A patient presents with a hernia medial to the inferior epigastric artery. What is the most likely diagnosis and appropriate management for the same?

Correct Answer: D. Direct hernia and Lichtenstein mesh repair

The inferior epigastric artery is the anatomical landmark that divides inguinal hernias into direct and indirect types. A hernia medial (medially) to the inferior epigastric artery is by definition a direct inguinal hernia. Direct hernias protrude through the Hesselbach triangle (bounded medially by the linea semilunaris, laterally by the inferior epigastric artery, and inferiorly by the inguinal ligament), representing a weakness in the transversus abdominis aponeurosis and conjoint tendon. These are typically acquired hernias in older men with chronic straining or connective tissue laxity. Lichtenstein mesh repair is the gold standard for direct inguinal hernia repair in modern practice because it provides superior recurrence rates (1–3%) compared to tissue repairs like Bassini (10–15% recurrence). The tension-free mesh technique distributes forces over a larger area, reducing strain on the repair site. In Indian surgical practice, Lichtenstein repair is the preferred first-line approach for both primary and recurrent direct hernias, as it is cost-effective, reproducible, and has excellent long-term outcomes. Bassini repair, though a classic tissue-to-tissue repair, is now reserved for specific scenarios (e.g., contaminated fields) due to higher recurrence rates and is not the standard of care for routine direct hernia repair.

Why the other options are wrong

A. Indirect hernia and Bassini repair — This is wrong because the hernia is medial to the inferior epigastric artery, which defines a direct hernia, not indirect. Indirect hernias occur lateral to the inferior epigastric artery and pass through the internal ring. Additionally, Bassini repair is an outdated tissue repair with high recurrence (10–15%) and is not the standard of care for modern hernia management in India. B. Indirect hernia and Lichtenstein mesh repair — This is wrong because the anatomical location (medial to inferior epigastric artery) clearly indicates a direct hernia, not indirect. While Lichtenstein repair is appropriate, pairing it with the wrong hernia type makes the answer incorrect. The NBE trap here is testing whether students confuse the anatomical classification of hernias based on the inferior epigastric artery landmark. C. Direct hernia and Bassini repair — This correctly identifies the hernia type (direct, medial to inferior epigastric artery) but recommends Bassini repair, which is a tissue-to-tissue repair with recurrence rates of 10–15%. Modern evidence and Indian surgical guidelines favor tension-free mesh repair (Lichtenstein) for direct hernias due to superior outcomes. Bassini is now considered suboptimal for routine primary direct hernia repair.

High-Yield Facts

Mnemonics

MEDIAL = DIRECT (Hernia Classification) MEDIAL to inferior epigastric artery = DIRECT hernia. LATERAL to inferior epigastric artery = INDIRECT hernia. Use the inferior epigastric artery as your anatomical compass—if the hernia is on the medial side (toward the midline), it's direct; if lateral (toward the groin), it's indirect. MESH > TISSUE (Modern Repair Choice) Lichtenstein (MESH) > Bassini (TISSUE) for recurrence rates and outcomes. Mesh = 1–3% recurrence; Tissue = 10–15% recurrence. In modern Indian practice, mesh is first-line unless contraindicated (e.g., active infection).

NBE Trap

NBE tests whether students conflate the anatomical classification of hernias with repair techniques. A common trap is pairing the correct repair (Lichtenstein) with the wrong hernia type (indirect), or pairing the correct hernia type (direct) with an outdated repair (Bassini). The question requires knowledge of both the inferior epigastric artery landmark AND modern surgical practice standards.

Clinical Pearl

In Indian surgical practice, a 65-year-old man with chronic cough (COPD) presenting with a bulge in the medial groin is almost certainly a direct hernia. Lichtenstein repair under local anesthesia is the standard outpatient approach in most Indian centers, allowing rapid recovery and return to work—critical for the Indian workforce. Bassini repair, though historically important, is rarely used today except in contaminated cases.

_Reference: Bailey & Love Ch. 36 (Inguinal Hernia); Sabiston Textbook of Surgery Ch. 43_