Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial

The Impact of Surgical Repair on Restlessness in Infants with Non-Incarcerated Inguinal Hernias: A Prospective Study

Background/Objectives: Pediatric inguinal hernias are usually described as asymptomatic unless they become incarcerated. Our aim was to evaluate possible restlessness associated with non-incarcerated inguinal hernias in infants. Methods: We performed a prospective multi-center cohort study that included infants, up to 18 months of age, with non-incarcerated inguinal hernias. Restlessness was evaluated by caregivers before ("Pre") and after ("Post") hernia repair using two scales, the soothability section of the Infant Behavioral Questionnaire (IBQ) and the Parents' Restlessness Score (PRS) on a 1-5 scale (5-highest degree of restlessness), and then compared to matched healthy controls. The change in restlessness after surgery was evaluated by Parents' Change in restlessness Score (PCS) and the difference between Pre- and Post-scores (Δ). A subgroup analysis for patients with Pre-PRS ≥ 3 was performed. Demographic and clinical characteristics were collected, and possible associations with levels of restlessness were evaluated. Results: Seventy-nine infants, median corrected age 2.5 (1.6-4.8) months, were included in this study during June 2022 to July 2024. Infants with inguinal hernias were found to suffer significant restlessness as compared to controls [Pre-PRS = 3 (2-4) vs. 2 (2-2), respectively, p < 0.001]. After hernia repair, PRS restlessness scores improved [ΔPRS = 1 (0-2)] to the level of controls (Post-PRS = 2 (1-3), p = 0.5). The difference in IBQ scores between hernia patients prior to repair and control patients was not statistically significant [3.2 (2.3-4.1) vs. 3.1 (2.3-4.1), respectively, p = 0.28], although both Post-PRS and Post-IBQ scores significantly improved as compared to Pre-PRS and Pre-IBQ scores [2 (1-3) and 2.8 (1.7-3.6) vs. 3 (2-4) and 3.2 (2.3-41), p < 0.001 and p = 0.005, respectively]. Fifty-two patients (66%) had Pre-PRS ≥ 3 and demonstrated a more pronounced improvement in restlessness following surgery [ΔPRS = 1.5 (1-2)]. Patients who had Emergency Department visits prior to hernia repair demonstrated both increased baseline restlessness and more pronounced improvement following repair as compared to patients with no visits (Pre-PRS = 3 (3-4) vs. 3 (2-3), p = 0.03; ΔPRS = 1.5 (1-2) vs. 0 (0-1), p < 0.01; ΔIBQ = 0.7 (0.02-1.45) vs. 0.12 (-0.5-1), p = 0.03). Conclusions: Non-incarcerated inguinal hernias in infants are associated with significant restlessness in most cases. Restlessness resolved after surgical repair.

Watchful waiting to surgery in men with mildly symptomatic or asymptomatic inguinal hernia: an individual participant data meta-analysis of long-term follow-up of randomized controlled trials

BACKGROUND

Individual studies on men with mildly symptomatic or asymptomatic inguinal hernia who have opted for watchful waiting (WW) vary considerably. Furthermore, long-term data on such patients who cross over to herniorrhaphy is scarce.

METHODS

PubMed, EMBASE, and Cochrane databases were searched systematically from inception to 3rd April 2024 for long-term follow-up of randomized controlled trials (RCTs) on men with mildly symptomatic or asymptomatic inguinal hernia. Individual participant survival data of cross over rates from WW to herniorrhaphy were extracted, reconstructed and combined. Secondary outcome was reason for cross over to herniorrhaphy.

RESULTS

Long-term follow-up of three RCTs with 592 participants was included. A total of 344/592 participants crossed over to herniorrhaphy during a median follow up period that ranged from 3.2 to 12.0 years. The median cumulative cross over rate was 54.2% (95% CI 45.5% - 66.3%). The cumulative 1-year, 5-year, and 10- year cross over rates were 28.7% (95% CI 25.2% - 32.5%), 51.5% (95% CI 47.4% - 55.6%), and 70.6% (95% CI 66.2% - 74.9%) respectively. During follow-up, the most frequent reasons for cross over to herniorrhaphy were increased pain 198/344 (57.6%) and incarceration 15/344 (4.4%).

CONCLUSION

This study provides valuable long-term data for patient counselling, indicating that while WW is a safe strategy for men with mildly symptomatic or asymptomatic inguinal hernia, symptoms would likely progress eventually, necessitating operative repair.

Incidence of contralateral metachronous inguinal hernia on long term follow-up after unilateral inguinal hernia repair: a systematic review and meta-analysis

BACKGROUND

The repair of inguinal hernias is a common surgical procedure. Some patients will need a second operation after developing a metachronous contralateral inguinal hernia (MCIH). The suggestion has been made to strengthen the contralateral side at the same time as primary unilateral surgery. In this systematic review we aim to determine how many adult patients with a unilateral inguinal hernia will develop a MCIH.

METHODS

This review was reported in line with PRISMA guidelines. We performed a literature review in PubMed Publisher, Embase, Google Scholar and Cochrane Library until May 2021, including articles reporting MCIH after unilateral inguinal hernia repair in adults. As outcome measure, the number of patients diagnosed with a MCIH was registered.

RESULTS

A total of 19 articles with a total of 277,288 patients were included. The combined estimate for MCIH after meta-analysis equaled 8.3% (95% CI 7.1%-9.5%), with a high index of heterogeneity (I2 = 97.9%). A random-effects meta-regression was performed to obtain the percentage of MCIH as a function of median follow-up time. The percentage of MCIH at 3, 5 and 10 years was estimated at 5.2%, 8.0% and 17.1%, respectively.

CONCLUSION

We suggest that there is insufficient clinical evidence to support prophylactic contralateral repair in all patients. We propose a patient-specific approach in the decision to perform prophylactic repair, taking into account potential risk factors for hernia development, type of surgical approach, and general risk factors for chronic postoperative inguinal pain. More long-term prospective data are needed to guide the decision for prophylactic contralateral mesh placement.

Exploring serum N-glycome patterns as candidate non-invasive biomarkers in inguinal hernia

Introduction

Although inguinal hernia (IH) is prevalent in elderly males, research on its specific diagnostic biomarkers is limited. Protein N-glycosylation is one of the most important and ubiquitous post-translational modifications and often results in a remarkable heterogeneity of protein glycoforms. Protein N-glycosylation often changes in a disease and holds great potential for discovering non-invasive biomarkers. This study aimed to gain insights into total serum protein N-glycosylation of IH to identify candidate non-invasive biomarkers for diagnosis and subtype classification of IH.

Methods

Linkage-specific sialylation derivatization combined with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry detection was used to analyze serum protein N-glycosylation patterns in IH patients and healthy controls.

Results

IH patients had abnormal glycan fucosylation and sialylation compared to healthy controls (HC), of which two glycan traits representing linkage-specific sialylation within monoantennary glycans showed high potential as diagnostic biomarkers for IH with an area under the curve (AUC) of 0.75. Additionally, serum N-glycans were different between indirect IH and direct IH in glycosylation features, namely complexity, fucosylation, galactosylation, sialylation, and α2,6-linked sialylation. Four distinctive glycans between the two subtypes showed good performance with AUC >0.8, suggesting that these glycan traits have potential as biomarkers for subtype classification.

