What is the best management for a 60‑year‑old man with a reducible, symptomatic inguinal hernia that enlarges with coughing or standing and reduces when supine?

Management of Reducible Symptomatic Inguinal Hernia in a 60-Year-Old Man

Surgical repair is recommended for this patient to prevent life-threatening complications such as incarceration and strangulation, and to avoid the need for future emergency surgery. 1

Rationale for Elective Surgical Intervention

• At age 60, this patient has sufficient life expectancy to benefit from definitive repair, making watchful waiting inappropriate despite the hernia being reducible. 1

• Even minimally symptomatic reducible inguinal hernias warrant repair because the natural history includes progressive enlargement and risk of acute complications that carry significantly higher morbidity and mortality when managed emergently. 1, 2

• The presence of symptoms (mild discomfort, bulging with Valsalva) indicates the hernia is already affecting quality of life, and symptoms typically worsen over time without intervention. 3

• Emergency repair of incarcerated or strangulated hernias carries substantially higher mortality risk in older adults compared to elective repair, making prophylactic surgery the safer long-term strategy. 2

Recommended Surgical Approach

A laparoscopic approach (either TAPP or TEP) is preferred over open Lichtenstein repair for this stable patient, as minimally invasive techniques demonstrate superior outcomes across multiple domains. 1, 4

Advantages of Laparoscopic Repair:

• Significantly reduced chronic postoperative pain compared to open repair (RR = 0.36 for both TAPP and TEP versus Lichtenstein). 4

• Faster return to normal activities and work by approximately 3-4 days (WMD = -3.3 to -3.6 days). 4

• Lower rates of wound complications including hematoma and infection. 4

• Equivalent recurrence rates to open mesh repair, eliminating the historical concern about laparoscopic durability. 4

• Reduced early postoperative pain at 12,24, and 48 hours as measured by VAS scores. 4

Pre-operative Optimization

• Ensure the patient is medically optimized for surgery, addressing any modifiable risk factors such as diabetes control, smoking cessation, and management of constipation. 1, 5

• Standard pre-operative assessment should confirm the patient can tolerate general anesthesia required for laparoscopic repair. 1

Critical Warning Signs Requiring Emergency Intervention

If any of the following develop before scheduled elective repair, proceed immediately to emergency surgery: 1

• Non-reducibility of the hernia
• Severe or escalating pain
• Nausea, vomiting, or signs of bowel obstruction
• Skin changes over the hernia (erythema, warmth)
• Systemic signs of sepsis

Why Other Options Are Inappropriate

• Lifestyle modification alone (Option B) does not address the underlying anatomical defect and will not prevent progression or complications. 3

• Activity modification alone (Option C) may temporarily reduce symptoms but leaves the patient at ongoing risk for incarceration and does not improve quality of life long-term. 3

• Watchful waiting (Option D) was studied in younger patients with truly asymptomatic hernias; this patient already has symptoms and is at an age where emergency surgery risk outweighs the benefits of observation. 2, 3

Common Pitfalls to Avoid

• Do not delay surgery based on "minimal" symptoms – even mild discomfort indicates the hernia is clinically significant and will likely progress. 1, 3

• Do not assume all 60-year-olds are "too old" for elective repair – age alone is not a contraindication, and elective repair is far safer than emergency surgery in this age group. 2

• Do not recommend open repair as first-line unless laparoscopic expertise is unavailable, as the evidence clearly favors minimally invasive approaches for primary unilateral inguinal hernias. 4