European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

Introduction

One of the aims of the European Hernia Society (EHS) is the development and implementation of specialised medical guidelines for hernia management. Guidelines are not only important for clinical practice, but also for (postgraduate) training, the registration of complications and the development of indicators. The process of developing guidelines can also direct scientific research, as it indicates the areas in which there is a lack of evidence for clinical practice.

Guidelines are:

An agreed line of conduct for appropriate care within the professional group, which is based as much as possible on scientific insights from systematic and current clinical research into the efficacy and effectiveness of the available alternatives, taking the patient situation into account.

Guidelines are developed to:

• Improve medical quality and effectiveness (management)

• Reduce the variation between physicians: the practice must be based more on evidence than on experiences or opinions (professionalism versus intuition)

• Make practice more transparent (accountability: who can expect what from whom?)

Improving the results of inguinal hernia treatment will have major medical and economic consequences. For the patient, a successful inguinal hernia repair means a lower risk of complications, a quick postoperative recovery and a minimal risk of persistent pain symptoms or recurrent hernias. Of course, the individual patients’ situation and the general costs of the treatment continue to be major considerations.

These guidelines concerning the treatment of inguinal hernia have been developed and are owned by the European Hernia Society (EHS). Development of the Guidelines was financed through a grant by Ethicon.

Motivation

In 2003, the Dutch Society of Surgeons published evidence-based guidelines for the treatment of inguinal hernias. The Dutch Society of Hernia proposed in 2005 to have the Guidelines translated and have some international experts in the field judge whether the Guidelines could be suitable for use by the EHS. A Steering Committee was installed and, after reading and commenting on the contents, it was agreed that they would be used as the base for the EHS Guidelines. A Working Group was formed. Ethicon agreed to sponsor the development. Ethicon would not become the owner and would not interfere in the methods and contents, thus, avoiding bias.

All member countries of the EHS were asked to name a representative to join the Working Group.

Objective

These guidelines form a document with recommendations to support the daily practice of the treatment of inguinal hernias by surgeons. These guidelines are based on the results of scientific research and the formation of opinions arising from this which are aimed at emphasising good clinical practice. These guidelines are intended as a reference manual for daily practice. These guidelines provide starting points for the drawing up of local protocols, which promote their implementation and serve as a base or tool for education and training in groin hernia surgery. The potential health benefit is an improvement of the level of care for patients with inguinal hernia by reducing complications like recurrence and chronic pain.

Definition

An inguinal hernia or hernia inguinalis is a protrusion of the contents of the abdominal cavity or preperitoneal fat through a hernia defect in the inguinal area, irrespective of whether this is preformed (congenital). This situation can give rise to complaints such as discomfort and pain. Sometimes, it is not possible to reduce the contents of the hernia sac (non-reducible hernia). In the case of a narrow hernia defect, there is a risk of the hernia sac contents becoming incarcerated, resulting in an obstruction of the intestine (ileus) and/or a circulatory disorder of the incarcerated content (strangulation), which can lead to necrosis and possible perforation of the intestine.

A recurrent inguinal hernia is a swelling due to a defect in the inguinal region where an inguinal hernia operation was previously performed.

Target population

The target population was all adult (>18 years of age) patients with a primary or recurrent inguinal hernia (asymptomatic or symptomatic, acute or elective). The Guidelines concern male patients unless stated otherwise.

Description of problem and initial questions

The committee which prepared these guidelines wished to gain answers to the following (deemed as the most important) questions that are known to give rise to discussion:

1. What are the indications for inguinal hernia treatment? Is operative treatment necessary?

2. What is the best technique for the treatment of an inguinal hernia (considering factors such as recurrence, complications, postoperative recovery, pain, costs)? What mesh is best?

3. What are the complications of the various techniques, and how can these be treated? What causes pain complications and how to treat these?

4. What is the best form of anaesthetic? Should local anaesthesia be recommended as the first choice?

5. Can an inguinal hernia be operated in ambulatory surgery? Thus, decreasing cost, possibly improving quality?

6. Is the routine use of antibiotics necessary?

Inguinal hernia treatment for adults in Europe in 2007

A number of studies provide insight into the treatment techniques which surgeons have used since 1992. Endoscopic surgery entered the scene in 1991 and the Lichtenstein technique around 1993. After 1993, other mesh techniques followed, such as plug and patch, PHS etc.

In many European countries, studies were performed to evaluate the different techniques used [32, 121, 134].

Many different techniques and strategies are used, reflecting different cultures, insights and economics.

Transparency of the process and method

The Steering Committee first met in Torino in December 2005. A Working Group was installed. The Working Group participated in a two-day workshop in Amsterdam in April 2007. A short course in evidence-based guideline development (EBGD) and clinical appraisal was followed, after which all relevant literature was searched in the Cochrane Database, Medline and Embase.

In September 2007, the Working Group had a one-day meeting in Amsterdam. Participation in the course “Evidence-Based Guideline Development” by Dr. Anco Vahl was desirable.

All chapters were divided among participants and two were assigned to each. According to evidence-based medicine guidelines, the quality was assessed.

The concept chapters were discussed and, where necessary, consensus was found, after which recommendations were agreed upon. From December 2007 till March 2008, comments from all participants were gathered via email by Maarten Simons and Prof. Marc Miserez. Prof. Andrew Kingsnorth edited and commented on the concept guidelines in March 2008. The March concept was sent to all participating countries for the national commentary phase. A third meeting was organised at the EHS meeting in Sevilla, May 2008. During a session, all chapters were presented by the respective authors. In the summer of 2008, minor comments were used to finalise the Guidelines. The Steering Committee agreed to the Guidelines, after which the results were published in Hernia and on the Internet (http://www.herniaweb.org).

Working Group members

When the Working Group was appointed, members with the following characteristics were sought:

• Clinical and scientific expertise in the area of inguinal hernia surgery

• Members drawn from as many European countries as possible

• Members drawn from university and non-university hospitals and teaching and non-teaching hospitals

• Supporters of as many different operation techniques as possible

• Epidemiological expertise

• No conflicts of interest concerning the contents of the guidelines

Members of the Steering Committee and Working Group.

Owner and legal significance

Intended (target) users

These guidelines are primarily intended for surgeons and trainee surgeons.

Some chapters are also intended for other care providers, such as general practitioners, who wish to provide information to patients with an inguinal hernia.

Collection and assessment of the literature

All relevant literature until April 2007 (Medline, Embase and Cochrane) was prepared by small groups and assessed by all Working Group members. The literature of all level 1A and/or 1B studies was searched during the development of the Guidelines until May 2008. The Oxford Centre for Evidence-Based Medicine was used. After this, a consensus, where necessary, was reached and the conclusions and recommendations were formulated. For all articles, in accordance with evidence-based guidelines criteria, two surgeons always determined whether or not an article was relevant (according to possible bias). Each time, a unanimous final opinion was sought and this was always realised. The Working Group met on three occasions. For chapters in which only level 2C or 3 articles were available, it was difficult to choose the best evidence from, at times, hundreds of articles. Search bias in these cases cannot be excluded.

• Levels of evidence:

1A

Systematic review of RCTs with consistent results from individual (homogenous) studies.

1B

RCTs of good quality.

2A

Systematic review of cohort or case–control studies with consistent results from individual (homogenous) studies.

2B

RCT of poorer quality or cohort or case–control studies.

2C

Outcome studies, descriptive studies.

3

Cohort or case–control studies of low quality.

4

Expert opinion, generally accepted treatments.

• Grades of recommendation:

A

Supported by systematic review and/or at least 2 RCTs of good quality.

 

Level of evidence 1A, 1B.

B

Supported by good cohort studies and or case–control studies.

 

Level of evidence 2A, 2B.

C

Supported by case series, cohort studies of low quality and/or ‘outcomes’ research.

 

Level of evidence 2C, 3.

D

Expert opinion, consensus committee.

 

Level of evidence 4.

Description of the implementation trajectory

For the Dutch Guidelines that were published in 2003, an implementation study and a pilot study among targetted users were performed.