Conclusions

We first reported the serum N-glycomic features of IH patients. Furthermore, we identified several potential biomarkers for the diagnosis and subtype classification of IH. These findings can deepen the understanding of IH.

Transinguinal preperitoneal (TIPP) versus Lichtenstein for inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

We aimed to perform a systematic review and meta-analysis comparing postoperative outcomes in inguinal hernia repair with TIPP versus Lichtenstein technique.

METHODS

Cochrane Central, Scopus, and PubMed were systematically searched for studies comparing TIPP and Lichtenstein´s technique for inguinal hernia repair. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, the Visual Analogue Pain Score, chronic pain, paresthesia rates, and recurrence. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics and random-risk effect was used if I2 > 25%.

RESULTS

790 studies were screened and 44 were thoroughly reviewed. A total of nine studies, comprising 8428 patients were included, of whom 4185 (49.7%) received TIPP and 4243 (50.3%) received Lichtenstein. We found that TIPP presented less chronic pain (OR 0.43; 95% CI 0.20-0.93 P = 0.03; I2 = 84%) and paresthesia rates (OR 0.27; 95% CI 0.07-0.99; P = 0.05; I2 = 63%) than Lichtenstein group. In addition, TIPP was associated with a lower VAS pain score at 14 postoperative day (MD - 0.93; 95% CI - 1.48 to - 0.39; P = 0.0007; I2 = 99%). The data showed a lower operative time with the TIPP technique (MD - 7.18; 95% CI - 12.50, - 1.87; P = 0.008; I2 = 94%). We found no statistical difference between groups regarding the other outcomes analyzed.

CONCLUSION

TIPP may be a valuable technique for inguinal hernias. It was associated with lower chronic pain, and paresthesia when compared to Lichtenstein technique. Further long-term randomized studies are necessary to confirm our findings. Study registration A review protocol for this meta-analysis was registered at PROSPERO (CRD42023434909).

Association of body mass index with 30-day outcomes following groin hernia repair

PURPOSE

Although groin hernia repairs are relatively safe, efforts to identify factors associated with greater morbidity and resource utilization following these operations are warranted. An emphasis on obesity has limited studies from a comprehensive evaluation of the association between body mass index (BMI) and outcomes following groin hernia repair. Thus, we aimed to ascertain the association between BMI class with 30-day outcomes following these operations.

METHODS

The 2014-2020 National Surgical Quality Improvement Program database was queried to identify adults undergoing non-recurrent groin hernia repair. Patient BMI was used to stratify patients into six groups: underweight, normal, overweight, and obesity classes I-III. Association of BMI with major adverse events (MAE), wound complication, and prolonged length of stay (pLOS) as well as 30-day readmission and reoperation were evaluated using multivariable regressions.

RESULTS

Of the 163,373 adults who underwent groin hernia repair, the majority of patients were considered overweight (44.4%). Underweight patients more commonly underwent emergent operations and femoral hernia repair compared to others. After adjustment of intergoup differences, obesity class III was associated with greater odds of an MAE (AOR 1.50), wound complication (AOR 4.30), pLOS (AOR 1.40), and 30-day readmission (AOR 1.50) and reoperation (AOR 1.75, all p < 0.05). Underweight BMI portended greater odds of pLOS and unplanned readmission.

CONCLUSION

Consideration of BMI in patients requiring groin hernia repair could help inform perioperative expectations. Preoperative optimization and deployment of a minimally invasive approach when feasible may further reduce morbidity in patients at the extremes of the BMI spectrum.

Effect of the SARS-CoV-2 pandemic on planned and emergency hernia repair in Sweden: a register-based study

PURPOSE

The COVID-19 has had a profound impact on the health care delivery in Sweden, including deprioritization of benign surgeries during the COVID-19 pandemic. The aim of this study was to assess the effect of COVID-19 pandemic on emergency and planned hernia repair in Sweden.

METHODS

Data on hernia repairs from January 2016 to December 2021 were retrieved from the Swedish Patient Register using procedural codes. Two groups were formed: COVID-19 group (January 2020-December 2021) and control group (January 2016-December 2019). Demographic data on mean age, gender, and type of hernia were collected.

RESULTS

This study showed a weak negative correlation between the number of elective hernia repairs performed each month during the pandemic and the number of emergency repairs carried out during the following 3 months for inguinal hernia repair (p = 0.114) and incisional hernia repair (p = 0.193), whereas there was no correlation for femoral or umbilical hernia repairs.

CONCLUSION

The COVID-19 pandemic had a great impact on planned hernia surgeries in Sweden, but our hypothesis that postponing planned repairs would increase the risk of emergency events was not supported.

Current opinions in inguinal hernia emergencies: A comprehensive review of related evidences

INTRODUCTION:

Groins hernia emergencies are evaluated under two definitions: incarceration that is defined as a hernia in which its content becomes irreducible at the passage in the abdominal wall and strangulation that compromises the blood supply to the omentum and/or intestines within the hernia sac. The purpose of this paper was to determine the latest knowledge about groin hernia emergencies.

MATERIALS AND METHODS:

PubMed and Google Scholar searches were done by using combinations of “inguinal hernia” and “emergency”, and “groin hernia” and “emergency” keywords at first. More detailed searches were performed to enrich the “Surgical treatment” part of the paper by using “emergency hernia” and “mesh”, “emergency hernia,” and “laparoscopic versus open” keywords afterward.

RESULTS:

Approximately 5%–10% of all inguinal repairs are performed in emergency settings. Both lateral and medial inguinal hernias can get incarcerated or strangulated, whereas the risk for femoral hernias is higher. Manual reduction of incarcerated inguinal hernias is successful in approximately 60% of the cases. The prediction of bowel ischemia due to strangulation may be possible with some blood tests and imaging studies like ultrasound and computed tomography. It has been shown that the longer the duration of incarceration the higher the risk of bowel ischemia. Bowel resection which is more frequently necessary in patients with advanced age, female gender, and femoral hernia, is associated with an increased risk of perioperative mortality. Some surgeons still use tissue-suture repairs in an emergency setting; however, mesh repairs have been shown to be safe unless there is an overt contamination.

CONCLUSION:

Early treatment of complicated groin hernias is the key to favorable outcomes. The need for bowel resection and advanced age are the most prominent factors for morbidity and mortality. Mesh repairs are safe in most cases. Minimally invasive approaches promise good results in experienced centers.

Asymptomatic inguinal hernia: does it need surgical repair? A systematic review and meta-analysis

BACKGROUND

The aim of this review is to compare the outcomes of surgical repair versus watchful waiting in asymptomatic or minimally symptomatic inguinal hernias.

