Bilateral Inguinal Hernia in the Obese Patient
A 45-year-old man has had bilateral groin swellings and dragging pain for six months. Examination shows small bilateral reducible inguinoscrotal swellings with positive cough impulses and a soft, non-tender abdomen. His body mass index is 30 kg/m2. He has had no previous abdominal or groin surgery and no cardiorespiratory disease. Which of the following is the most appropriate definitive management?
- A.Bilateral repair with biological mesh
- B.Bilateral herniotomy without mesh
- C.Laparoscopic bilateral preperitoneal mesh repairCorrect
- D.Bilateral open Lichtenstein mesh repair
Explanation
Symptomatic inguinal hernias in a fit adult warrant elective mesh repair, so the question is which technique suits this particular patient. Two features drive the choice: the hernias are bilateral, and the patient is obese with a body mass index of 30 kg/m2. A laparoscopic preperitoneal approach repairs both sides through the same three small ports and a single sheet of mesh on each side, avoiding two separate groin incisions. In obese patients the laparoscopic route also avoids dissecting through a thick subcutaneous fat layer, which lowers wound infection and seroma rates. It is additionally associated with less postoperative pain, less chronic inguinodynia, and earlier return to work than open repair. Open Lichtenstein repair is an excellent operation for a unilateral primary hernia but is not the preferred technique when both sides need repair. Herniotomy, which is simple sac excision without posterior wall reinforcement, is appropriate only in children, since adults have an attenuated posterior wall and would recur. Biological mesh is expensive and reserved for contaminated or infected fields, not for a clean elective groin repair.
Why each option
- A.
- Biological mesh is reserved for contaminated or infected fields and offers no benefit in a clean elective repair.
- B.
- Herniotomy without mesh is appropriate only in children; in adults it has an unacceptably high recurrence rate.
- C.
- Correct. A single laparoscopic procedure repairs both sides, and the small incisions are particularly advantageous in an obese patient.
- D.
- Open Lichtenstein repair is a sound operation for a unilateral hernia but requires two separate groin incisions when disease is bilateral.
Reference: HerniaSurge Group, International Guidelines for Groin Hernia Management, Hernia 2018
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