A national inventory of all inguinal hernia operations carried out in two periods was performed. The first period was a “baseline measurement” in the period prior to the publication of the Guidelines (January to March of 2001) and the second period was quite some time after the publication of the Guidelines (January to March of 2005). By means of the registration forms, the number of inguinal hernia operations carried out in all of the hospitals in these periods were counted (see registration form). The same system will be implemented on a European basis. A prospective database will be necessary for this. Plans for such a registration system are under development. In the Guidelines, operative methods and a registration form are proposed (Appendix 2). The EHS is developing a skills and teaching institute to facilitate and train surgeons and residents to be able to work according to the guidelines.

Procedure for authorising guidelines with the European Hernia Society

Guidelines should be developed on the basis of results from scientific research and opinions related to this which are aimed at making good medical practice more explicit. In addition to this, there should be a broad level of support within the EHS.

Applicability and costs

A pilot study among targetted users was performed in two large district hospitals in the Netherlands in 2002 [24]. There were no barriers to implementation either in costs or logistical possibilities. There are, possibly, European countries where certain hospitals cannot afford endoscopic hernia surgery.

Expiry date

The Guidelines are valid until 1st January 2012. Updating of the Guidelines (RCT literature) will be performed continuously by the two authors of each chapter, with a yearly meeting at the EHS at which the publication of relevant updates will be decided upon.

Validation

The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used to validate the Guidelines.

Almost all criteria were fulfilled. Review was performed by four external experts in surgery and epidemiology. Two members of the Dutch Cochrane Institute performed a rigorous analysis, which led to many adjustments (Appendix 6).

Indications for treatment

Authors: Jean Luc Bouillot and Maarten Simons

What are the indications for a surgical treatment of inguinal hernia?

Can a non-surgical (conservative) treatment be considered?

Search terms: inguinal hernia, treatment.

Conclusions

Level 1B

Watchful waiting is an acceptable option for men with minimally symptomatic or asymptomatic inguinal hernias.

Level 4

A strangulated inguinal hernia (with symptoms of strangulation and/or ileus) should be operated on urgently.

Recommendations

Grade A

It is recommended in minimally symptomatic or asymptomatic inguinal hernia in men to consider a watchful waiting strategy.

Grade D

It is recommended that strangulated hernias are operated on urgently.

 

It is recommended that symptomatic inguinal hernias are treated surgically.

The incidence and prevalence of inguinal hernia are not precisely known [263]. The chance of a person having to undergo an inguinal hernia operation during his/her life is quite high, 27% in the case of men and 3% in the case of women [248]. As almost all diagnosed inguinal hernias are operated on, the natural course of an untreated inguinal hernia is scarcely known. Spontaneous recovery has never been described in adults.

An inguinal hernia is operated in order to reduce the symptoms, when acute complications occur or to prevent complications.

Non-surgical diagnostics

Authors: Giampiero Campanelli and György Weber

Which diagnostic modality is the most suitable for diagnosing inguinal hernia in patients with groin complaints (without clear swelling in the groin region)?

Search terms: inguinal hernia, diagnosis, herniography, MRI, ultrasound, CT scan, laparoscopy, combinations.

Conclusions

Level 2C

In case of an evident hernia, clinical examination suffices.

 

Differentiation between direct and indirect hernia is not useful; only cases of obscure pain and/or doubtful swelling in the groin require further diagnostic investigation.

 

In everyday practice, the sensitivity and specificity of ultrasonography for diagnosing inguinal hernia is low.

 

A CT scan has a limited place in the diagnosis of an inguinal hernia.

 

MRI has a sensitivity and specificity of more than 94% and is also useful to reveal other musculo-tendineal pathologies.

 

Herniography has high sensitivity and specificity in unclear diagnosis, but has a low incidence of complications. It does not reveal lipomas of the cord.

Recommendations

Grade C

It is recommended that groin diagnostic investigations are performed only in patients with obscure pain and/or swelling.

 

The flow chart recommended in these cases:

• Ultrasound (if expertise is available)
• If ultrasound negative → MRI (with Valsalva)
• If MRI negative → consider herniography

Differential diagnosis

The differential diagnosis of the swelling in the groin:

• Inguinal (recurrent) hernia

• Femoral hernia

• Incisional hernia

• Lymph gland enlargement

• Aneurysm

• Varix (vena saphena magna)

• Soft-tissue tumour

• Abscess

• Genital anomalies (ectopic testis)

• Endometriosis

The differential diagnosis in pain without typical swelling:

• Adductor tendinitis

• Pubic osteitis

• Hip artrosis

• Bursitis Ileopectinea

• Irradiating low back pain

• Endometriosis

Classification

Author: Giampiero Campanelli

Is it necessary to classify inguinal hernias and which classification is the most suitable?

Search terms: inguinal hernia, classification.

Recommendations

Grade D

It is recommended that the EHS classification for hernia in the groin is used.

An unequivocal classification of inguinal hernias is important for the rational choice of treatments (in case of tailored surgery) and for the analysis of scientific data. It is also possible to compare the various treatments in clinical trials when hernias can be classified in an unequivocal manner.

Current inguinal hernia classifications are numerous: traditional (medial/lateral/recurrent), Nyhus, Gilbert, Rutkow/Robbins, Schumpelick, Harkins, Casten, Halverson and McVay, Lichtenstein, Bendavid, Stoppa, Alexandre, Zollinger Unified [60, 224, 324].

As it is important that a classification system is simple to use and remember, the guidelines committee advises the EHS classification [208]. This classification can be found on the website of the EHS.

European Hernia Society Classification

One classification system for recurrent hernia has been described by Campanelli et al. [60].

Risk factors and prevention

Authors: Maciej Smietanski and Jean Luc Bouillot

What are the risk factors for developing an inguinal hernia and are there preventive measures?

Search terms: inguinal hernia, risk factors.

Conclusions

Level 3

Smokers, patients with positive family hernia history, patent processus vaginalis, collagen disease, patients with an abdominal aortic aneurysm, after an appendicectomy and prostatectomy, with ascites, on peritoneal dialysis, after long-term heavy work or with COPD have an increased risk of inguinal hernia. This is not proven with respect to (occasional) lifting, constipation and prostatism.

Recommendations

Grade C

Smoking cessation is the only sensible advice that can be given with respect to preventing the development of an inguinal hernia.

Textbooks mention many risk factors for the development of an inguinal hernia or a recurrence. Smoking is almost certainly a risk factor [239, 283]. People with abnormal collagen metabolism (also known among smokers) have an increased risk, which is also revealed in a higher incidence of inguinal hernias in patients with aortic aneurysm. Also, patent processus vaginalis is a risk factor [181, 239, 308]. Abnormal collagen metabolism possibly clarifies the fact that there are families with an abnormally large number of hernias of all types [157]. In one case–control study, the family history of hernia seems to be the only independent risk factor of hernia [177]. Chronic coughing (COPD) seems to be a risk factor [62].

Additional risk has not been demonstrated for prostatism and constipation. Although the majority of studies reveal that physical work is not a risk factor, two retrospective case–control studies revealed that long-term and heavy work does increase the risk of hernias [62, 101]. A case–control study among women did not demonstrate this, and this was also the case for smoking, whereas many sports and obesity were protecting factors. In this study, constipation and a positive family history were positive risk factors [188]. A low (cosmetic) incision for appendectomy can disrupt the shutter mechanism and increase the risk of an inguinal hernia on the right-hand side [297].

Ascites and peritoneal dialysis can increase the risk of inguinal hernia or a recurrence thereof [61, 90, 280].

The only pragmatic prevention for an inguinal hernia is smoking cessation and possibly not undertaking long-term and heavy physical work.

Known factors for the development of a recurrent inguinal hernia are: technique (see the next chapter), type of hernia (direct higher risk than indirect) and recurrent inguinal hernia (the more frequently a recurrence occurs, the higher the risk of a new recurrence).

Inguinal hernia is a known complication after radical retropubic prostatectomy, open procedure as well as endoscopic, and has been reported to occur in 7–21% of patients [6, 190, 287–289]. Even other types of lower midline incision surgery could promote the development of postoperative inguinal hernia [5, 289]. Urologists should be aware of this important postoperative complication and prophylactic surgical procedures must be evaluated to address the problem.

