Management of Reducible Inguinal Hernia with Moderate Pain in a 72-Year-Old Male
For this 72-year-old man with a reducible inguinal hernia causing moderate pain, open repair with mesh (Option B) is the most appropriate management, as mesh repair is the definitive standard approach for all non-complicated inguinal hernias with significantly lower recurrence rates (0% vs 19% with tissue repair) without increased infection risk. 1
Rationale for Mesh-Based Repair
Mesh repair is strongly recommended as the standard approach for all non-complicated inguinal hernias according to the European Hernia Society, with synthetic mesh demonstrating significantly superior outcomes compared to tissue repair alone. 1
The presence of moderate pain indicates this is a symptomatic hernia requiring surgical intervention, as symptomatic groin hernias should be treated surgically according to the European Hernia Society. 2
Simple repair (Option C) without mesh is not appropriate because it carries a 19% recurrence rate compared to 0% with mesh repair in clean surgical fields. 1
Conservative management (Option D) is not appropriate for symptomatic hernias, as the goal is to prevent complications that would necessitate emergency surgery with higher complication rates. 2
Open vs Laparoscopic Approach in This Patient
Open repair with mesh is preferred over laparoscopic repair (Option A) for this specific patient based on the following considerations:
While laparoscopic approaches (TEP or TAPP) offer comparable outcomes to open repair with advantages including reduced chronic postoperative pain and faster return to activities 1, open repair can be performed under local anesthesia, which provides effective anesthesia with fewer cardiac and respiratory complications, shorter hospital stays, and faster recovery compared to general anesthesia. 1
This is particularly relevant in a 72-year-old patient who may have comorbidities that increase anesthetic risk. 1
General anesthesia is mandatory for laparoscopic approaches, which may pose higher risks in elderly patients. 1
Open mesh repair (Lichtenstein technique) has demonstrated excellent outcomes with recurrence rates as low as 0.2% and minimal morbidity in large series. 3
Technical Considerations for Open Mesh Repair
The mesh should overlap the defect edge by 1.5-2.5 cm to ensure adequate coverage. 1
Mesh fixation can be performed using sutures or tackers, though recent evidence suggests non-fixation techniques may reduce operative time and postoperative pain without increasing recurrence rates. 4
The procedure can be safely performed under local anesthesia when the surgeon is experienced in this technique, offering multiple advantages including reduced complications and costs. 1
Common Pitfalls to Avoid
Do not perform simple tissue repair without mesh - this carries an unacceptably high 19% recurrence rate compared to mesh repair. 1
Do not delay surgical intervention in symptomatic hernias, as this increases the risk of developing incarceration or strangulation requiring emergency surgery with higher morbidity and mortality. 5, 2
Examine both groins bilaterally to avoid missing occult contralateral hernias, which occur in 11-50% of cases. 2
Assess carefully for signs of incarceration or strangulation (irreducibility, tenderness, erythema, systemic symptoms) which would require emergency intervention. 2
Postoperative Management
Encourage acetaminophen and NSAIDs as primary pain control, with limited opioid prescribing (15 tablets of hydrocodone/acetaminophen 5/325mg or 10 tablets of oxycodone 5mg for open repair) to minimize risk of opioid dependence. 1
Monitor for potential complications including wound infection, chronic pain, and recurrence. 1