METHODS

Preferred reporting items for systematic reviews and meta-analyses guidelines were employed. We analysed primary outcomes: pain, quality of life, pain during daily activities and visual analogue scale (VAS that measures pain at rest and on movement) and secondary outcomes: postoperative complications and recurrence.

RESULTS

Pain and quality of life were not comparable due to differences in the parameters used in different articles. Pain interfering with normal daily activity was evaluated in one study and appears more favourable in the post-repair group respect to the watchful waiting (WW) group (5.1% versus 2.2%). VAS, measured in one study, at 6 months was more favourable in the surgery group (37% versus 44%). After 12 months the outcome was better in the control group than in the repair group (28% versus 30%). Conversion rate of the patient cohorts from watchful waiting to elective surgery was between 35.03% and 57.8%. The meta-analysis did not find significant statistical differences in the two groups examined for postoperative complications [RR = 0.95, 95% CI (0.50, 1.80), P = 0.88], as for hernia recurrence [RR = 1.01, 95% CI (0.50, 2.02), P = 0.98].

CONCLUSION

WW seems to be an acceptable option for the patient with asymptomatic or minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms appear is safe. Acute hernia incarcerations are not particularly frequent. The incidence of chronic pain after the repair is high. Physicians must select patients carefully and explain to them the risks and benefits of surgery.

A study of the effectiveness of the bilateral and contralateral occult inguinal hernia repair by total extraperitoneal repair with intraperitoneal examination

PURPOSE

Of the various methods used, the laparoscopic surgical repair of inguinal hernias is widely performed. We aimed to estimate the incidence of bilateral and contralateral occult inguinal hernias in our surgical population and to compare the results of total extraperitoneal repair (TEP) for bilateral and unilateral inguinal hernias, occult and non-occult hernias.

METHODS

We retrospectively reviewed data of patients who underwent TEP for the repair of adult inguinal hernias from January 2012 to November 2018 in our hospital.

RESULTS

Of the data of 259 patients included, 134 (51.7%) and 125 (48.3%) had unilateral and bilateral inguinal hernias, respectively, while 70 patients (27%) were found to have a contralateral occult inguinal hernia, intraoperatively. The mean operative time was 129 ± 48 minutes (range, 43-300 minutes) and 167 ± 55 minutes (range, 85-390 minutes) for the unilateral and bilateral groups, respectively, indicating a significantly longer duration of surgery for the bilateral group (P < .05). Recurrence occurred in 1.5% (5/134) and 0.4% (1/250) of the operated hernias in the unilateral and the bilateral groups, respectively, indicating a significantly lower rate of recurrence in the latter group (P < .05). The two groups showed no statistically significant differences with respect to the remaining perioperative data. The incidence of postoperative complications in occult hernias was not significantly different from that in non-occult hernias.

CONCLUSIONS

Our TEP method, involving a laparoscopic exploration from the intraperitoneal side, can be safely and effectively utilized for the repair of both bilateral and contralateral occult inguinal hernias.

Controversies in Inguinal Hernia

Inguinal hernias represent one of the most common pathologic conditions presenting to the general surgeon. In surgical practice, several controversies persist: when to operate, the utility of a laparoscopic versus open approach, the applicability of robotic surgery, the approach to bilateral hernias, management of athletic-related groin pain ("sports hernia"), and the role of tissue-based repairs in modern hernia surgery. Ideally, surgeons should approach each patient individually and tailor their approach based on patient factors and preferences. The informed consent process is critical, especially given increasing recognition of the risk of long-term chronic pain following hernia repair.

The Value of Preoperative Ultrasound in the Detection of Contralateral Occult Inguinal Hernia in the Treatment of Symptomatic Inguinal Hernia

BACKGROUND

The true incidence of contralateral occult inguinal hernia (OIH) is a debate. The repair of contralateral OIH in the treatment context of clinical symptomatic unilateral inguinal hernia (IH) is controversial. This study aimed to assess the effect and clinical benefit of preoperative ultrasound (US) in the diagnosis of contralateral OIH performed before surgery.

METHODS

The retrospective data of 155 consecutive male patients who underwent IH repair between January 2014 and January 2020 were analyzed. The surgical procedures for IH and the clinical outcomes of the US were evaluated.

RESULTS

Of 155 patients, 29 (18.7%) presented with bilateral IH. Preoperative US was performed in 73 cases of clinical unilateral IH (n=126), and 30 (23.8%) patients were found to have a contralateral OIH. The totally extrapreperitoneal (TEP) or Lichtenstein repair was conducted. Bilateral IH repair was proposed for all, but only 28 agreed and underwent bilateral repair. Patients with clinically bilateral hernia had more complications compared with patients diagnosed to have occult contralateral IH after the US (n=3 vs. n=0). In the overall group, the TEP procedure resulted in shorter hospital stay (P=0.001) and less pain (P=0.021).

CONCLUSIONS

The preoperative US may be recommended to assess the presence of a contralateral OIH as it is a noninvasive, radiation-free, widely available, relatively cheap diagnostic method. The preoperative US may change the surgical approach in up to 1/4 patients with a clinical unilateral IH. Either Lichtenstein repair or TEP repair can be performed with an acceptable complication rate in the case of OIH.

Surgical and non-surgical treatment of inguinal hernia during non-elective admissions in the Nationwide Readmissions Database

INTRODUCTION

Inguinal hernia repair is one of the most common surgical operations, yet the optimal treatment strategy remains undefined. Treatment of symptomatic inguinal hernias include both surgical and non-surgical approaches. The objective of this study was to determine differences in population, readmission rates, and costs between operative and non-operative approaches for patients admitted non-electively for an inguinal hernia in a national dataset. In addition, we sought to define the baseline characteristics of the two groups and identify potential predictive factors in the non-surgically managed subgroup who were readmitted and treated operatively within 90 days of their first visit.

METHODS

This study was a retrospective review of data from the Nationwide Readmissions Database (NRD) from 2010 to 2014. Patients above age 18 who were admitted non-electively for a primary diagnosis of inguinal hernia were included. Patients whose length of stay was < 1% or > 95% percentile or died during the initial visit were excluded. Readmissions within 90 days of the initial visit were flagged. Patients were classified according to initial management strategy: operative versus non-operative. Demographic, clinical, and organizational characteristics were compared between the two cohorts.

RESULTS

14,249 patients met inclusion criteria and were operative (n = 8996, 63.13%) and non-operative (n = 5255, 36.88%) cohorts. When comparing the two groups, readmission rate was lower (0.49% for surgical, 1.78% for non-surgical, p < 0.01), mean length of stay (LOS) longer (3.27 [SE = 0.05] days for surgical, 2.76 days [SE = 0.06] for non-surgical, p < 0.01), and mean total cost higher ($9597 for surgical, $7167 for non-surgical, p < 0.01) in surgically treated patients. The non-surgical population was on average older (63.05 years for surgical, 64.52 years for non-surgical, p < 0.01) with more chronic conditions (3.57 for surgical, 4.05 for non-surgical, p < 0.01). Of the patients initially managed non-surgically, 1.78% (n = 91) were readmitted, and of them, 62.63% (n = 57) were readmitted and managed surgically within 90 days of initial admission (i.e., crossed over from watchful waiting to surgical treatment). Average number of chronic conditions (3.79 versus 4.03, p = 0.74), average number of comorbidities (2.26 versus 2.18, p = 0.87), and average total number of ICD-9 discharge codes (7.44 versus 8.23 p = 0.54 did not differ significantly between the operative versus non-operative sample of the readmitted population. The total cost ($5562.38 versus $8737.28, p = 0.01) was greater in the operative versus non-operative sample.