Treatment of inguinal hernia

Authors: Marc Miserez, Maarten Simons and Theo Aufenacker

What is the best technique for treating an inguinal hernia taking into account the type of hernia and the patient?

Search terms: RCT, hernia and specific names of the surgical techniques (46 combinations in total) in Medline, Cochrane library, references, correspondence and unpublished results.

Conclusions

Level 1A

Operation techniques using mesh result in fewer recurrences than techniques which do not use mesh.

 

Shouldice hernia repair technique is the best non-mesh repair method.

 

Endoscopic inguinal hernia techniques result in a lower incidence of wound infection, haematoma formation and an earlier return to normal activities or work than the Lichtenstein technique.

 

Endoscopic inguinal hernia techniques result in a longer operation time and a higher incidence of seroma than the Lichtenstein technique.

Level 1B

Mesh repair appears to reduce the chance of chronic pain rather than increase it. Endoscopic mesh techniques result in a lower chance of chronic pain/numbness than the Lichtenstein technique. In the long term (more than 3 to 4 years follow-up), these differences (non-mesh-endoscopic-Lichtenstein) seem to decrease for the aspect pain but not for numbness.

 

For recurrent hernias after conventional open repair, endoscopic inguinal hernia techniques result in less postoperative pain and faster reconvalescence than the Lichtenstein technique.

 

Material-reduced meshes have some advantages with respect to long-term discomfort and foreign-body sensation in open hernia repair, but are possibly associated with an increased risk for hernia recurrence (possibly due to inadequate fixation and/or overlap) (Chap. 2.9).

 

From the perspective of the hospital, an open mesh procedure is the most cost-effective operation in primary unilateral hernias. From a socio-economic perspective, an endoscopic procedure is probably the most cost-effective approach for patients who participate in the labour market, especially for bilateral hernias. In cost–utility analyses including quality of life (QALYs), endoscopic techniques (TEP) may be preferable, since they cause less numbness and chronic pain (Chap. 2.18).

Level 2A

For endoscopic inguinal hernia techniques, TAPP seems to be associated with higher rates of port-site hernias and visceral injuries, whilst there appear to be more conversions with TEP.

Level 2B

There appears to be a higher rate of rare but serious complications with endoscopic repair, especially during the learning curve period.

 

Other open-mesh techniques: PHS, Kugel patch, plug and patch (mesh plug) and Hertra mesh (Trabucco), in short-term follow-up, result in comparable outcome (recurrence) to the Lichtenstein technique.

 

A young man (aged 18–30 years) with a lateral inguinal hernia has a risk of recurrence of at least 5% following a non-mesh operation and a long follow-up (>5 years) (Chap. 2.8).

Level 2C

Endoscopic inguinal hernia techniques with a small mesh (≤8 × 12 cm) result in a higher incidence of recurrence compared with the Lichtenstein technique.

 

Women have a higher risk of recurrence (inguinal or femoral) than men following an open inguinal hernia operation due to a higher occurrence of femoral hernias (Chap. 2.7).

 

The learning curve for performing endoscopic inguinal hernia repair (especially TEP) is longer than for open Lichtenstein repair, and ranges between 50 and 100 procedures, with the first 30–50 being the most critical (Chap. 2.12).

 

For endoscopic techniques, adequate patient selection and training might minimise the risks for infrequent but serious complications in the learning curve (Chap. 2.12).

Level 2C 

There does not seem to be a negative effect on outcome when operated by a resident versus an attending surgeon (Chap. 2.12).

  

Specialist centres seem to perform better than general surgical units, especially for endoscopic repairs (Chap. 2.12).

Level 4

All techniques (especially endoscopic techniques) have a learning curve that is underestimated.

 

For large scrotal (irreducible) inguinal hernias, after major lower abdominal surgery, and when no general anaesthesia is possible, the Lichtenstein repair is the preferred surgical technique.

 

For recurrent hernias, after previous posterior approach, an open anterior approach seems to have clear advantages, since another plane of dissection and mesh implantation is used.

 

Stoppa repair is still the treatment of choice in case of complex hernias.

Recommendations

Grade A

All male adult (>30 years) patients with a symptomatic inguinal hernia should be operated on using a mesh technique.

 

When considering a non-mesh repair, the Shouldice technique should be used.

 

The open Lichtenstein and endoscopic inguinal hernia techniques are recommended as the best evidence-based options for the repair of a primary unilateral hernia, providing the surgeon is sufficiently experienced in the specific procedure.

 

For the repair of recurrent hernias after conventional open repair, endoscopic inguinal hernia techniques are recommended.

 

When only considering chronic pain, endoscopic surgery is superior to open mesh.

 

In inguinal hernia tension-free repair, synthetic non-absorbable flat meshes (or composite meshes with a non-absorbable component) should be used (Chap. 2.9).

 

The use of lightweight/material-reduced/large-pore (>1,000-μm) meshes can be considered in open inguinal hernia repair to decrease long-term discomfort, but possibly at the cost of increased recurrence rate (possibly due to inadequate fixation and/or overlap) (Chap. 2.9).

 

It is recommended that an endoscopic technique is considered if a quick postoperative recovery is particularly important (Chap. 2.14).

 

It is recommended that, from a hospital perspective, an open mesh procedure is used for the treatment of inguinal hernia (Chap. 2.18).

 

From a socio-economic perspective, an endoscopic procedure is proposed for the active working population, especially for bilateral hernias (Chap. 2.18).

Grade B

Other open-mesh techniques than Lichtenstein (PHS, Kugel patch, plug and patch [mesh-plug] and Hertra mesh [Trabucco]) can be considered as an alternative treatment for open inguinal hernia repair, although only short-term results (recurrence) are available.

 

It is recommended that an extraperitoneal approach (TEP) is used for endoscopic inguinal hernia operations.

 

It is recommended that a mesh technique is used for inguinal hernia correction in young men (aged 18–30 years and irrespective of the type of inguinal hernia) (Chap. 2.8).

Grade C

(Endoscopic) hernia training with adequate mentoring should be started with junior residents (Chap. 2.12).

Grade D

For large scrotal (irreducible) inguinal hernias, after major lower abdominal surgery, and when no general anaesthesia is possible, the Lichtenstein repair is the preferred surgical technique.

 

In endoscopic repair, a mesh of at least 1 × 15 cm should be considered.

 

It is recommended that an anterior approach is used in the case of a recurrent inguinal hernia which was treated with a posterior approach.

 

In female patients, the existence of a femoral hernia should be excluded in all cases of a hernia in the groin (Chap. 2.7).

 

A preperitoneal (endoscopic) approach should be considered in female hernia repair (Chap. 2.7).

 

All surgeons graduating as general surgeons should have a profound knowledge of the anterior and posterior preperitoneal anatomy of the inguinal region (Chap. 2.12).

 

Complex inguinal hernia surgery (multiple recurrences, chronic pain, mesh infection) should be performed by a hernia specialist (Chap. 2.12).

Inguinal hernia in women

Authors: Joachim Conze and Morten Bay Nielsen

Following a non-mesh inguinal hernia operation, is the risk of recurrence lower for women than for men? Should women be treated with a different strategy?

Search terms: inguinal hernia, treatment, women, female.

Conclusions

Level 2C

Women have a higher risk of recurrence (inguinal or femoral) than men following an open inguinal hernia operation due to a higher occurrence of femoral hernias.

Recommendations

Grade D

In female patients, the existence of a femoral hernia should be excluded in all cases of a hernia in the groin.

 

A preperitoneal (endoscopic) approach should be considered in female hernia repair.

Women account for 8–9% of all inguinal and femoral hernia operations performed. In subgroup analyses from many studies, the recurrence rate of a non-mesh inguinal hernia operation in women seems to be comparable to that after type I and type II (EHS) inguinal hernia operations in men (2–13%), dependent on the follow-up duration [85, 106, 134, 259]. In epidemiological studies from national databases, reoperation rates after female herniorrhaphy are higher, compared to males, without any difference between anterior mesh and non-mesh repairs [30, 162]. In approximately 40% of reoperations, a femoral recurrence is found. It is not known whether these femoral ‘recurrences’ represent hernias overlooked at the primary operation or de novo hernias. The high frequency of femoral recurrence after inguinal herniorrhaphy in women argues for the use of endoscopic repair, covering both the inguinal and femoral orifices simultaneously.

