A 44-year-old man is listed for elective repair of a primary unilateral inguinal hernia. He is a self-employed plasterer, has a body mass index of 26 and no comorbidity. He asks which approach will get him back to work soonest with the least chance of long-term groin pain.
Which approach is best supported by the evidence?
- AOpen Lichtenstein repair, which has the lowest rate of chronic pain of any technique
- BLaparo-endoscopic repair, provided the operating surgeon has adequate experience with it
- COpen Shouldice repair, avoiding mesh and therefore avoiding mesh-related pain entirely
- DOpen plug-and-patch repair, which shortens operating time and speeds recovery
- EWatchful waiting, since this hernia is unlikely to need repair within the next decade
Show answer and explanation
Correct answer: B
For a primary unilateral inguinal hernia in a fit adult, international guidance recommends a laparo-endoscopic approach (TEP or TAPP) where the necessary expertise exists. Compared with open repair it produces less early post-operative pain, faster return to work and a lower rate of chronic post-operative inguinal pain, with equivalent recurrence. The caveat matters: the learning curve is long, and outside experienced hands the advantage disappears and complication rates rise, which is why the recommendation is conditional on surgeon experience.
Why the others are wrong: A — Lichtenstein is an excellent, durable and widely applicable operation and remains the standard open repair, but chronic groin pain is if anything commoner after open repair than after a laparo-endoscopic one. C — Shouldice is the best of the pure tissue repairs and is a reasonable choice where mesh is to be avoided, but recurrence is higher than with mesh and avoiding mesh does not abolish chronic pain, much of which is neuropathic. D — plug-and-patch offers no advantage over a flat mesh and the plug can migrate or erode. E — watchful waiting is reasonable for a minimally symptomatic hernia in an older or unfit patient, but most men crossing over to surgery do so within a few years, and this man is symptomatic enough to seek repair.
Key point: the choice of technique should follow the surgeon's expertise as much as the evidence. Laparo-endoscopic repair wins on early pain and return to work in trained hands; Lichtenstein remains the reliable default.
Guidelines: HerniaSurge international guidelines for groin hernia management: a mesh-based technique for all adult inguinal hernias, with laparo-endoscopic repair recommended where expertise is available.