CONCLUSION

Watchful-waiting strategy is the most common treatment approach in patients admitted non-electively for symptomatic inguinal hernia. Readmission after non-elective hospitalization for inguinal hernia is rare, but surgical intervention decreased the likelihood of readmission compared to non-operative management, while also increasing LOS and cost of care. Our data supports a patient centric approach to the management; non-surgical treatment is a viable temporary option even in symptomatic inguinal hernias, while surgical treatment may reduce the likelihood of future readmission.

Loss of independence after emergency inguinal hernia repair in elderly patients: How aggressive should we be?

BACKGROUND

Loss of independence (LOI) assesses patient quality of life after surgery and is associated with increased readmission and death. This paper compares LOI among the elderly who received elective versus emergent inguinal hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files from 2015 to 2017 were reviewed for inguinal hernia repairs in patients 70-years-old or older. Chi-square analysis, Student t-test, and backwards multivariate logistic analysis were performed appropriately.

RESULTS

Patients undergoing elective open or laparoscopic repair were less likely to experience LOI (OR 0.061, CI 0.035-0.106) and (OR 0.052 CI 0.024-0.113), respectively, and they were less likely to experience mortality (OR 0.07, CI 0.026-0.185) and (OR 0.059, CI 0.015-0.229), respectively.

CONCLUSIONS

Significant debility occurs following emergency inguinal hernia repair in elderly patients. Elective surgery may be indicated more often in order to reduce emergencies and LOI in elderly patients.

Asymptomatic abdominal wall and incisional hernias: Is therapeutic decision consensual? An international survey

Introduction

Hernia pathology is one of the leading causes of surgery worldwide. For asymptomatic patients, surgery remains questionable. The objective of this study was to evaluate the practices of a large population of digestive surgeons with asymptomatic hernia.

Methods

Between October 2016 and March 2017, French-speaking digestive surgeons were invited to respond to an online survey consisting of 13 common clinical situations concerning primary or asymptomatic incisional hernia pathology where a therapeutic decision was requested. A consensual attitude was defined by identical care by at least 75% of surgeons.

Results

Of the 204 surgeons responding to the study, 44% were under 45 years of age. The therapeutic attitude was consensual in 2 out of 13 clinical cases: surgical abstention was chosen consensually for inguinal hernia in the elderly with comorbidities while surgical treatment was consensually chosen for incisional hernia in a young patient in remission of pancreatic cancer. The under-45s were more likely to undergo surgical repair (5 cases of 13 vs 4 cases of 13, p = 0.03).

Conclusion

Although frequent, the management of primary and incisional hernias of the abdominal wall does not reach consensus in the surgical community. Specific recommendations for indications of surgical management or watchful waiting are required.

•

There is a great heterogeneity among surgeons in management of asymptomatic abdominal wall pathology, without any consensus.

•

While a surgical indication should be retained in women with a femoral hernia, the consensus threshold has not been reached.

•

The age of the surgeons has an impact on their therapeutic decision, the young surgeons favoring an intervention.

•

The type of care structure does not imply modifications of therapeutic practices of asymptomatic hernias among the surgeons.

Watchful waiting vs repair for asymptomatic or minimally symptomatic inguinal hernia in men: a systematic review

PURPOSE

One-third of patients presenting with inguinal hernia are asymptomatic and the best treatment for these patients is unclear. The aim of this study was to assess the feasibility of applying a watchful waiting strategy for asymptomatic or minimally symptomatic inguinal hernia in men.

METHODS

PubMed, EMBASE, and Cochrane Library were searched from database inception to May 14, 2020. Included were all types of original data written in English, German, Danish, Swedish, or Norwegian involving ≥ 5 male patients aged ≥ 18 years old with asymptomatic or minimally symptomatic inguinal hernia and undergoing watchful waiting. This review was reported according to the PRISMA guideline.

RESULTS

A total of nine studies were included; three randomized controlled trials, three prospective cohort studies, and three retrospective cohort studies. Data on a total of 858 unique patients following a watchful waiting strategy were included. Approximately one-third of patients crossed over from watchful waiting to surgery after 3 years increasing to more than two-thirds after 10 years. The most frequent reason for crossover was hernia-related pain (median 79%, range 48-91%). The rate of acute hernia-related operations was low (2-3%), and watchful waiting was not associated with increased mortality or postoperative complications. Levels of pain and discomfort after randomization were similar over time between patients undergoing elective repair or watchful waiting.

CONCLUSION

Applying a watchful waiting strategy to men with asymptomatic or minimally symptomatic inguinal hernia was safe, but two-thirds of patients crossed over to surgical repair within 10 years mainly due to pain.

A study of contralateral occult inguinal hernia in adult male patients undergoing total extraperitoneal herniorraphy

BACKGROUND

The incidence of contralateral occult hernia (COH) varies from 4.2% to 57.5%. Total extraperitoneal (TEP) gives us opportunity to visualize contralateral groin for occult hernia and its simultaneous repair. Ultrasonography (USG) helps to diagnose occult hernia preoperatively with detection rate of 96.6% with specificity 84.4%.

OBJECTIVE

The aims of this study were to identify the incidence of contralateral occult inguinal hernia in clinically diagnosed unilateral inguinal hernia patients using USG as diagnostic modality and to compare the clinical outcomes of unilateral TEP vs. bilateral TEP with respect to pain, duration of hospital stay, time for return to normal work, and postoperative complications.

SETTING AND DESIGN

This was a prospective observational, single-center study.

MATERIALS AND METHODS

A total of 30 male patients were included in the study who was having clinically diagnosed unilateral hernia. All patients were assessed by USG for contralateral occult inguinal hernia.

RESULTS

Incidence of COH was 10%, two (6.7%) had indirect defect, and 1 (3.3%) had direct defect. Two (6.7%) patients underwent bilateral TEP and 28 (93.3%) underwent unilateral TEP. No significant difference was observed in terms of mean duration of hospital stay, duration of surgery, and visual analog scale score for pain in both unilateral and bilateral TEP. The mean for resuming daily work in unilateral TEP was 4.86 ± 0.833 days and in bilateral TEP the mean was 7.50 ± 0.70 days and this showed statistically significant difference (P < 0.001).

CONCLUSION

Patients with COH should be counselled for synchronous repair as there is no significant difference in clinical outcomes of unilateral and bilateral TEP. On the basis of this pilot study, it can be concluded that preoperative USG is mandatory for diagnosis and simultaneous management of preexisting contralateral hernia.