Lateral inguinal hernia in young men (aged 18–30 years)

Authors: Morten Bay Nielsen and Joachim Conze

Does a young man have a very low risk of recurrence following a non-mesh inguinal hernia operation due to an indirect hernia? Is mesh treatment indicated for this category of patients?

Search terms: inguinal hernia, treatment.

Conclusions

Level 2B

A young man (aged 18–30 years) with a lateral inguinal hernia has a risk of recurrence of at least 5% following a non-mesh operation and a long follow-up (>5 years).

Recommendations

Grade B

It is recommended that a mesh technique is used for inguinal hernia correction in young men (18–30 years of age and irrespective of the type of inguinal hernia).

In view of the discussion concerning the risk of recurrence in young men following a non-mesh inguinal hernia operation due to a lateral inguinal hernia and the concern for fertility issues, this category deserves to be considered in a separate chapter. About 5% of all inguinal hernia operations are performed on men between the ages of 18 and 30 years. Indirect inguinal hernias account for the majority of these operations. From studies (level 3 and 4), it is known that after 2 to 5 years of follow-up, the risk of recurrence after Shouldice repair is 1–3% lower than for an operation due to a direct inguinal hernia. For this category of patients, Friis and Lindahl compared a Lichtenstein and an annuloraphy and saw recurrence rates of 0 and 2.2%, respectively, with 2 years of follow-up after the repair of a primary hernia [105]. In a randomised study after a follow-up of more than 10 years, Beets et al. described recurrence rates of more than 30% for an indirect inguinal hernia after both an annuloraphy as well as a modified Bassini technique [36]. In a retrospective series of more than 1,000 annuloraphies for a lateral inguinal hernia, the recurrence rate rose to 18% after a follow-up of 10 years [145]. Analysis of data from the Danish Hernia Database shows a reoperation rate almost twice as high after non-mesh repairs compared to Lichtenstein and other open mesh repairs in males <30 years of age, operated for a primary indirect hernia (unpublished data).

In a questionnaire study, in patients below 55 years of age operated for an indirect hernia, no relevant difference in chronic pain was found between patients operated with mesh and non-mesh techniques and no study has shown specific mesh-related problems in this subgroup of patients [33]. In summary, there is no evidence to support a non-mesh approach in this subgroup of patients.

Biomaterials

Authors: Jan Kukleta and Joachim Conze

What mesh type is the most suitable in inguinal hernia repair, and what mesh-related complications can occur?

Search terms: mesh, biomaterial, inguinal hernia, mesh complications.

Conclusions

Level 1A

Operation techniques using mesh result in fewer recurrences than techniques which do not use mesh.

Level 1B

Material-reduced meshes have some advantages with respect to long-term discomfort and foreign-body sensation in open hernia repair, but are possibly associated with an increased risk for hernia recurrence (possibly due to inadequate fixation and/or overlap).

Recommendations

Grade A

In inguinal hernia tension-free repair, synthetic non-absorbable flat meshes (or composite meshes with a non-absorbable component) should be used.

 

The use of lightweight/material-reduced/large-pore (>1,000-μm) meshes in open inguinal hernia repair can be considered to decrease long-term discomfort, but possibly at the cost of increased recurrence rate (possibly due to inadequate fixation and/or overlap).

The use of synthetic mesh substantially reduces the risk of hernia recurrence irrespective of the placement method. Mesh repair appears to reduce the chance of persisting pain rather than increase it [72].

Only non-absorbable meshes or composite meshes with a non-absorbable component should be used in inguinal hernia repair in adults.

There is a great variety of meshes available differing in textile parameters (polymer, filament, construction, pore size, elasticity, tensile strength, weight, surface). We do not know the parameters of the ideal mesh. The use of mesh can be related to some non-specific complications (pain, infection, recurrence) and some specific complications (shrinkage, dislocation, migration, erosion). In open inguinal hernia repair, the use of a monofilament polypropylene mesh is advised to reduce the chance of incurable chronic sinus formation or fistula which can occur in patients with a deep infection. The chance of complete wound healing after adequate drainage is virtually impossible when a multifilament mesh is used as bacteria (Ø 1 μm) can hide from the leucocytes (Ø >10 μm) because the mesh has a closer weave structure with a smaller pore diameter (Ø 10 μm) and the mesh cannot be ‘sterilised.’ [293].

Weight-reduced mesh materials (>1,000 μm), macroporous and oligofilament structures seem to shrink less, cause less inflammatory reaction and induce less extensive scar-tissue formation and are, therefore, more likely to be integrated with less long-term discomfort and foreign-body sensation when implanted in open hernia repair [47–50, 131, 137, 171, 172] but, possibly, they are associated with an increased risk for hernia recurrence [50, 137, 153, 228, 244] in high-risk conditions (large direct hernia), if the mesh is not adequately fixed and/or overlapping.

There is not sufficient data on sexual dysfunction in relation to the variable properties of different prosthetic materials or different surgical techniques used.

Day surgery

Authors: Maciej Smietanski and Rene Fortelny

Can inguinal hernia surgery be performed in a day surgery setting? Is this safe and cost-effective?

Search terms: (groin or inguinal) hernia, ambulatory, day surgery, random* in PubMed; function: related articles in PubMed; literature lists of relevant articles.

Conclusions

Level 2B

Inguinal hernia surgery as day surgery is as safe and effective as that in an inpatient setting, and more cost-effective.

Level 3

Inguinal hernia surgery can easily be performed as day surgery, irrespective of the technique used.

 

Selected older and ASA III/IV patients are also eligible for day surgery.

Recommendations

Grade B

An operation in day surgery should be considered for every patient.

Day surgery is an admission to a unit for a diagnostic or therapeutic treatment by a medical specialist, in which discharge takes place on the same day after a period of recovery under (para)medical supervision [111]. An inguinal hernia repair performed in the outpatient department under local anaesthetic, in which the patient goes home shortly after the intervention, is considered to be day surgery.

As early as 1955, the advantages of inguinal hernia repair as day surgery were already described in the literature: quicker mobilisation, patient-friendly and lower costs [94]. Some time later, from the end of the 1970s onwards, several retrospective series were published [114, 204], as well as two small randomised studies in which day surgery was compared with inpatient treatment [237, 247, 262]. A recent randomised study compared how much patients valued different treatments [255]. These studies showed that day surgery is just as safe and effective, and, in addition, cheaper. In two of the three studies, patients were at least as content with day surgery [255, 262]. In a large American cohort study, the costs of an inguinal hernia repair in a clinical setting were found to be 56% higher than those for day surgery [209]. Also in Germany, this procedure is generating less costs [317]. In addition to the few randomised studies, there are a multitude of cohort studies concerning patients successfully operated on as day surgery, under general, regional and local anaesthetics, and with both classical operation techniques as well as open tension-free repairs and endoscopic techniques. A large study conducted in Denmark noted the hospital readmission rate of 0.8% [89, 317]. Although a tension-free repair under local anaesthetic seems to be the most suitable operation, the published series showed that other surgical and anaesthesiological techniques can also be effectively used as day surgery. Only the extensive open preperitoneal approach (Stoppa technique) has not been described in the context of day surgery.

When day surgery was in its infancy, there was a strict selection of patients with a low risk of complications (ASA I–II, age limit, length of operation <1 h, no serious obesity etc.). Such a strict selection is becoming less common and, in principle, an inguinal hernia repair as day surgery can be considered for every patient who has satisfactory care at home [76, 142, 245]. In this consideration, the preoperative assessment of the anaesthetist is extremely important, because he/she carries the main responsibility for the perioperative and immediately postoperative phase [245]. A number of factors will either encourage or discourage day surgery. These include hospital, physician and patient-related factors [111]. In a hospital with considerable experience in day surgery and a good infrastructure, such as the presence of a pre-assessment consultation and a day surgery department, a large percentage of inguinal hernia treatments will take place as day surgery. The same applies to surgical factors, such as quick operations with a low percentage of complications, and anaesthesia factors, such as pain alleviation and nausea control, which make a quick discharge possible.

