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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 -
The Cochrane Database of Systematic... Sep 2018This is an update of a Cochrane Review first published in 2001.Hernias are protrusions of all or part of an organ through the body wall that normally contains it. Groin... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is an update of a Cochrane Review first published in 2001.Hernias are protrusions of all or part of an organ through the body wall that normally contains it. Groin hernias include inguinal (96%) and femoral (4%) hernias, and are often symptomatic with discomfort. They are extremely common, with an estimated lifetime risk in men of 27%. Occasionally they may present as emergencies with complications such as bowel incarceration, obstruction and strangulation. The definitive treatment of all hernias is surgical repair, inguinal hernia repair being one of the most common surgical procedures performed. Mesh (hernioplasty) and the traditional non-mesh repairs (herniorrhaphy) are commonly used, with an increasing preference towards mesh repairs in high-income countries.
OBJECTIVES
To evaluate the benefits and harms of different inguinal and femoral hernia repair techniques in adults, specifically comparing closure with mesh versus without mesh. Outcomes include hernia recurrence, complications (including neurovascular or visceral injury, haematoma, seroma, testicular injury, infection, postoperative pain), mortality, duration of operation, postoperative hospital stay and time to return to activities of daily living.
SEARCH METHODS
We searched the following databases on 9 May 2018: Cochrane Colorectal Cancer Group Specialized Register, Cochrane Central Register of Controlled Trials (Issue 1), Ovid MEDLINE (from 1950), Ovid Embase (from 1974) and Web of Science (from 1900). Furthermore, we checked the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for trials. We applied no language or publication restrictions. We also searched the reference lists of included trials and review articles.
SELECTION CRITERIA
We included randomised controlled trials of mesh compared to non-mesh inguinal or femoral hernia repairs in adults over the age of 18 years.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Where available, we collected information on adverse effects. We presented dichotomous data as risk ratios, and where possible we calculated the number needed to treat for an additional beneficial outcome (NNTB). We presented continuous data as mean difference. Analysis of missing data was based on intention-to-treat principles, and we assessed heterogeneity using an evaluation of clinical and methodological diversity, Chi test and I statistic. We used GRADE to assess the quality of evidence for each outcome.
MAIN RESULTS
We included 25 studies (6293 participants) in this review. All included studies specified inguinal hernias, and two studies reported that femoral hernias were included.Mesh repair probably reduces the risk of hernia recurrence compared to non-mesh repair (21 studies, 5575 participants; RR 0.46, 95% CI 0.26 to 0.80, I = 44%, moderate-quality evidence). In absolute numbers, one hernia recurrence was prevented for every 46 mesh repairs compared with non-mesh repairs. Twenty-four studies (6293 participants) assessed a wide range of complications with varying follow-up times. Neurovascular and visceral injuries were more common in non-mesh repair groups (RR 0.61, 95% CI 0.49 to 0.76, I = 0%, NNTB = 22, high-quality evidence). Wound infection was found slightly more commonly in the mesh group (20 studies, 4540 participants; RR 1.29, 95% CI 0.89 to 1.86, I = 0%, NNTB = 200, low-quality evidence). Mesh repair reduced the risk of haematoma compared to non-mesh repair (15 studies, 3773 participants; RR 0.88, 95% CI 0.68 to 1.13, I = 0%, NNTB = 143, low-quality evidence). Seromas probably occur more frequently with mesh repair than with non-mesh repair (14 studies, 2640 