Chronic postoperative inguinal pain: A narrative review

Inguinodynia or chronic postoperative inguinal pain is a growing problem between patients who undergo surgical repair of an inguinal hernia. The change in results measurement proposed by many authors towards Patient Reported Outcome Measurement has underlined the importance of chronic postoperative inguinal pain, because of the great limitations in everyday life and the huge socioeconomic impact that it causes. In this article a narrative review of the available literature in PUBMED, EMBASE and Cochrane Library is performed and the most relevant aspects about epidemiology, etiology prevention, diagnosis and treatment of chronic postoperative inguinal pain are discussed. A new management algorithm is also proposed. The variability in its incidence and clinical presentation makes diagnosis of chronic postoperative inguinal pain a very challenging issue. There is no standardized therapy and an adequate etiological diagnosis is key point for a successful treatment. There are many treatment options that have to be sequentially used and adjusted to each patient and their clinical features.

How I Do It: Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Inguinal hernia repair (IHR) is one of the most commonly performed general surgery operations. Currently, an inguinal hernia can be repaired through an open, laparoscopic, or robot-assisted approach. Herein, we detail our perioperative evaluation and management of patients with a groin hernia as well as our surgical technique for the performance of the laparoscopic transabdominal preperitoneal IHR.

The Effects of Operation Technique on Recurrence of Incisional Hernia Repair

OBJECTIVES

The selection of incision type, closure type of incision and the suture material are some of the important factors to prevent hernia development. We should aim to perform the best procedure with the best technique to reduce the risk of recurrence. Surgical options include primary repair and open or laparoscopic repair with mesh. Mesh repairs can be performed as onlay, sublay or inlay according to the area where the mesh is to be laid. In this retrospective study, our main goal was to compare the recurrence rates in patients who underwent incisional hernia repair with onlay and inlay mesh techniques.

METHODS

This retrospective study included 185 patients who underwent surgery due to incisional hernia in our clinic between January 2012 and October 2017. Patients were divided into two groups according to the technique as Group 1 with onlay mesh repair and Group 2 with inlay mesh repair. The same type of mesh (prolen) was applied to all patients.

RESULTS

There were 121 patients in Group 1 and 64 patients in Group 2. According to data we obtained, 64.3% of the patients were women and the mean age of all patients was 58.4±16.4 years. Postoperative complications (such as seroma-hematoma, surgical site infection, mesh rejection, postoperative ileus) developed in 29.2% (n=54) of the patients. The length of hospital stay was 4.2±3 days in Group 1 and 5.6±5 days in Group 2. The mean follow-up period was 48.6 months (24-93 months), with the recurrence rates of 5.8% (n=7) in Group 1 and 10.9% (n=7) in Group 2, respectively. There was a statistically significant difference between the groups concerning comorbidity, postoperative complications, the length of hospitalization stay and recurrence.

CONCLUSION

We believe that the onlay technique will be more appropriate than the inlay technique when only prolen mesh is preferred because the recurrence rates are higher in the inlay technique.

Management of Occult Contralateral Inguinal Hernia: Diagnosis and Treatment With Laparoscopic Totally Extra Peritoneal Repair

BACKGROUND

Up to 33% risk of occult contralateral inguinal hernia has been reported. This study aims to evaluate diagnostic and treatment modalities in the case of occult contralateral hernia and the role of ultrasonography (USG).

MATERIALS AND METHODS

Patients who had undergone inguinal hernia repair between 2009 and 2018 were studied retrospectively. The detection rate of occult inguinal hernia by USG and results of laparoscopic totally extra peritoneal repair (TEP) were evaluated.

RESULTS

Of 295 patients, USG was performed to the contralateral site in 80 with clinically unilateral hernia and occult hernia was detected in 44 (55%). Bilateral TEP was performed for these patients. There was no recurrence and no significant complication.

CONCLUSIONS

As it is noninvasive, easily accessible and has high sensitivity, USG is recommended in diagnosis. In the case of occult contralateral inguinal hernia, bilateral TEP is considered as a safe procedure. Thus, the need for a second operation and related complications can be prevented. We recommend routine USG to detect whether contralateral occult inguinal hernia is present.

A network analysis revealed the essential and common downstream proteins related to inguinal hernia

Although more than 1 in 4 men develop symptomatic inguinal hernia during their lifetime, the molecular mechanism behind inguinal hernia remains unknown. Here, we explored the protein-protein interaction network built on known inguinal hernia-causative genes to identify essential and common downstream proteins for inguinal hernia formation. We discovered that PIK3R1, PTPN11, TGFBR1, CDC42, SOS1, and KRAS were the most essential inguinal hernia-causative proteins and UBC, GRB2, CTNNB1, HSP90AA1, CBL, PLCG1, and CRK were listed as the most commonly-involved downstream proteins. In addition, the transmembrane receptor protein tyrosine kinase signaling pathway was the most frequently found inguinal hernia-related pathway. Our in silico approach was able to uncover a novel molecular mechanism underlying inguinal hernia formation by identifying inguinal hernia-related essential proteins and potential common downstream proteins of inguinal hernia-causative proteins.

Prophylactic Intraperitoneal Onlay Mesh Following Midline Laparotomy-Long-Term Results of a Randomized Controlled Trial

OBJECTIVES

Incisional hernia, a serious complication after laparotomy, is associated with high morbidity and costs. This trial examines the value of prophylactic intraperitoneal onlay mesh to reduce the risk of incisional hernia after a median follow-up time of 5.3 years.

METHODS

We conducted a parallel group, open-label, single center, randomized controlled trial (NCT01003067). After midline incision, the participants were either allocated to abdominal wall closure according to Everett with a PDS-loop running suture reinforced by an intraperitoneal composite mesh strip (Group A) or the same procedure without the additional mesh strip (Group B).

RESULTS

A total of 276 patients were randomized (Group A = 131; Group B = 136). Follow-up data after a median of 5.3 years after surgery were available from 183 patients (Group A = 95; Group B = 88). Incisional hernia was diagnosed in 25/95 (26%) patients in Group A and in 46/88 (52%) patients in Group B (risk ratio 0.52; 95% CI 0.36-0.77; p < 0.001). Eighteen patients with asymptomatic incisional hernia went for watchful waiting instead of hernia repair and remained free of symptoms after of a median follow-up of 5.1 years. Between the second- and fifth-year follow-up period, no complication associated with the mesh could be detected.

CONCLUSION

The use of a composite mesh in intraperitoneal onlay position significantly reduces the risk of incisional hernia during a 5-year follow-up period.

TRIAL REGISTRATION NUMBER

Ref. NCT01003067 (clinicaltrials.gov).

Contribution of heparin to recovery of incarcerated intestine in a rat incarcerated hernia model

PURPOSE

Inguinal hernias are the most common type of abdominal wall hernias. Although surgery is the only effective treatment for these hernias in adults, several problems associated with surgical treatment have been reported. If the hernia exits from a weak point of the abdominal wall, it can obstruct the bowel, thereby causing serious complications, including intestinal obstruction or strangulation. Through this study, we aimed to analyze the optimal incarceration induction time taken to cause some degree of necrosis from which recovery would be possible in a rat incarcerated abdominal wall hernia model and to determine the efficacy of heparin for expedite recovery from intestinal incarceration.

