1, 8
   • If scrotal extension is massive or patient prefers local anesthesia: Open Lichtenstein repair 8

4. Schedule semi-urgent repair within 2-4 weeks to minimize incarceration risk while allowing for proper surgical planning 1

Critical Pitfalls to Avoid

• Never observe a reducible hernia in an adult—all inguinal hernias require surgical correction 1
• Never use tissue repair (herniorrhaphy) when mesh is available—this results in 50-75% higher recurrence rates 1, 3
• Never delay repair in physically active patients—their occupation increases intra-abdominal pressure and strangulation risk 2
• Do not overlook the contralateral side—laparoscopic approach allows identification of occult hernias in up to 50% of cases 1

Postoperative Considerations for This Builder

• Encourage acetaminophen and NSAIDs as primary pain control 1
• Limit opioid prescribing to 15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg for laparoscopic repair 1
• Expected return to work: faster with laparoscopic approach (mean difference of several days to weeks) 7
• Advise temporary activity modification but emphasize that mesh repair allows earlier return to heavy lifting compared to tissue repair 1