What is the best treatment for an elderly patient with a recurrent inguinal hernia (hernia in the groin area), presenting with an irreducible hernia (incarcerated hernia) and distension, who has failed a trial of reduction and has a history of retropubic prostatectomy (surgical removal of the prostate gland through an abdominal incision)?

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 open plasty (option A). This recommendation is based on the guidelines for emergency repair of complicated abdominal wall hernias, which suggest that open preperitoneal approach is preferable in cases where there is suspicion of bowel strangulation or the need for bowel resection 1. The patient's history of retropubic prostatectomy creates scarring in the preperitoneal space, making laparoscopic approaches (TEP and TAPP) technically challenging and potentially dangerous.

The irreducible nature of the hernia with distension suggests possible bowel involvement or strangulation, which requires immediate intervention and direct visualization that open surgery provides. According to the guidelines, patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected, and systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, CPK, and D-dimer levels are predictive of bowel strangulation 1. Open plasty allows the surgeon to safely dissect through scarred tissue, reduce the hernia contents, assess bowel viability, and place a mesh reinforcement to prevent further recurrence.

Key points to consider in this scenario include:

• The use of mesh in clean surgical fields is associated with a lower recurrence rate, and prosthetic repair with a synthetic mesh is recommended for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection 1.
• For patients having complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage, emergent prosthetic repair with synthetic mesh can be performed 1.
• The choice of mesh and surgical approach should be evaluated depending on the defect size, degree of contamination, and patient stability 1.

In this case, given the patient's history and presentation, open plasty (option A) is the most appropriate treatment, as it allows for direct visualization, assessment of bowel viability, and safe placement of mesh reinforcement, while minimizing the risks associated with laparoscopic approaches in the presence of altered anatomy and potential bowel compromise.

From the Research

Treatment Options for Recurrent Inguinal Hernia

The patient in question has a history of retropubic prostatectomy and is now presenting with an irreducible hernia, distension, and a failed trial of reduction. Considering the provided evidence, the following treatment options can be evaluated:

• Laparoscopic Transperitoneal Inguinal Hernioplasty (TAPP): This approach has been shown to be safe and effective in patients with inguinal hernias after radical open retropubic prostatectomy 2. The study found low intra- and postoperative complications and low hernia recurrences.
• Single-Port Laparoscopic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair: This technique has been demonstrated to be safe and feasible in patients with inguinal hernia after radical prostatectomy, utilizing the previous prostatectomy scar 3.
• Robotic Inguinal Hernia Repair: Robotic-assisted laparoscopic inguinal hernia repair has been found to be safe and feasible in patients with previous prostatectomy, with no documented major intraoperative complications or recurrences 4, 5.
• Open Anterior Repair with Mesh (Lichtenstein): This approach can be used for inguinal hernia repair after previous transabdominal prostatectomy, but may have a higher risk of complications compared to minimally invasive techniques 5.

Key Considerations

When choosing a treatment option, the following factors should be considered:

• The patient's history of retropubic prostatectomy and the potential for scarring in the retropubic space
• The size and location of the hernia defect
• The patient's overall health and potential for complications
• The surgeon's experience and expertise with the chosen technique

Comparison of Treatment Options

The provided evidence suggests that:

• Laparoscopic TAPP and robotic-assisted laparoscopic inguinal hernia repair are safe and effective options for patients with inguinal hernias after radical open retropubic prostatectomy
• Single-port laparoscopic TAPP inguinal hernia repair is a feasible option for patients with inguinal hernia after radical prostatectomy
• Open anterior repair with mesh (Lichtenstein) can be used, but may have a higher risk of complications compared to minimally invasive techniques

Based on the provided evidence, the best treatment option for the patient would be:

• c. Lap TAPP or d. Lap TEP, as these approaches have been shown to be safe and effective in patients with inguinal hernias after radical open retropubic prostatectomy 2, 3. However, the final decision should be made based on the individual patient's needs and the surgeon's expertise.