From the Guidelines
The best treatment for an old patient with a recurrent inguinal hernia that is irreducible, causing distension, and has failed reduction attempts, especially with a history of retropubic prostatectomy, is option A: Open plasty. This approach is preferred because the patient's history of prostatectomy creates scarring in the preperitoneal space, making laparoscopic approaches (TEP and TAPP) technically challenging and potentially dangerous, as suggested by guidelines that recommend open preperitoneal approach in certain cases 1. The irreducible nature of the hernia with distension suggests possible bowel involvement or strangulation, which requires direct visualization and careful dissection that is better achieved through an open approach, in line with recommendations for emergency hernia repair when intestinal strangulation is suspected 1. Open plasty allows for better control of the operative field in this complex case, facilitates proper management of the hernia contents, and permits appropriate repair of the defect with mesh reinforcement, which is associated with a lower recurrence rate in clean surgical fields 1. Some key points to consider in the management of this patient include:
- The use of mesh in clean surgical fields is recommended due to its association with lower recurrence rates without increasing wound infection rates 1.
- Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels can help predict bowel strangulation, guiding the need for urgent intervention 1.
- Diagnostic laparoscopy may be useful in assessing bowel viability after spontaneous reduction of strangulated groin hernias, but the patient's presentation and history suggest a need for a more direct approach 1. Given the potential for bowel involvement and the need for careful dissection and mesh repair, open plasty is the most appropriate choice, offering the best balance of morbidity, mortality, and quality of life outcomes for this patient.
From the Research
Treatment Options for Recurrent Inguinal Hernia
The patient presents with an irreducible hernia, distension, and a failed trial of reduction, along with a history of retropubic prostatectomy. Considering the provided evidence, the following treatment options can be evaluated:
- Laparoscopic Transperitoneal Inguinal Hernioplasty (TAPP): Studies 2, 3 suggest that TAPP is a safe and effective procedure for inguinal hernia repair after radical open retropubic prostatectomy, with low intra- and postoperative complications and low hernia recurrences.
- Robotic-Assisted Laparoscopic Inguinal Hernia Repair: Evidence from studies 4, 5 indicates that robotic-assisted laparoscopic inguinal hernia repair is also a feasible and safe option for patients with previous prostatectomy, offering advantages in the treatment of bilateral inguinal hernia repairs.
- Open Plasty and Herniorrhaphy: While open plasty and herniorrhaphy are traditional treatment options, the provided evidence does not specifically support their use in this patient's scenario, especially considering the history of retropubic prostatectomy.
- Laparoscopic Totally Extraperitoneal (TEP) Repair: Although TEP is a well-established procedure for inguinal hernia repair, the evidence provided does not directly address its use in patients with a history of retropubic prostatectomy.
Key Considerations
When choosing the best treatment option, the following factors should be considered:
- The patient's history of retropubic prostatectomy and its potential impact on the retropubic space
- The presence of an irreducible hernia and distension, which may require a more urgent intervention
- The failed trial of reduction, which may indicate a more complex hernia
- The potential benefits and risks of each treatment option, including intra- and postoperative complications, hernia recurrences, and the need for additional procedures.