participants; RR 1.63, 95% CI 1.03 to 2.59, I = 0%, NNTB = 72, moderate-quality evidence), as does wound swelling (two studies, 388 participants; RR 4.56, 95% CI 1.02 to 20.48, I = 33%, NNTB = 72, moderate-quality evidence). The comparative effect on wound dehiscence is uncertain due to wide confidence intervals (two studies, 329 participants; RR 0.55, 95% CI 0.12 to 2.48, I = 37% NNTB = 77, low-quality evidence). Testicular complications showed nearly equivocal results; they probably occurred slightly more often in the mesh group however the confidence interval around the effect was wide (14 studies, 3741 participants; RR 1.06, 95% CI 0.63 to 1.76, I = 0%, NNTB = 2000, low-quality evidence). Mesh reduced the risk of postoperative urinary retention compared to non-mesh (eight studies, 1539 participants; RR 0.53, 95% CI 0.38 to 0.73, I = 56%, NNTB = 16, moderate-quality evidence).Postoperative and chronic pain could not be compared due to variations in measurement methods and follow-up time (low-quality evidence).No deaths occurred during the follow-up periods reported in the seven studies (2546 participants) reporting this outcome (high-quality evidence).The average operating time was longer for non-mesh repairs by a mean of 4 minutes 22 seconds, despite wide variation across the studies regarding size and direction of effect, thus this result is uncertain (20 studies, 4148 participants; 95% CI -6.85 to -1.60, I= 97%, very low-quality evidence). Hospital stay may be shorter with mesh repair, by 0.6 days (12 studies, 2966 participants; 95% CI -0.86 to -0.34, I = 98%, low-quality evidence), and participants undergoing mesh repairs may return to normal activities of daily living a mean of 2.87 days sooner than those with non-mesh repair (10 studies, 3183 participants; 95% CI -4.42 to -1.32, I = 96%, low-quality evidence), although the results of both these outcomes are also limited by wide variation in the size and direction of effect across the studies.
AUTHORS' CONCLUSIONS
Mesh and non-mesh repairs are effective surgical approaches in treating hernias, each demonstrating benefits in different areas. Compared to non-mesh repairs, mesh repairs probably reduce the rate of hernia recurrence, and reduce visceral or neurovascular injuries, making mesh repair a common repair approach. Mesh repairs may result in a reduced length of hospital stay and time to return to activities of daily living, but these results are uncertain due to variation in the results of the studies. Non-mesh repair is less likely to cause seroma formation and has been favoured in low-income countries due to low cost and reduced availability of mesh materials. Risk of bias in the included studies was low to moderate and generally handled well by study authors, with attention to details of allocation, blinding, attrition and reporting.
Topics: Activities of Daily Living; Adult; Hernia, Femoral; Hernia, Inguinal; Herniorrhaphy; Humans; Length of Stay; Operative Time; Postoperative Complications; Randomized Controlled Trials as Topic; Secondary Prevention; Surgical Mesh
PubMed: 30209805
DOI: 10.1002/14651858.CD011517.pub2 -
Danish Medical Journal May 2014Recurrence after inguinal hernia surgery is a considerable clinical problem, and several risk factors of recurrence such as surgical technique, re-recurrence, and family... (Review)
Review
BACKGROUND
Recurrence after inguinal hernia surgery is a considerable clinical problem, and several risk factors of recurrence such as surgical technique, re-recurrence, and family history have been identified. Non-technical patient related factors that influence the risk of recurrence after inguinal hernia surgery are sparsely studied. The purpose of the studies included in this PhD thesis, was to describe the epidemiologic characteristics of inguinal hernia occurrence and recurrence, as well as investigating the patient related risk factors leading to recurrence after inguinal hernia surgery. Four studies were included in this thesis.
