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Hernia : the Journal of Hernias and... Feb 2018Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques...
INTRODUCTION
Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.
METHODS
An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.
CONCLUSIONS
The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
Topics: Adult; Anesthesia; Antibiotic Prophylaxis; Biomedical Research; Groin; Hernia, Femoral; Hernia, Inguinal; Herniorrhaphy; Humans; Laparoscopy; Learning Curve; Surgical Mesh
PubMed: 29330835
DOI: 10.1007/s10029-017-1668-x -
American Family Physician Oct 2020Groin hernias are caused by a defect of the abdominal wall in the groin area and comprise inguinal and femoral hernias. Inguinal hernias are more common in men. Although... (Review)
Review
Groin hernias are caused by a defect of the abdominal wall in the groin area and comprise inguinal and femoral hernias. Inguinal hernias are more common in men. Although groin hernias are easily diagnosed on physical examination in men, ultrasonography is often needed in women. Ultrasonography is also helpful when a recurrent hernia, surgical complication after repair, or other cause of groin pain (e.g., groin mass, hydrocele) is suspected. Magnetic resonance imaging has higher sensitivity and specificity than ultrasonography and is useful for diagnosing occult hernias if clinical suspicion is high despite negative ultrasound findings. Herniography, which involves injecting contrast media into the hernial sac, may be used in selected patients. Becoming familiar with the common types of surgical interventions can help family physicians facilitate postoperative care and assess for complications, including recurrence. Laparoscopic repair is associated with shorter recovery time, earlier resumption of activities of daily living, less pain, and lower recurrence rates than open repair. Watchful waiting is a reasonable and safe option in men with asymptomatic or minimally symptomatic inguinal hernias. Watchful waiting is not recommended in patients with symptomatic hernias or in nonpregnant women.
Topics: Hernia, Inguinal; Herniorrhaphy; Humans; Laparoscopy; Magnetic Resonance Imaging; Physical Examination; Sex Factors; Ultrasonography; Watchful Waiting
PubMed: 33064426
DOI: No ID Found -
Laeknabladid Sep 2019Inguinal hernia is the most frequently diagnosed hernia and during their lifetime one third of males are diagnosed with an inguinal hernia. The age distribution is... (Review)
Review
Inguinal hernia is the most frequently diagnosed hernia and during their lifetime one third of males are diagnosed with an inguinal hernia. The age distribution is bimodal with the highest incidence in childhood and after 50 years of age. Diagnosis is usually reached through clinical examination of a lump in the inguinal region although some patients can present with intestinal obstruction. Inguinal hernia repair is the only definitive treatment and is one of the most common surgical procedures performed. It is usually performed as an elective procedure in local, spinal or general anasthesia. The repair constitutes of reinforcing the posterior wall of the inguinal canal, often using a polypropylene mesh; either via an open anterior approach or posteriorly from within the abdomen with laparoscopy. The most common complications following a hernia repair are recurrent hernia and chronic -discomfort but recurrence rates have improved with the use of mesh and laparoscopic techniques. This evidence based review describes the -epidemiology and etiology of inguinal hernia together with the most common surgical procedures; focusing on recent innovations.