METHODS

A rat incarcerated abdominal wall hernia model was constructed, intestinal activity and the incarceration induction time were determined based on the color of the intestine and HE staining of intestinal sections. Heparin and procaine were sprayed onto intestinal surfaces, and their effects on the recovery from intestinal incarceration were evaluated.

RESULTS

Recovery from intestinal incarceration would be better if the incarceration induction time was maintained below 2.5 h in our rat model, and heparin was found to be superior to procaine in the expedite recovery from intestinal incarceration, particularly immediately after relieving such intestines.

CONCLUSIONS

The results of this study are significant for planning the treatment of incarcerated inguinal hernia. Further, heparin is superior to procaine in terms of expedite recovery from intestinal incarceration.

Shift from androgen to estrogen action causes abdominal muscle fibrosis, atrophy, and inguinal hernia in a transgenic male mouse model

Inguinal hernia is one of the most common disorders that affect elderly men. A major pathology underlying inguinal hernia is the fibrosis and other degenerative changes that affect the lower abdominal muscle strength adjacent to the inguinal canal. Here we describe a critical role of estrogen and its nuclear receptor that enhance fibroblast proliferation and muscle atrophy, leading to inguinal hernia. Further research may reveal a potential role of estrogen ablation to prevent muscle fibrosis or hernia in a subset of elderly men.

Inguinal hernia develops primarily in elderly men, and more than one in four men will undergo inguinal hernia repair during their lifetime. However, the underlying mechanisms behind hernia formation remain unknown. It is known that testosterone and estradiol can regulate skeletal muscle mass. We herein demonstrate that the conversion of testosterone to estradiol by the aromatase enzyme in lower abdominal muscle (LAM) tissue causes intense fibrosis, leading to muscle atrophy and inguinal hernia; an aromatase inhibitor entirely prevents this phenotype. LAM tissue is uniquely sensitive to estradiol because it expresses very high levels of estrogen receptor-α. Estradiol acts via estrogen receptor-α in LAM fibroblasts to activate pathways for proliferation and fibrosis that replaces atrophied myocytes, resulting in hernia formation. This is accompanied by decreased serum testosterone and decreased expression of the androgen receptor target genes in LAM tissue. These findings provide a mechanism for LAM tissue fibrosis and atrophy and suggest potential roles of future nonsurgical and preventive approaches in a subset of elderly men with a predisposition for hernia development.

COMPARATIVE STUDY OF POSTOPERATIVE PAIN BETWEEN THE LICHTENSTEIN AND LAPAROSCOPY SURGICAL TECHNIQUES FOR THE TREATMENT OF UNILATERAL PRIMARY INGUINAL HERNIA

Background:

There are several surgical treatment options for inguinal hernia; however, there is no consensus on the literature identifying which surgical technique promotes less postoperative pain.

Aim:

To compare the intensity of postoperative pain between the surgical techniques Lichtenstein and transabdominal pre-peritoneal laparoscopy for the treatment of unilateral primary inguinal hernia.

Methods:

Were included 60 patients, of which 30 were operated through the Lichtenstein technique and 30 patients through the transabdominal pre-peritoneal laparoscopy. The pain levels were evaluated through the analogue visual scale for 2, 10 and 30 days after the surgery. Additionally, the recurrence rate and the presence of chronic pain and paresthesia were evaluated 12 months after the surgery.

Results:

Overall, the data analysis showed significant differences on pain levels between the surgical techniques. There were no significant differences between the pain levels for day 2. However, for 10 and 30 days after the surgery, the pain levels were significantly lower for the patients operated through the transabdominal pre-peritoneal laparoscopy technique compared to the Lichtenstein technique. Furthermore, despite no recurrent hernias for both surgical techniques, 32 % of patients operated through the Lichtenstein technique reported chronic pain and paresthesia 12 months after the surgery, compared with 3,6% of patients operated through the transabdominal pre-peritoneal laparoscopy technique.

Conclusion:

There are differences between the surgical techniques, with the transabdominal pre-peritoneal laparoscopy procedure promoting significantly lower postoperative pain (10 and 30 days) and chronic pain (12 months) compared to the Lichtenstein procedure.

Factors influencing inguinal hernia symptoms and preoperative evaluation of symptoms by patients: results of a prospective study including 1647 patients

Background

Current recommendations for hernia treatment suggest applying techniques aimed at reducing postoperative pain in patients experiencing intense preoperative pain. However, there is still no reliable stratification method of preoperative pain, its circumstances, intensity and frequency, and the current assessments of hernia symptoms are performed by means of a subjective evaluation. The aim of this work is to discuss preoperative pain before hernia repair and determine its nature depending on the type and length of hernia persistence and the patient’s age.

Materials and methods

The data from 1647 patients before inguinal hernia repairs (2010–2017) were registered prospectively in the National Hernia Repair Register (demographic data, pain score and influence on everyday activities).

Results

The most common symptom upon admission was pain (949 patients at rest; 57.6% and 1561 at physical activity; 94.8%). A significant influence of hernia persistence on the pain occurrence and intensity was not observed between patients with hernia < 12-months (60.8%;VAS5.0) and > 5-years (58.3%;VAS5.4) (p = 0.068). The occurrence and intensity of pain was significantly higher patients < 40-years (63.7%;VAS5.4) than patients > 60-years (54.3%;VAS4.8) (p = 0.008).

Conclusions

While pain at rest is not a significant problem, undertaking physical activities may intensify pain and increase the number of patients suffering from it. Preoperative assessment of pain may help determine the group of younger patients who could benefit the most from inguinal hernia repair. New indications for prompter admission for treatment should be planned in future studies of patients showing pain at rest for possible prevention of postoperative neuropathy.

The change in groin pain perception after transabdominal preperitoneal inguinal hernia repair with glue fixation: a prospective trial of a single surgeon's experience

Background

Although inguinal hernia is one of the most common conditions requiring surgical treatment, no reliable information is available on the quality of life of patients with inguinal hernias before surgery. Additionally, patients with intense inguinal pain prior to surgery are more susceptible to postoperative chronic pain. In such cases, less invasive laparoscopic techniques can be used, allowing atraumatic mesh fixation to reduce postoperative pain. The aim of the study was to determine, whether these treatments for patients with preoperative pain would minimize upsetting experiences after surgery.

Materials and methods

Data were gathered prospectively from the National Hernia Repair Register for 146 patients who underwent TAPP repairs in the general surgery department (2013–2016). The demographic data were recorded, the pain intensity was determined and patients described the occurrence of pain during ten everyday activities.