METHODS AND RESULTS
Study 1: The study was a nationwide register-based study combining the Civil Registration System and the Danish National Hospital Register during a five-year period. We included a total of 46,717 persons operated for a groin hernia from the population of 5,639,885 people (2,799,105 males, 2,008,780 females). We found that 97% of all groin hernia repairs were inguinal hernias and 3% femoral hernias. Data showed that inguinal hernia surgery peaked during childhood and old age, whereas femoral hernia surgery increased throughout life. Study 2: Using data from the Danish Hernia Database (DHDB), we included all male patients operated for elective primary inguinal hernia during a 15-year period (n = 85,314). The overall inguinal hernia reoperation rate was 3.8%, and subdivided into indirect inguinal hernias and direct inguinal hernias, the reoperation rates were 2.7% and 5.2%, respectively (p <0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 1,90 (CI 95% 1.77-2.04) compared with an indirect inguinal hernia at primary operation (p < 0.001). We found that there was a significant relationship between the type of hernia at the primary operation and reoperation, when controlling for the effect of the operation method, r = 0.45 (p < 0.001). This corresponded to odds ratios (OR) of 7.1 (CI 95% 6.0-8.4) of being reoperated for a direct inguinal hernia if the hernia at the primary operation was a direct inguinal hernia, and an OR of 3.0 (CI 95% 2.7-3.3) of being reoperated for an indirect inguinal hernia if the primary operation was for an indirect inguinal hernia. As subsequent findings, we saw that the frequency of laparoscopic hernia repair increased during the study period and that the laparoscopic repair of indirect inguinal hernias recurred more often than indirect inguinal hernias operated by Lichtenstein's technique (p < 0.001). Study 3: Using data from the DHDB, we included all female patients operated for elective primary inguinal hernia during a 15-year period (n = 5,893). Of those, a total of 305 operations for recurrences were registered (61 % inguinal recurrences, 38 % femoral recurrences, 1 % no hernial), which corresponded to an overall crude reoperation rate of 5.2%. A noticeable difference was found in reoperation rates after primary operation for direct inguinal hernias (DIH), indirect inguinal hernias (IIH) and combined IIH+DIH of 11.0%, 3.0%, and 0.007% respectively (p < 0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 3.1 (CI 95% 2.4-3.9) compared with an indirect inguinal hernia at primary operation (p < 0.001). Laparoscopic operation was found to give a lower risk of recurrence with a Hazard ratio of 0.57 (CI 95% 0.43-0.75) compared with Lichtenstein's technique (p < 0.001). We found that all femoral recurrences (n = 116) occurred after Lichtenstein's procedure and none occurred after laparoscopic operation (p < 0.001, Log Rank test). Study 4: This study was a systematic review and meta-analysis of non-technical patient-related risk factors for recurrence after inguinal hernia surgery. From a total of 5,061 potentially relevant records we included 40 studies in the review covering 719,901 procedures in 714,167 patients and of those 14 studies covering 378,824 procedures in 375,620 patients were included into meta-analysis of eight risk factors (gender, age, hernia type, hernia size, re-recurrence, bilaterality, mode of admission and smoking). We found that female gender (RR 1.38, 95% CI 1.28-1.48, I2 = 0%), direct inguinal hernias at primary procedure (RR 1.91, 95% CI 1.62-2.26, I2 = 10%), operation for a recurrent inguinal hernia (RR 2.2, 95% CI 2.0-2.42, I2 = 6%), and smoking (OR 2.53, 95% CI 1.43-4.47, I2 = 0%) were risk factors for recurrence after inguinal hernia surgery. Furthermore, emergency admission; connective tissue composition and degradation; and positive family history were found to have an impact on the risk of recurrence, while post-operative convalescence and age had no impact on the risk of recurrence.
CONCLUSION
The studies included in the thesis have studies the natural history of groin hernias on a nationwide basis; have identified the epidemiologic distribution of groin hernias and the non-technical risk factors associated with recurrence. Data showed that non-technical patient-related risk factors have great impact on the risk of recurrence after inguinal hernia surgery. The reason to why inguinal hernias recur is most likely multifactorial and lies in the span of technical and non-technical patient-related risk factors and it is possible that the different groin hernia subtypes have different pathophysiology. This knowledge should be implemented into clinical practice in order to reduce the risk of recurrence and in future research design examining recurrence after inguinal hernia surgery as outcome.
Topics: Age Factors; Denmark; Hernia, Femoral; Hernia, Inguinal; Herniorrhaphy; Humans; Prevalence; Recurrence; Reoperation; Risk Factors; Sex Factors; Smoking
PubMed: 24814748
DOI: No ID Found -
Journal of Abdominal Wall Surgery : JAWS 2023
PubMed: 38312398
DOI: 10.3389/jaws.2023.12013 -
Clinical Epidemiology 2016To monitor and improve nation-wide surgical outcome after groin hernia repair based on scientific evidence-based surgical strategies for the national and international... (Review)
Review
AIM OF DATABASE
To monitor and improve nation-wide surgical outcome after groin hernia repair based on scientific evidence-based surgical strategies for the national and international surgical community.