On a worldwide basis, there is a clear increase in the percentage of inguinal hernia repairs that are being carried out as day surgery [77, 142]. There is considerable variation between different countries, which cannot be clarified solely by the degree of acceptability of day surgery among patients and surgeons but, to a significant extent, is also determined by the healthcare financing system. In the last years (2000–2004), 35% of inguinal hernia operations carried out in the Netherlands and 33% in Spain were done on a day surgery basis [197, 249]; there is room for this number to be increased. In the Swedish National Registry, 75% of inguinal hernia repairs are performed in day care.

Antibiotic prophylaxis

Authors: Theo Aufenacker and Maarten Simons

Is antibiotic prophylaxis routinely indicated for elective inguinal surgery for primary inguinal hernia?

Search terms: hernia, antibiotic prophylaxis, RCT, systematic review.

Conclusions

Level 1A

In conventional hernia repair (non-mesh), antibiotic prophylaxis does not significantly reduce the number of wound infections. NNT 68.

Level 1B

In open mesh repair in low-risk patients, antibiotic prophylaxis does not significantly reduce the number of wound infections. NNT 80.

 

For deep infections, the NNT is 352.

Level 2B

In endoscopic repair, antibiotic prophylaxis does not significantly reduce the number of wound infections. NNT ∞.

Recommendations

Grade A

In clinical settings with low rates (<5%) of wound infection, there is no indication for the routine use of antibiotic prophylaxis in elective open groin hernia repair in low-risk patients.

Grade B

In endoscopic hernia repair, antibiotic prophylaxis is probably not indicated.

Grade C

In the presence of risk factors for wound infection based on patient (recurrence, advanced age, immunosuppressive conditions) or surgical (expected long operating times, use of drains) factors, the use of antibiotic prophylaxis should be considered.

The risk of infection following an inguinal hernia operation, with or without mesh, is between 0 and 14.4%. In RCTs, the average incidence of wound infections is 4.3% in conventional repair and 2.4% in open mesh repair [19, 22, 64, 92, 178, 210, 230, 235, 238, 268, 274, 294, 303, 322].

Since the use of antibiotics is not likely to increase the percentage of wound infection, the net effect of randomised controlled studies will almost always be in favour of the patients receiving prophylaxis.

In a meta-analysis on the use of antibiotic prophylaxis in 1,867 patients with non-mesh repairs, the overall infection rates were 2.88% in the prophylaxis group and 4.30% in the control group (OR 0.65, 95% CI: 0.35–1.21) [268]. This is a non-significant reduction with a number needed to treat of 68.

In two meta-analyses on the use of antibiotic prophylaxis in open mesh-based groin repairs, conflicting conclusions are drawn [23, 267]. In these two analyses, the same six studies are included but in one, the analysis is fixed and in the other, it was random [22, 64, 210, 230, 235, 322]. The choice of the correct method should be based on the prevalence of statistical heterogeneity (data), together with the clinical diversity and methodological diversity of the studies.

In the six studies, there is no statistical heterogeneity but clinical and methodological diversity is present and, therefore, the random method should be used. When the results of fixed and random analysis conflict, the choice of meta-analysis method should be preferably conservative and, in these situations, the random method should be used.

Currently, eight studies regarding open mesh repair are available; the results are displayed in Table 7 [22, 64, 141, 210, 230, 235, 303, 322].

In summary, one study found a significant decrease in infections. This study revealed no difference between deep infections and reported a very high percentage of superficial infections, possibly caused by long duration of operation, more usage of drains and repeated aspiration of seromas.

The results of the meta-analysis (random effect) of 3,006 patients with mesh-based groin repair are an overall infection rate of 1.6% in the prophylaxis group and 3.1% in the control group (OR 0.59, 95% CI: 0.34–1.03). This is not a significant reduction, with a number needed to treat of 80 (Fig. 5).

For the prevention of a deep infection, data is available on 2,103 patients. The deep infection rate is 0.3% in the prophylaxis group and 0.6% in the placebo group (OR 0.50, 95% CI: 0.12–2.09). The reduction is not significant and the number needed to treat is 352 to prevent one deep infection.

Training

Authors: Marc Miserez and Maarten Simons

What is the learning curve and training in inguinal hernia repair?

Search terms: hernia, training, learning curve.

Conclusions

Level 2C

The learning curve for performing endoscopic inguinal hernia repair (especially TEP) is longer than that for open Lichtenstein repair, and ranges between 50 and 100 procedures, with the first 30–50 being the most critical.

 

For endoscopic techniques, adequate patient selection and training might minimise the risks for infrequent but serious complications in the learning curve.

 

There does not seem to be a negative effect on outcome when operated by a resident versus an attending surgeon.

 

Specialist centres seem to perform better than general surgical units, especially for endoscopic repairs.

Recommendations

Grade C

(Endoscopic) hernia training with adequate mentoring should be started with junior residents.

Grade D

All surgeons graduating as general surgeons should have a profound knowledge of the anterior and posterior preperitoneal anatomy of the inguinal region.

 

Complex inguinal hernia surgery (multiple recurrences, chronic pain, mesh infection) should be performed by a hernia specialist.

Surgeons recognise technical issues, experiences in deciding to act and manual skills as major predictors of outcome [285]. A learning curve for a specific procedure can be evaluated by means of operative times, but mainly by the rate of conversions (for endoscopic surgery) and complications. It is generally believed that the learning curve for performing endoscopic inguinal hernia repair is longer than for open Lichtenstein repair, although the Lichtenstein technique also has a learning curve with respect to the prevention of recurrence and the prevention of chronic groin pain. However, this learning curve seems to be more favourable than that for the endoscopic techniques [298]. This is especially the case for TEP, due to a limited working space and different appreciation of the usual anatomical landmarks seen from inside the peritoneal cavity or through an anterior approach. The risk of serious complications may be higher during the learning curve period, and adequate patient selection and training might minimise the risks for rare but serious complications.

Very limited data are available on the learning curves for endoscopic repair, but it is suggested that operators become experienced after between 50 and 100 procedures, with the first 30–50 being the most critical [40, 79, 86, 95, 174, 184, 312, 313]. Lamb et al. showed for TEP that recurrence rates (median follow-up time 7 years) are <2% if more than 80 procedures had been performed and, recently, the learning curve specifically for TAPP was suggested to be >75 [192]. Of course, this number is clearly dependent on the structure of the training (programme), such as the type of supervision and the expertise of the trainer [184]. The number of 250, especially in surgeons aged 45 years and above as reported in the VA trial, has been criticised because of several reasons (learning curve effect, size of the mesh) [207, 215, 216].

There is a substantial variation in the amount of training and supervision given for inguinal hernia repair and, currently, an increased number of complications during the learning curve period due to nonoptimal training conditions is no longer acceptable [75]. Although there are no RCTs concerning hernia surgery that compare the outcome of trainee versus surgeon or specialist, most surgical data, even on pancreatic surgery, show no negative effect on outcome when operated by a resident versus an attending surgeon [69, 139, 246, 276]. Of course, the quality and extent of supervision is an important factor in outcome [93]. Registration in a prospective database in Scotland showed that junior residents, when supervised by a senior resident or a consultant surgeon (for open surgery) and senior residents, whether supervised or unsupervised (for open and endoscopic surgery), obtained comparable recurrence rates as the consultant surgeons [261]. More or less comparable data on morbidity and recurrence rate (although associated with a higher operation time for residents) were found for the Lichtenstein procedure [74]. In a retrospective analysis of 264 TEP interventions, mainly performed by surgical residents under the guidance of a single staff surgeon, the mean operation time was 85 min (unilateral hernias) and the recurrence rate was 2%, with a mean follow-up of 3.5 years [120]. In a TAPP inguinal hernia repair, the learning curve seemed to be shorter for junior trainees than for the senior surgeons (who were training them now) years before [40]. Other conflicting data state that surgical training for endoscopic treatment of inguinal hernias is associated with a longer operation time and hospital stay, and with higher morbidity and costs [29].