Results

The average surgery time was 56.4 min. The follow-up was 23.4 months. The pain before surgery was 4.28 and 12 months after surgery 0.38 (p < 0.001). Pain intensity before surgery was scored as 4.1, 4.3, and 4.9 among patients who had a hernia < 12 months, > 1 year, and > 5 years, respectively (p = 0.028). Twelve months after surgery, the pain was 0.26, 0.34, and 0.40 (p = 0.037), respectively. Patients < 40 years experienced pain before the surgery more often. The intensity of pre-/postoperative pain was significantly higher < 40 years (4.9/0.63) than > 60 years (3.8/0.29).

Conclusions

TAPP inguinal hernia repair with glue fixation significantly decreased the frequency and intensity of the pain compared to that experienced preoperatively. After TAPP repair, the influence of pain on basic everyday activities is substantially lower. Patients under 40 years of age experience frequent and intense pre- and postoperative pain. A longer hernia duration prior to surgery causes increased pre- and postoperative pain.

Operation versus watchful waiting in asymptomatic or minimally symptomatic inguinal hernias: The meta-analysis results of randomized controlled trials

INTRODUCTION

The aim of this article was to compare and analyze the outcomes of surgical repair and watchful waiting (WW) in the treatment of asymptomatic or minimally symptomatic inguinal hernias.

METHODS

A systematic literature review was undertaken to identify studies that compare surgical repair and watchful waiting in asymptomatic or minimally symptomatic inguinal hernias. And all related data matching our standards were abstracted for Meta-analysis with RevMan 5.0.1.

RESULTS

Less pain was observed in Operation group. However, there were no significant differences in Physical Component Score (PCS), mortality, surgical complications and postoperative hernia recurrence between WW group and Operation group. But a great number of patients would develop significant hernia-related symptoms and cross over to surgery over time in WW group.

CONCLUSIONS

Patients have relative less pain in operation group compared with WW group. Although WW is safe in patients with asymptomatic or minimally symptomatic inguinal hernias, however, this strategy would merely delay rather than avoid surgical repair of hernias in the majority of inguinal hernia patients.

Risk of recurrence following mesh associated incisional hernia repair using the retromuscular technique in patients with relevant medical conditions

BACKGROUND

Incisional hernia is a common problem following open abdominal surgery. Hernia repair in patients with relevant medical conditions is a topic of controversy due to the high risk of morbidity and recurrence. We investigated the risk of recurrence in patients with relevant medical conditions managed with a prosthesis in the retromuscular position.

METHODS

A retrospective review of the data of patients undergoing midline incisional hernia repair was performed. The outcomes of patients with relevant concomitant medical conditions defined as ASA scores >2 were compared with those of healthier patients with ASA scores ≤2.

RESULTS

115 patients including 41 with ASA >2 and 74 with ASA ≤2 were included for analysis. There were no statistically significant differences amongst both groups with regard to the size of the hernia defect, the duration of surgery (123.0 ± 71 vs. 149.0 ± 92 min, p = 0.73), the incidence of postoperative seroma (14.6% vs. 29.7%, p = 0.07), postoperative hematoma (12.2% vs. 4.1%, p = 0.10) and surgical site infection (14.6% vs. 8.1%, p = 0.27). No statistically significant difference was seen amongst both groups with respect to the rate of long-term recurrence after a median follow-up of 63.0 ± 36 months (12.2% vs. 6.8%, p = 0.32).

CONCLUSION

Relevant medical condition alone cannot be seen as a contraindication for midline incisional hernia repair using the retromuscular technique. Rates of morbidity and long-term recurrence following mesh-associated closure are not difference from those of healthier patients.

Systematic review and simulation study of ignoring clustered data in surgical trials

BACKGROUND

Multiple surgical procedures in a single patient are relatively common and lead to dependent (clustered) data. This dependency needs to be accounted for in study design and data analysis. A systematic review was performed to assess how clustered data were handled in inguinal hernia trials. The impact of ignoring clustered data was estimated using simulations.

METHODS

PubMed, Embase and the Cochrane Library were reviewed systematically for RCTs published between 2004 and 2013, including patients undergoing unilateral or bilateral inguinal hernia repair. Study characteristics determining the appropriateness of handling clustered data were extracted. Using simulations, various statistical methods accounting for clustered data were compared with an analysis ignoring clustering by assuming 100 hernias, with a varying percentage of patients having bilateral hernias.

RESULTS

Of the 50 eligible trials including patients with bilateral hernias, 20 (40 per cent) did not provide information on how they dealt with clustered data and 18 (36 per cent) avoided clustering by assessing the outcome by patient and not by hernia. None of the remaining 12 trials (24 per cent) considered clustering in the design or analysis. In the simulations, ignoring clustering led to an increased type I error rate of up to 12 per cent and to a loss in power of up to 15 per cent, depending on whether the patient or the hernia was the randomization unit.

CONCLUSION

Clustering was rarely considered in inguinal hernia trials. The simulations underline the importance of considering clustering as part of the statistical analysis to avoid false-positive and false-negative results, and hence inappropriate study conclusions.

International guidelines for groin hernia management

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.

Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomized Controlled Trial

OBJECTIVE

To compare if watchful waiting is noninferior to elective repair in men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia.

BACKGROUND

The role of watchful waiting in older male patients with mildly symptomatic or asymptomatic inguinal hernia is still not well-established.

METHODS

In this noninferiority trial, we randomly assigned men aged 50 years and older with mildly symptomatic or asymptomatic inguinal hernia to either elective inguinal hernia repair or watchful waiting. Primary endpoint was the mean difference in a 4-point pain/discomfort score at 24 months of follow-up. Using a 0.20-point difference as a clinically relevant margin, it was hypothesized that watchful waiting was noninferior to elective repair. Secondary endpoints included quality of life, event-free survival, and crossover rates.

RESULTS

Between January 2006 and August 2012, 528 patients were enrolled, of whom 496 met the inclusion criteria: 234 were assigned to elective repair and 262 to watchful waiting. The mean pain/discomfort score at 24 months was 0.35 [95% confidence interval (CI) 0.28-0.41)] in the elective repair group and 0.58 (95% CI 0.52-0.64) in the watchful waiting group. The difference of these means (MD) was -0.23 (95% CI -0.32 to -0.14). In the watchful waiting group, 93 patients (35·4%) eventually underwent elective surgery and 6 patients (2·3%) received emergent surgery for strangulation/incarceration. Postoperative complication rates and recurrence rates in these 99 operated individuals were comparable with individuals originally assigned to the elective repair group (8.1% vs 15.0%; P = 0.106, 7.1% vs 8.9%; P = 0.668, respectively).

CONCLUSIONS

Our data could not rule out a relevant difference in favor of elective repair with regard to the primary endpoint. Nevertheless, in view of all other findings, we feel that our results justify watchful waiting as a reasonable alternative compared with surgery in men aged 50 years and older.

Why do inguinal hernia patients have pain? Histology points to compression neuropathy

PURPOSE

The purpose of this study is to describe the known soft tissue neuro-histology factors associated with compression neuropathy in relation to the incidence of preoperative pain in primary inguinal hernia. Enlargement of the ilioinguinal nerve occurs in 63% of patients with primary inguinal hernia; compression neuropathy has similar gross features.