Topics: Age Distribution; Female; Hernia, Inguinal; Herniorrhaphy; Humans; Laparoscopy; Male; Middle Aged; Postoperative Complications; Risk Factors; Sex Distribution; Treatment Outcome
PubMed: 31482863
DOI: 10.17992/lbl.2019.09.247 -
Journal of Robotic Surgery Aug 2022The aim of this study was to review the latest evidence on the robotic approach (RHR) for inguinal hernia repair comparing the pooled outcome of this technique with... (Meta-Analysis)
Meta-Analysis Review
The aim of this study was to review the latest evidence on the robotic approach (RHR) for inguinal hernia repair comparing the pooled outcome of this technique with those of the standard laparoscopic procedure (LHR). A systematic literature search was performed in PubMed, Web of Science and Scopus for studies published between 2010 and 2021 concerning the comparison between RHR versus LHR. After screening 582 articles, 9 articles with a total of 64,426 patients (7589 RHRs) were eligible for inclusion. Among preoperative variables, a pooled higher ratio of ASA > 2 patients was found in the robotic group (12.4 vs 8.6%, p < 0.001). Unilateral hernia repair was more common in the laparoscopic group (79.9 vs 68.1, p < 0.001). Overall, operative time was longer in the robotic group (160 vs 90 min, p < 0.001); this was confirmed also in the sub-analysis on unilateral procedures (88 vs 68 min, p = 0.040). The operative time for robotic bilateral repair was similar to the laparoscopic one (111 vs 100, p = 0.797). Conversion to open surgery was 0% in the robotic group. The pooled rate of chronic pain and postoperative complications was similar between the groups. The standardized mean difference MD of the costs between LHR versus RHR was - 3270$ (95% CI - 4757 to - 1782, p < 0.001). In conclusion, laparoscopic and robotic inguinal hernia repair have similar safety parameters and postoperative outcomes. Robotic approach may require longer operative time if the unilateral repair is performed. Costs are higher in the robotic group.
Topics: Hernia, Inguinal; Herniorrhaphy; Humans; Laparoscopy; Operative Time; Robotic Surgical Procedures
PubMed: 34609697
DOI: 10.1007/s11701-021-01312-6 -
Australian Journal of General Practice 2020An inguinal hernia is one of the most common paediatric surgical presentations in a primary care setting. Hernias can present in multiple ways, ranging from an emergency...
BACKGROUND
An inguinal hernia is one of the most common paediatric surgical presentations in a primary care setting. Hernias can present in multiple ways, ranging from an emergency such as a strangulated hernia to a less urgent reducible hernia.
OBJECTIVE
The aim of this article is to aid in appropriate diagnosis and management of hernias in children. The article also provides useful tips for hernia reduction that are especially beneficial in the primary care setting and assist with the identification of hernias that require urgent referral.
DISCUSSION
Recognising the signs of a hernia containing compromised contents is essential to prevent serious complications such as intestinal perforation, testicular atrophy and ovarian damage. Other common conditions such as hydrocoele and undescended testis are sometimes confused with an inguinal hernia. Young patients under the age of three months and patients with concern for compromised contents require urgent referral. Recent evidence regarding controversial issues in inguinal hernia repair such as the role of laparoscopy and the relevance of a contralateral patent internal inguinal ring will be discussed.
Topics: Diagnosis, Differential; Hernia, Inguinal; Humans; Laparoscopy; Pediatrics; Treatment Outcome
PubMed: 32008266
DOI: 10.31128/AJGP-08-19-5037 -
Surgical Endoscopy Jul 2022Inguinal hernia has a lifetime incidence of 27% in men and 3% in women. Surgery is the recommended treatment, but there is no consensus on the best method. Open repair... (Review)
Review
BACKGROUND
Inguinal hernia has a lifetime incidence of 27% in men and 3% in women. Surgery is the recommended treatment, but there is no consensus on the best method. Open repair is most popular, but there are concerns about the risk of chronic groin pain. Laparoscopic repair is increasingly accepted due to the lower risk of chronic pain, although its recurrence rate is still unclear. The aim of this overview is to compare the risk of recurrence and chronic groin pain in laparoscopic versus open repair for inguinal hernia.
METHODS
We searched Ovid MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for systematic reviews and meta-analyses. Only reviews of randomised controlled trials (RCTs) in adults published in English were included. Conference proceedings and editorials were excluded. The quality of the systematic reviews was assessed using the AMSTAR 2 checklist. Two outcomes were considered: hernia recurrence and chronic pain.
RESULTS
Twenty-one systematic reviews and meta-analyses were included. Laparoscopic repair was associated with a lower risk of chronic groin pain compared with open repair. In the four systematic reviews assessing any laparoscopic versus any open repairs, laparoscopic repair was associated with a statistically significant (range: 26-46%) reduction in the odds or risk of chronic pain. Most reviews showed no difference in recurrence rates between laparoscopic and open repairs, regardless of the types of repair considered or the types of hernia that were studied, but most reviews had wide confidence intervals and we cannot rule out clinically important effects favouring either type of repair.