For the Lichtenstein repair, a post-hoc analysis of the VA trial data (where surgical residents assisted during the whole operation by an attending surgeon who performed most of the repairs) showed higher recurrence rates (but not other complications) for junior residents operating versus senior residents. For the endoscopic repair, the attending effect was so important that no resident effects on the recurrence and complication rates could be detected [319]. (Endoscopic) hernia training with adequate mentoring should, therefore, probably be started with junior residents.

Specialist centres seem to perform better than general surgical units, especially for endoscopic repairs and complex inguinal hernia surgery (multiple recurrences, chronic pain, mesh infection etc.) should, thus, be best performed by a hernia specialist [40, 225, 291]. It is unclear whether subspeciality training, centre volume and/or surgeon volume are equally important to determine the outcome [125], but for many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume [39]. For open paediatric inguinal hernia repair (excluding premature babies), hernia recurrence was higher in the general surgery group compared with paediatric surgeons; in addition, only among paediatrics surgeons—having a higher surgical volume—was the estimated risk of hernia recurrence independent of surgical volume [43]. On the other hand, the results of non-expert surgeons and even supervised residents using the Lichtenstein repair for primary inguinal hernias showed comparable excellent results to those of the experts [74, 277].

All surgeons graduating as general surgeons should have a profound knowledge of the anterior and posterior preperitoneal anatomy of the inguinal region. As long as they also treat recurrent hernias, it is logical to be adequately trained in both the anterior and posterior approach to the groin by means of adequately tested (pre)clinical training models and curricula [126]. Most authors agree that the two major techniques to be taught early during surgical residency are the Lichtenstein technique for the anterior approach and the endoscopic techniques for the posterior approach. All new procedures should be compared to these techniques. In order to decrease patient exposure to learning curve errors during inguinal hernia repair and due to the current lack of realistic hands-on simulation models, at least 30–50 of each procedure should be performed during residency, with adequate mentoring by a motivated expert surgeon (and instructor!), provided the resident already has experience with endoscopic cholecystectomy (~endoscopic experience) [79, 86, 184, 312].

Every surgical resident graduating in the USA in 1999 performed during the whole residency period seven endoscopic/endoscopic and 50 open procedures, on average [79]. Currently, a resident should ideally have performed at least ten complete endoscopic/endoscopic and 50 open inguinal hernia repairs independently [254]. In addition, a specific effort for postgraduate training in endoscopic inguinal hernia repair should be made for inexperienced consultant surgeons.

Anaesthesia

Authors: Par Nordin and Sam Smedberg

Can an open inguinal hernia operation under local anaesthesia be performed with the same patient satisfaction? Is this safer and more cost-effective than other anaesthesia techniques? Should regional anaesthesia be avoided?

Search terms: herniorrhaphy, groin hernia, local anaesthesia.

Conclusions

Level 1B

Open anterior inguinal hernia techniques can be satisfactorily performed under local anaesthetic.

 

Regional anaesthesia, especially when using high-dose and/or long-acting agents, has no documented benefits in open inguinal hernia repair and increases the risk of urinary retention.

Recommendations

Grade A

It is recommended that, in the case of an open repair, local anaesthetic is considered for all adult patients with a primary reducible unilateral inguinal hernia.

Grade B

Use of spinal anaesthesia, especially using high-dose and/or long-acting anaesthetic agents, should be avoided.

 

General anaesthesia with short-acting agents and combined with local infiltration anaesthesia may be a valid alternative to local anaesthesia.

Ideally, inguinal hernia repair should be performed using a simple and safe anaesthetic technique that is acceptable for the patient and easily mastered in general surgical practice. The technique should carry a low morbidity risk and also be cost-effective. Postoperative side effects and prolonged hospital stay after groin hernia surgery are often related to the effects of anaesthesia.

General anaesthesia can provide the surgeon with optimal operating conditions in terms of patient immobility and muscular relaxation. Modern general anaesthesia with short-acting agents and combined with local infiltration anaesthesia is safe and fully compatible with day-case surgery [282]. Disadvantages are risk for airway complications, cardiovascular instability, nausea and vomiting. Furthermore, urinary complications and recovery from central hypnotic effects may prolong the hospital stay.

Regional anaesthesia for groin hernia repair can be provided by either subarachnoid (spinal), epidural techniques or, more uncommonly, paravertebral techniques [156]. Spinal anaesthesia regularly results in urine retention, which results in prolonged postoperative recovery [98, 221, 264, 290].

In recent years, improvements of the regional anaesthetic techniques have been made with the use of more short-acting local anaesthetic agents. Also, the use of additional spinal opioids combined with a reduction in the amount of spinal doses may reduce the postoperative side effects.

The open treatment of primary reducible inguinal hernias in adults is nearly always possible under local anaesthesia [59, 149, 150] and can be provided by a local infiltration technique [16, 17] or by a specific blockade of the ilioinguinal and iliohypogastric nerves or a combination of the two methods (see Appendix 4) [80]. The administration is technically quite easy but it requires training and is only successful if the surgeon handles the tissues gently, has patience and is fully conversant with the technique [80, 241]. Intraoperative pain seems to be the most common reason for dissatisfaction with local anaesthesia [222, 295]. Some patients may prove to be unsuitable for local anaesthesia, notably very young patients, anxious patients, the morbidly obese and patients with suspected incarceration or strangulation. Whether scrotal hernias and obese patients are suitable depends entirely upon the surgeon’s familiarity with the technique [80, 241].

Fourteen randomised studies comparing local anaesthesia with general and/or regional anaesthesia [11, 37, 104, 112, 113, 118, 158, 221, 227, 231, 273, 282, 295, 310] and one comparing general with regional anaesthesia [52] was found. One study did not reveal any difference [227], while the others bear witness to the advantages for local anaesthetic, such as less postoperative pain, less anaesthesia-related complaints, less micturition difficulties, faster discharge and faster short-term recovery.

Cost comparisons for the anaesthetic alternatives have given similar results [31, 57, 151, 223, 282]. Local anaesthesia provides cost advantages over both regional and general anaesthesia, regarding both total intraoperative as well as postoperative costs. Of three RCTs [223, 227, 282], two found local to be cheaper than both general and spinal anaesthesia [223, 282], while one observed no major difference between local and general anaesthesia [227].

Local anaesthesia carries a lower mortality risk in both elective and emergency operations [219].

Postoperative recovery

Authors: Rene Fortelny and Maciej Smietanski

Which technique gives the fastest postoperative recovery?

Search terms: inguinal hernia, treatment, recovery, pain, outcome.

Conclusions

Level 1A

Endoscopic inguinal hernia techniques result in an earlier return to normal activities or work than the Lichtenstein technique.

Recommendations

Grade A

It is recommended that an endoscopic technique is considered if a quick postoperative recovery is particularly important.

Postoperative recovery is defined as a return to normal activities of daily living and the resumption of paid work.

The most important economic short-term effect after inguinal hernia surgery is the recommended postoperative recovery time, which was formerly 6 weeks on average [266, 284]. This figure originates from the period in which almost every surgeon treated inguinal hernia by means of an anterior approach without using mesh [25]. The duration of convalescence varies considerably, basically due to the variation in recommendations and on the level of the patients’ preoperative activity [56]. The resumption of work relies on different factors and is not only dependant on the operation technique [44, 255, 258]. The main cause of prolonged recovery is predominantly pain [56]. In addition, co-morbidity and cultural background affect the time of recovery [197]. An early resumption of daily activities and work has been advocated in all published recommendations but has not generally been adopted [91]. Based on these widely accepted facts, the patients should be informed that they can immediately return to all of their usual activities of daily life if pain permits [56, 91].

All tension-free hernia operation techniques (open, e.g. Lichtenstein procedure and plug and patch repair, or endoscopic approach, e.g. TAPP and TEP) have been analysed in various trials and result in a quicker postoperative recovery [41, 46, 56, 68, 129, 147, 168, 176, 178, 197, 198, 272, 311].

The meta-analyses revealed that, after an open mesh procedure, patients recovered four days earlier on average than after a conventional repair, and recovered seven days earlier on average following an endoscopic operation than after an open technique with mesh [41, 46, 68, 115, 129, 168, 176, 197, 198, 272, 275].