METHODS

Patients completed pain questionnaires pertaining to preoperative pain and the quality of pain experienced. During routine inguinal hernia repair, nerve segments were sampled for histologic evaluation.

RESULTS

Twenty-two thickened nerve segments (63% of total) with proximal and distal specimens were resected for examination and comparison. We quantified various histologic indicators including nerve diameter, fascicle count, myxoid content within the epineurium, perineurium and endoneurium. Increased preoperative patient pain scores correlate with increased nerve diameter, increased fascicle count and increased myxoid material both within the perineurium and endoneurium.

CONCLUSION

These findings support the concept that preoperative hernia pain is associated with compression neuropathy.

Evidence-Based Hernia Treatment in Adults

BACKGROUND

Inguinal hernia repair is the most common general surgical procedure in industrialized countries, with a frequency of about 200 operations per 100 000 persons per year. Suture- and mesh-based techniques can be used, and the procedure can be either open or minimally invasive.

METHODS

This review is based on a selective search of the literature, with interpretation of the published findings according to the principles of evidence-based medicine.

RESULTS

Inguinal hernia is diagnosed by physical examination. Surgery is not necessarily indicated for a primary, asymptomatic inguinal hernia in a male patient, but all inguinal hernias in women should be operated on. For hernias in women, and for all bilateral hernias, a laparoscopic or endoscopic procedure is preferable to an open procedure. Primary unilateral hernias in men can be treated either by open surgery or by laparoscopy/endoscopy. Patients treated by laparoscopy/endoscopy develop chronic pain less often than those treated by open surgery. A mesh-based repair is generally recommended; this seems reasonable in view of the pathogenesis of the condition, which involves an abnormality of the extracellular matrix.

CONCLUSION

The choice of procedure has been addressed by international guidelines based on high-level evidence. Surgeons should deviate from their recommendations only in exceptional cases and for special reasons. Guideline conformity implies that hernia surgeons must master both open and endoscopic/laparoscopic techniques.

Is contralateral exploration justified in endoscopic total extraperitoneal repair of clinical unilateral groin hernias - A Prospective cohort study

BACKGROUND

Laparoscopic adult hernia repair has the clinical advantage of allowing the surgeon to explore asymptomatic contralateral inguinal hernia. We conduct a retrospective study to compare the occurrence of contralateral metachronous inguinal hernia (CMIH) after laparoscopic total extraperitoneal (TEP) repair with or without contralateral exploration.

METHODS

One hundred and fifty-one consecutive patients undergoing unilateral laparoscopic TEP repair during November 2007 to November 2012 were enrolled into groups with contralateral or no contralateral exploration. Preoperative, intraoperative, and postoperative factors were recorded then reviewed for analysis. The primary end-point was the occurrence of contralateral inguinal hernia. The patients were regularly interviewed postoperatively at outpatient clinics.

RESULTS

Finally, 68 patients in the exploration group and 46 in the non-exploration group were eligible for analysis. All demographic data, except age, was comparable between the two groups. Twenty-three of 68 (33.8%) in the exploration cohort had at least one occult contralateral inguinal hernia detected and repaired at the time of primary repair. In contrast to the high incidence (6/46, 13%) of CMIH in the non-exploration cohort, there was only one metachronous occurrence (1/68, 1.4%) after negative contralateral exploration at a median follow-up of longer than 3 yrs (p = 0.02). The peri-operative results were comparable between groups regarding operative time, analgesic requirements, complications, and chronic pain.

CONCLUSIONS

Simultaneous exploration and repair of the incidental defects on the contralateral inguinal region during laparoscopic TEP repair of unilateral inguinal hernia is recommended in selected patients based on its high safety and clinical effectiveness in preventing later CMIH.

Cost-conscious decisions in the timing of operation for minimally symptomatic inguinal hernias in male patients

BACKGROUND

Expectant management (EM) and early open repair (OR) are safe and effective as initial management strategies for minimally symptomatic inguinal hernia in male patients. Extended follow-up of patients in EM protocols have shown that most patients will eventually require repair, but it is not clear which strategy is less costly over the long term.

METHODS

We constructed a mathematical model to compare 3rd-party payer expenditures for EM vs OR or laparoscopic repair in a simulated cohort of patients with inguinal hernia. Cohort characteristics and expenditures were calibrated to recent randomized trials that reported initial follow-up and expenditures at 2 years and long-term crossover rates from EM to OR.

RESULTS

Cost comparisons between OR and EM are sensitive to direct long-term costs of inpatient and outpatient care, the likelihood of crossover from EM to operation, cost differences between OR and laparoscopic repair, and the net present value of longer-term costs.

CONCLUSIONS

Our findings suggest that short-term costs of EM are less than those of OR and Lap-R, but early OR provides the highest long-term savings.

Totally extraperitoneal (TEP) endoscopic hernia repair in elderly patients

BACKGROUND

Inguinal hernias are common in elderly males. We addressed outcome following totally extraperitoneal (TEP) hernia repair in patients older than 70 years.

METHODS

We prospectively collected data of patients >70 years with a unilateral or bilateral inguinal hernia operated in our hospital between January 2005 and January 2010 using the TEP technique.

RESULTS

A total of 429 patients underwent TEP hernia repair under general anaesthesia, mostly men (n = 405; 94.4%). Median age was 74 years (range 70-89). The mean pre-operative pain score was 3.7 (SD ± 2.5). Ninety-four percent of patients had an ASA score of 1 or 2. Three hundred thirty-six patients underwent a unilateral repair (78%). The conversion rate to an anterior procedure was 0.7 % (n = 3). In 8 patients (1.9%), intra-operative complications occurred, and the postoperative course was complicated in 3 patients (0.7 %). Severe complications attributable to the endoscopic approach occurred in 6 patients (1.4%): a bladder injury (n = 5) and a trocar-induced bowel perforation (n = 1). The mean postoperative pain score after 6 weeks was 1.6 (SD ± 1.2). Patients were able to resume their daily activities after a median of 7 days (range 1-42).

CONCLUSION

Totally, extraperitoneal endoscopic inguinal hernia repair in elderly patients is associated with low overall complication rates and a fast recovery. In a small proportion of patients, severe complications occur attributable to the endoscopic approach.

Current trends in laparoscopic groin hernia repair: A review

Hernia is a common problem of the modern world with its incidence more in developing countries. Inguinal hernia is the most common groin hernia repaired worldwide. With advancement in technology operative techniques of repair have also evolved. A PubMed and COCHRANE database search was accomplished in this regard to establish the current status of laparoscopic inguinal hernia repair in view of recent published literature. Published literature support that laparoscopic hernia repair is best suited for recurrent and bilateral inguinal hernia although it may be offered for primary inguinal hernia if expertise is available.

Inguinal hernia: follow or repair?

Observation is an acceptable management strategy for asymptomatic and minimally symptomatic inguinal hernias because it is safe. The rate of hernia accident is very low and is not an indication for surgery. However, patients who present to their physician with a hernia will almost certainly undergo a hernia repair if they live long enough.