CONCLUSION
Meta-analyses suggest that laparoscopic repairs have a lower incidence of chronic groin pain than open repair, but there is no evidence of differences in recurrence rates between laparoscopic and open repairs.
Topics: Adult; Chronic Pain; Hernia, Inguinal; Herniorrhaphy; Humans; Laparoscopy; Male; Pain, Postoperative; Randomized Controlled Trials as Topic; Recurrence; Surgical Mesh; Systematic Reviews as Topic
PubMed: 35286471
DOI: 10.1007/s00464-022-09161-6 -
CMAJ : Canadian Medical Association... May 2015
Topics: Hernia, Inguinal; Humans; Male
PubMed: 25991853
DOI: 10.1503/cmaj.1150036 -
CMAJ : Canadian Medical Association... May 2015
Topics: Hernia, Inguinal; Humans; Male
PubMed: 25991852
DOI: 10.1503/cmaj.1150035 -
Annals of the Royal College of Surgeons... Feb 2020Gynaecological structures such as the ovaries, fallopian tubes, ligaments and uterus are rarely encountered inside a hernial sac. The prevalence of groin hernias...
INTRODUCTION
Gynaecological structures such as the ovaries, fallopian tubes, ligaments and uterus are rarely encountered inside a hernial sac. The prevalence of groin hernias containing parts of female genitalia remains unknown. The aim of this review was to summarise the existing evidence on inguinal hernias containing ovaries with or without the other female adnexa.
METHODS
A systematic search was conducted for literature published up to February 2018 using the MEDLINE, Scopus and Google Scholar™ databases along with the references of the full-text articles retrieved. Papers on observational studies and case reports concerning women who were diagnosed with an ovarian inguinal hernia (pre or intraoperatively) were considered eligible for inclusion in the review.
RESULTS
Fifteen papers (13 case reports, 2 case series) comprising seventeen patients (mean age 47.9 years) were evaluated. A left-sided hernia was noted in 13 cases (77%) whereas 4 patients had a right-sided hernia. Eight patients underwent preoperative imaging with computed tomography, ultrasonography or both. This was diagnostic in five cases. In 11 patients, hernia contents were repositioned, 2 had a salpingo-oophorectomy and 2 an oophorectomy. Eight patients underwent hernia repair with mesh placement while three had a herniorrhaphy.
CONCLUSIONS
Ovarian inguinal hernias should be considered among the differential diagnoses of a groin mass or swelling. In women of reproductive age, repair of the hernia with the intent to preserve fertility is of critical importance.
Topics: Female; Hernia, Inguinal; Herniorrhaphy; Humans; Inguinal Canal; Ovarian Diseases; Ovariectomy; Ovary; Prevalence; Salpingo-oophorectomy; Surgical Mesh; Tomography, X-Ray Computed; Ultrasonography
PubMed: 31696731
DOI: 10.1308/rcsann.2019.0137 -
Acta Medica Okayama Apr 2020A 76-year-old Japanese man was transferred to our hospital to undergo rehabilitation after traffic accident-related injuries. Seven days post-admission, he presented...
A 76-year-old Japanese man was transferred to our hospital to undergo rehabilitation after traffic accident-related injuries. Seven days post-admission, he presented with abdominal pain and an 8-cm lump in the right inguinal region. He was diagnosed with an incarcerated inguinal hernia and underwent elective surgery the day after manual reduction. He had a normal vermiform appendix which was observed to have adhered to the right indirect hernia sac. An appendectomy and hernia repair using lightweight mesh were performed. We discuss the surgical management of this rare incarcerated Amyand's hernia and the relevant literature.
Topics: Aged; Appendectomy; Appendix; Hernia, Inguinal; Herniorrhaphy; Humans; Male; Surgical Mesh
PubMed: 32341593
DOI: 10.18926/AMO/58277