The recovery was mostly measured using (non)-validated questionnaires or by enquiring about an end point (only the resumption of normal activities and/or paid work): so-called ADL questionnaires or a generic quality of life questionnaire (SF-36 or EuroQol) [185, 187, 296, 316].

The results of these quality of life studies demonstrate that the recovery of hernia patients is not only restricted to the dimension of pain. It seems obvious that favourable physical outcomes facilitate the return to normal social life and productivity [198]. Although the social and psychological impairment has already been observed in hernia patients, these aspects of recovery have, so far, been neglected by the surgical research in the field.

However, the growing body of literature underlines the importance of quality of life assessment in future studies on hernia repair.

In a number of studies, this quicker postoperative recovery was objectively confirmed by abdominal muscle exercises being carried out [82, 187, 233].

Aftercare

Author: Maarten Simons

Is a lifting, sports or work ban indicated following inguinal hernia surgery?

Search terms: groin hernia, herniorrhaphy, aftercare, postoperative regime, postoperative recommendations, guidelines.

Conclusions

Level 3

The imposition of a temporary ban on lifting, participating in sports or working after inguinal hernia surgery, is not necessary. Probably a limitation on heavy weight lifting for 2–3 weeks is enough.

Recommendations

Grade C

It is recommended that limitations are not placed on patients following an inguinal hernia operation and patients are, therefore, free to resume activities. “Do what you feel you can do.” Probably a limitation on heavy weight lifting for 2–3 weeks is enough.

In a single prospective trial, two postoperative regimes (after Bassini technique) were compared with each other using a recurrence within 1 year as an end point [292]. The resumption of heavy work after 3 weeks was compared with that after about 10 weeks and has no influence on the recurrence rate.

If (after Lichtenstein technique under local anaesthetic) postoperatively patients were allowed to do what they could, and only excessive sport and heavy work were limited during the first 3 weeks, it resulted in >75% doing their own shopping without assistance within 6 days. Following light work, patients resumed work after an average of 6 days, and resumed heavy work 4 days after the proposed resting period was over [58].

Recommendations about driving after an inguinal hernia operation differ considerably. A study showed that, after seven days, the normal response time was achieved in 82% of cases following an endoscopic repair, in 64% of cases after Lichtenstein operation and in 33% of cases after Bassini technique [320]. In the Lichtenstein clinic, the opinion is that driving can be resumed straight away [13]. It is hardly surprising that every surgeon gives a different recommendation [140].

Postoperative pain control

Authors: Par Nordin and Sam Smedberg

What is the best method for realising an effective postoperative pain control?

Search terms: herniorrhaphy, local anaesthetic(s), groin hernia, local anaesthesia, local infiltration.

Conclusions

Level 1B

Wound infiltration with a local anaesthetic results in less postoperative pain following inguinal hernia surgery.

Recommendations

Grade A

Local infiltration of the wound after hernia repair provides extra pain control and limits the use of analgesics.

In addition to the medicinal postoperative analgesia, which is not discussed further, there are sufficient studies which demonstrate that wound infiltration with a local anaesthetic results in less postoperative pain than the administration of placebos [81, 302].

http://www.postoppain.org covers evidence-based recommendations.

Complications

Authors: Sam Smedberg and Par Nordin

How frequent are complications after inguinal hernia operations, and can the risk of complications be reduced?

Which are the specific complications following inguinal hernia operation and how should they be treated?

Search terms: inguinal hernia, clinical trial, randomised controlled trial and the terms associated with the complication.

The overall risk of complications after inguinal hernia operations reported vary from 15 to 28% in systematic reviews [41, 272]. With active monitoring such as phone calls, questionnaires or clinical examination, the rates have been reported to be higher, ranging from 17 to 50% [87, 215, 222]. The most frequent early complications were haematomas and seromas (8–22%), urinary retention and early pain, and late complications were mainly persistent pain and recurrences [41, 197, 272]. Life-threatening complications were rarely reported [197]. Risks of complications are related to several factors, as described below. Hernia surgery is reconstructive surgery and it appears that meticulous technique pays off, e.g. regarding nerve damage and recurrences, irrespective of what method of repair has been used (level 2). Differences in the results between methods will be described in more detail.

Which are the specific complications following inguinal hernia operation and how should they be treated?

Search terms: inguinal hernia, clinical trial, randomised controlled trial and the terms associated with the complication.

In this chapter, the literature on chronic pain and related conditions will be evaluated. For other complications, only recommendations will be stated due to the low level of evidence and for the sake of readability.

Inguinal hernia surgery has a relatively low risk of peri-operative and early postoperative complications of some significance. A study of the literature, however, reveals a number of issues:

• Results published by specialist centres (level 3–4) are much better than the results from everyday practice (level 1–3)

• Open inguinal hernia surgery and endoscopic inguinal hernia surgery have specific technique-related complications

• The definitions of complications vary between reports, which makes the evaluation of results difficult

• Postoperative chronic pain is more frequent than previously understood, and has recently become one of the most important primary endpoints in hernia surgery

• Serious peri- and postoperative complications in respect of visceral and vascular injuries are rare

• The risk for serious complications appears to be lower for open repair compared with endoscopic techniques [198]

Costs

Authors: Timo Heikkinen and Marc Miserez

What is the most cost-effective operation for the treatment of primary inguinal hernia?

Search terms: inguinal hernia, costs.

Conclusions

Level 1B

From the perspective of the hospital, an open mesh procedure is the most cost-effective operation in primary unilateral hernias. From a socio-economic perspective, an endoscopic procedure is probably the most cost-effective approach for patients who participate in the labour market, especially for bilateral hernias. In cost–utility analyses including quality of life (QALYs), endoscopic techniques (TEP) may be preferable since they cause less numbness and chronic pain.

Grade A

It is recommended that, from a hospital perspective, an open mesh procedure is used for the treatment of inguinal hernia.

 

From a socio-economic perspective an endoscopic procedure is proposed for the active working population especially for bilateral hernias.

The economic aspects of inguinal hernia operations can be examined from different perspectives:

• From the perspective of the hospital accounting for the direct costs of the operation, the outpatient department visit, the stay in the hospital etc.

• From the perspective of the health insurer who funds this

• From the societal perspective in which the indirect costs of the restrictions in usual activities (e.g. time from absence from work, production losses) are also included

In 2005, McCormack et al. (Health Technology Assessment) performed a systematic review of the economic aspects of endoscopic surgery for inguinal hernia repair [198]. Fourteen studies on cost-effectiveness evaluation were reviewed until August 2003. TEP and TAPP were compared indirectly. A Markov model was used to perform the economic analysis. Hernia recurrence and return to work were the main outcome parameters. Also, numbness and persisting pain were included in the QALY analyses. It has been stated by others that a cost per QALY gained of $50,000 (= 37,000€) is generally viewed as a reasonable cutoff for the public funding of a medical procedure.

Endoscopic hernia was estimated to be 450–675€ more expensive to the health service per patient.

Unilateral hernia: in most cases, open mesh repair was the least costly option, but provided less QALYs compared to TEP or TAPP. TEP was likely to dominate TAPP.

Bilateral hernias: TEP was found to be the most cost-effective in most cases, since the difference in operation times was not significant.

Recurrent hernias: the data was sparse and the results unreliable to make any conclusions on recurrent hernias. This might be a reflection of the current situation, where surgeons usually choose the endoscopic approach after open recurrence and vice versa. Thus, starting a study in this group might feel needless and ethically inappropriate.

Gholghesaei et al. [110] performed a qualitative review of 18 prospective (R)CT explicitly involving cost-effectiveness and outcome measurements associated with costs (Medline and Cochrane Central Controlled Trials Registry) in the period 1994–2004 with similar findings concluded in the Health Technology Assessment.

A very recent paper compared in 66 patients the level of postoperative pain, the use of analgetics and return to work in a RCT comparing TAPP, TEP and Lichtenstein [53]. No differences were found, except a higher operative cost for the endoscopic groups.