STUDY POPULATION
Patients ≥18 years operated for groin hernia.
MAIN VARIABLES
Type and size of hernia, primary or recurrent, type of surgical repair procedure, mesh and mesh fixation methods.
DESCRIPTIVE DATA
According to the Danish National Health Act, surgeons are obliged to register all hernia repairs immediately after surgery (3 minute registration time). All institutions have continuous access to their own data stratified on individual surgeons. Registrations are based on a closed, protected Internet system requiring personal codes also identifying the operating institution. A national steering committee consisting of 13 voluntary and dedicated surgeons, 11 of whom are unpaid, handles the medical management of the database.
RESULTS
The Danish Inguinal Hernia Database comprises intraoperative data from >130,000 repairs (May 2015). A total of 49 peer-reviewed national and international publications have been published from the database (June 2015).
CONCLUSION
The Danish Inguinal Hernia Database is fully active monitoring surgical quality and contributes to the national and international surgical society to improve outcome after groin hernia repair.
PubMed: 27822094
DOI: 10.2147/CLEP.S99512 -
Ghana Medical Journal Sep 2021The caecum and appendix are uncommon contents of femoral hernia (Duari hernia). Diagnosis is usually intraoperative. We report a rare case of obstructed right femoral...
UNLABELLED
The caecum and appendix are uncommon contents of femoral hernia (Duari hernia). Diagnosis is usually intraoperative. We report a rare case of obstructed right femoral hernia in a 65-year-old woman. She was admitted into the accident and emergency department because of sudden irreducibility of a previously reducible right groin swelling of 5 years duration. She had obstructive symptoms with an irreducible right groin mass clinically diagnosed as obstructed right femoral hernia. A combination of infra-inguinal transverse incision and a lower midline laparotomy incision was used. The intraoperative findings included the herniation of the caecum and appendix into the right femoral canal. Patient had an uneventful recovery. Duari hernia is uncommon. A high index of suspicion and an experienced surgeon, who can handle uncommon findings should be involved in the management of obstructed femoral hernias.
FUNDING
None declared.
Topics: Aged; Emergency Service, Hospital; Female; Hernia, Femoral; Humans; Laparotomy
PubMed: 35950172
DOI: 10.4314/gmj.v55i3.9 -
African Journal of Paediatric Surgery :... 2021Femoral hernias are an uncommon groin pathology among pediatric patients. Therefore, they are frequently misdiagnosed. In the present study, we review our experience... (Review)
Review
BACKGROUND
Femoral hernias are an uncommon groin pathology among pediatric patients. Therefore, they are frequently misdiagnosed. In the present study, we review our experience with this rare surgical entity during the past 25 years.
METHODS
The medical records of 19 patients who underwent 22 femoral hernia repairs between January 1994 and December 2019 were retrospectively analysed.
RESULTS
Patients' age ranged from 2 to 12 years (mean age was 5. 5 years) with an approximately equal sex ratio (10 girls/9 boys). There were three bilateral cases identified separately. They were discovered and managed at different times. All the children were referred with a groin lump, but the correct pre-operative diagnosis was made in only 13 cases (59%). In the remaining cases, four were identified intraoperatively following negative exploration for a supposed inguinal hernia. The other five were found to have a femoral hernia 1 month to 12 months after ipsilateral inguinal hernia repair. All patients underwent elective surgery. The femoral canal was closed using either Lytle or McVay procedure. Recurrence occurred in only one patient 2 months after initial repair.
CONCLUSION
Femoral hernias are often misdiagnosed. Pre-operative diagnosis can be obtained through careful clinical assessment. In equivocal cases, ultrasonography and laparoscopy could be useful. A correct pre-operative diagnosis will lead to suitable treatment, thus avoiding unnecessary reoperations and their related complications.
Topics: Child; Child, Preschool; Diagnostic Errors; Female; Hernia, Femoral; Hernia, Inguinal; Humans; Laparoscopy; Male; Retrospective Studies
PubMed: 34341202
DOI: 10.4103/ajps.AJPS_74_20 -
Buffalo Medical and Surgical Journal Aug 1863
PubMed: 36664438
DOI: No ID Found