For the cost price of synthetic mesh, it is generally true that prefabricated products are more expensive than simple flat prostheses that can be cut to the desired shape.

Two RCTs have suggested that mesh fixation is not necessary in endoscopic surgery, provided a large prosthesis with wide overlap is used. The only exception might be large direct hernias (and femoral hernias?), although the first group used an expensive self-expandable, three-dimensional prosthesis [163, 211].

Taken together, the paper by McCormack et al. gives the best overview of the current evidence, with an overall advantage for endoscopic surgery (TEP) when productivity costs and quality of life are included in the analyses (level 1B, recommendation A) [198]. Many estimations were done for primary unilateral hernia. However, data from individual trials and meta-analyses is mainly based on trials carried out in the 1990s, when the endoscopic technique was in the developing stages. For example, it has been concluded in all of the meta-analyses that endoscopic procedures take longer to perform. According to the Swedish Hernia Registry data from 2006, the mean operating times with Lichtenstein and TEP procedures were 56 min and 39 min, respectively. Thus, the conclusions should be interpreted with care since local expertise, the used instrumentation and its cost can vary significantly compared to the available data. More data for bilateral and recurrent hernias are necessary.

Ideally, the total cost for Lichtenstein repair in day surgery under local anaesthesia should be compared with TEP (or TAPP) (general anaesthesia) also in day surgery, both for unilateral and bilateral/recurrent hernias. The type of employment is probably also an important determinant of indirect costs. Of course, many decisions are driven by the local health care and insurance reimbursement systems, which makes it difficult to compare studies in different European countries.

Other means to reduce direct costs are the use of reusable instruments (vs. sterilisation costs) and a shorter learning curve period with longer operation times. Therefore, a structured training programme both for open and endoscopic hernia repair is likely to be very useful. Long-term data should be investigated more closely, since, for example, chronic pain can have a significant impact on patients’ quality of life and cost-effectiveness, accordingly.

Questions for the future

These guidelines provide an answer to many of the questions concerning the treatment of inguinal hernia. However, a large number of questions remain unanswered. A number of these questions can only be answered if clinical studies are performed:

• What are the late complications of mesh implantations?

• What is the best mesh?

• Does mesh cause infertility?

• Is mesh the cause of prolonged postoperative pain symptoms?

• Should inguinal hernia surgery be individualised?

• What is the precise indication area of endoscopic inguinal hernia surgery?

• How can postoperative pain be prevented?

• Is a conservative treatment for an inguinal hernia safe?

• Which diagnostic modality is the most sensitive and specific for excluding an inguinal hernia?

• What are the real risk factors for the development of an inguinal hernia?

• Are there non-operative options for treating an inguinal hernia? For example, influencing collagen synthesis? Growth factors?

• What is the best approach for teaching inguinal hernia surgery?

• Should inguinal surgery take place in specialised centres?

• What is the relation between inguinal hernia surgery and prostatic disease?

Summary for the general practitioner

• In 95% of cases, an inguinal hernia can be diagnosed by means of a physical examination.

• Not all inguinal hernias require surgical treatment. Asymptomatic inguinal hernias (particularly in older male patients) can remain untreated.

• In female patients, the existence of a femoral hernia should be excluded in all cases of a hernia in the groin.

• It is recommended to offer patients with femoral hernia early planned surgery, even if symptoms are vague or absent.

• The risk of an inguinal hernia becoming incarcerated is less than 3% per year.

• An inguinal hernia operation can be performed adequately under local anaesthetic.

• An inguinal hernia operation can be performed on a day surgery basis, unless the comorbidity of the patient requires clinical observation.

• The use of a polypropylene prosthesis is the best technique for treating inguinal hernia. In total, 85% of operations are performed using an open approach and 15% are performed endoscopically. The surgeon should discuss the advantages and disadvantages of each technique with the patient.

• A period of rest or ‘not lifting’ is not necessary after an inguinal hernia operation. Patients can do what they feel capable of doing.

Shouldice

Ilio-inguinal incision. Ligation of superficial veins. Cleave external oblique (preserve ilio-inguinal nerve). Surround spermatic cord. Assess posterior wall. Cleave and ligate medial cremaster at the height of the internal ring. Cleave and ligate external spermatic vessels (not always necessary) and preserve genital branch of genito-femoral nerve. Dissect hernia sac until inside internal ring, transect, resect or reduce. Cleave fascia transversalis until in entirely healthy tissue or as far as is necessary to perform reconstruction. Reconstruction with continuous suturing using 2.0 or 3.0 polypropropylene; starting medially, not through periosteum of the pubic tubercle. Suture inferior edge of the fascia transversalis (Thomson’s ligament) to a fold of the anterior side of the conjoined tendon (‘white line’) until the internal ring is constricted (allowing passage for the spermatic cord and point of tweezers). Return as a second layer after including cremaster stump with the same thread to the iliopubic tract (inferior edge of the inguinal ligament). Third layer begin laterally, closure of the conjoined tendon to inguinal ligament. Original Shouldice has a fourth layer in the same plane. Closure of the external oblique aponeurosis with soluble suture material without constriction of the external ring. Approximation of Scarpa’s fascia. Closure of the skin.

Lichtenstein

Incision sufficiently medially for good exposure of the tubercle of pubic bone and rectus sheath. Ligation of superficial veins. Cleave external oblique (preserve ilio-inguinal nerve). Surround spermatic cord. Assess posterior wall. Cremaster does not need to be excised unless hypertrophic, thus, leaving an unacceptably wide internal ring. Dissect hernia sac until inside the internal ring, transect, resect or preferably reduce. If necessary, suture a large direct hernia tension-free with continuous soluble sutures until a flat posterior wall has been created with a normal internal ring. Preserve all nerves in principle, but cut without hesitation if damaged or interference with the placement of mesh. Pay particular attention to the ilio-hypogastric nerve; this may lie under the mesh, but preferably not against a sharp edge (cut prosthesis to the size it needs to be; dividing a nerve is better than causing neuralgic pain). Apply polypropylene mesh 7 × 14 cm (trimming is often necessary) with a 2-cm overlap at the pubic tubercle. Suture continuously with polypropylene sutures 3.0 starting 2 cm mediocranially from the pubic tubercule on the lateral rectus edge and then on the inguinal ligament to the internal ring. Make an incision in the mesh on 1/3 of the lower side until just medial to the spermatic cord. Suture both flaps of the prosthesis overlapping on the lateral side to the inguinal ligament with one polypropylene suture; upper flap over the lower flap. Fix cranial edge of the mesh with one or more sutures (may be soluble) to the aponeurosis of the internal oblique, avoiding muscle in order to avoid injury to the intramuscular segment of the iliohypogastric nerve. Take care not to entrap nerves by suturing! Mesh must lie tension-free (domed) after removal of the wound spreader. Close as in the Shouldice technique. In women, try to preserve the round ligament and the ilioinguinal nerve and handle in the same way as the spermatic cord. If both structures are cut, it is not necessary to create flaps in the mesh.

Endoscopic (TEP)

Anaesthetise. Bladder empty before the operation! Incision (2 cm) just under and next to the umbilicus until inside the anterior rectus sheath. Open preperitoneal space with the finger and, if needs be, insert balloon (optional) up to the pubic bone. Insufflation with gas under camera control. Replace balloon with blunt balloon or Hasson trocar, 10–15 mm Hg. Patient 20° Trendelenburg. Identification of os pubis, Cooper’s ligament, epigastric vessels and internal ring. Differentiate between direct hernia or indirect hernia. Dissect with second trocar (5 or 10 mm in medial line) lateral space until ASIS and insert third trocar (5 mm). Dissect lateral hernia sac from the spermatic cord and separate and put aside cord structures over 5–7 cm. (Via rendez-vous) insert 15 × 15 or 10 × 15 cm polypropylene prosthesis and drape over abdominal wall with plenty of overlap for all potential hernia defects. Be aware that mesh edges can curl up. Carefully desufflate and remove instruments while holding the peritoneal sac ‘inside’ the mesh. Close the fascial defects >10 mm.

http://www.uzleuven.be/be/en/abdominal-surgery/operative-procedures

Operation for an inguinal hernia (Hernia Inguinalis)