Combined anterior and posterior inguinal hernia repair: Intermediate recurrence rates with three groups of surgeons

Massive Retroperitoneal Hematoma After Inguinal Hernia Repair Using Prolene® Hernia System: A Case Report

Retroperitoneal hematoma is a possibly fatal condition that is frequently observed as a complication of procedures such as femoral artery catheterizations. We currently present a case of massive retroperitoneal hematoma after inguinal hernioplasty using Prolene® Hernia System mesh in a warfarin-treated patient. Especially in the case of inguinal hernioplasty in a patient receiving warfarin therapy, surgeons must pay close attention to prevent hemorrhage from the preperitoneal space, or they may opt for a different technique, such as the Lichtenstein method or laparoscopic approach.

Postoperative Quality of Life after Open Transinguinal Preperitoneal Inguinal Hernia Repair Using Memory Ring or Three-dimensional Devices

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m2. MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different ( P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD ( P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation ( P = 0.02); 28.7 versus 14.8 per cent had movement limitations ( P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.

Laparoscopic Experience for Recurrent Inguinal Hernia Repair in a Single Center for 14 Years

Laparoscopic techniques are now well pervading in the treatment of inguinal hernia. This study aims to investigate the laparoscopic strategy for recurrent inguinal hernia repair. Laparoscopic technique was retrospectively applied to 330 patients with 352 recurrent inguinal hernias in the past 14 years. The surgical strategies were further evaluated. There were 22 cases with bilateral recurrent hernias, whereas the rest 308 cases with unilateral disorders. Patients were further categorized by previous repair approaches as high ligation, sclerotherapy, conventional suture repair, Lichtenstein repair, plug and patch repair, and preperitoneal repair. All cases were successfully repaired by laparoscopic approaches including transabdominal preperitoneal (TAPP) (288 cases), totally extraperitoneal (50 cases), and intraperitoneal onlay mesh (14 cases). The median operation duration was 39.5 ± 13.4 minutes. The average Visual Analog Scales score on postoperative day 1 was 2.4 ± 1.1. The median follow-up time was 36 (14–61) months. There was one case of recurrence during the follow-ups. One severe complication, i.e., bowel injury, was observed and cured, whereas other complications were as follows: 22 seroma, 8 urinary retention, 3 transient paresthesia, and 1 ileus. Laparoscopic procedures for recurrence inguinal hernia are safe and applicable. A surgeon can choose to reinforce the myopectineal orifice or only fix the hernia defect accordingly. The strategy of choosing TAPP and/or totally extraperitoneal depends on the type of previous repair, the exact anatomical position of the previous implanted mesh, and more importantly, the surgeon's experience. Moreover, the intraperitoneal onlay mesh technique can be regarded as a backup option for TAPP in certain cases.

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.

The clinical effectiveness and cost-effectiveness of open mesh repairs in adults presenting with a clinically diagnosed primary unilateral inguinal hernia who are operated in an elective setting: systematic review and economic evaluation

BACKGROUNDS

Current open mesh techniques for inguinal hernia repair have shown similar recurrence rates. However, chronic pain has been associated with Lichtenstein mesh repair, the most common surgical procedure for inguinal hernia in the UK. The position of the mesh is probably an important factor. The Lichtenstein method requires dissection of the inguinal wall and fixation of the mesh. In contrast, in the open preperitoneal approach the mesh is placed in the preperitoneal space and held in place with intra-abdominal pressure. Currently, there is no consensus regarding the best open approach for repair of inguinal hernia.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of open preperitoneal mesh repair compared with Lichtenstein mesh repair in adults presenting with a clinically diagnosed primary unilateral inguinal hernia.

DATA SOURCES

We searched major electronic databases (e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed, EMBASE, Cochrane Controlled Trials Register) from inception to November 2014 and contacted experts in the field.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) that compared open preperitoneal mesh repair with Lichtenstein mesh repair for the treatment of inguinal hernia. Two reviewers independently selected studies for inclusion. One reviewer completed data extraction and assessed risk of bias for included studies, and two reviewers independently cross-checked the details extracted. Meta-analyses techniques were used to combine results from included studies. A Markov model was developed to assess the cost-effectiveness of open mesh procedures from a NHS health services perspective over a 25-year time horizon.

RESULTS

Twelve RCTs involving 1568 participants were included. Participants who underwent open preperitoneal mesh repair returned to work and normal activities significantly earlier than those who underwent Lichtenstein mesh repair [mean difference -1.49 days, 95% confidence interval (CI) -2.78 to -0.20 days]. Although no significant differences were observed between the two open approaches for incidence of pain [risk ratio (RR) 0.50, 95% CI 0.20 to 1.27], numbness (RR 0.48, 95% CI 0.15 to 1.56), recurrences (Peto odds ratio 0.76, 95% CI 0.38 to 1.52) or postoperative complications, fewer events were generally reported after open preperitoneal mesh repair. The results of the economic evaluation indicate that the open preperitoneal mesh repair was £256 less costly and improved health outcomes by 0.041 quality-adjusted life-years (QALYs) compared with Lichtenstein mesh repair. The open preperitoneal procedure was the most efficient and dominant treatment strategy with a high (> 98%) probability of being cost-effectiveness for the NHS at a willingness to pay of £20,000 for a QALY. Results were robust to a range of sensitivity analyses. However, the magnitude of cost saving or QALY gain was sensitive to some model assumptions.

LIMITATIONS

Overall, the included trials were of small sample size (mean 130.7 participants) and at high or unclear risk of bias. Meta-analyses results demonstrated significant statistical heterogeneity for most of the assessed outcomes.

CONCLUSIONS

Open preperitoneal mesh repair appears to be a safe and efficacious alternative to Lichtenstein mesh repair. Further research is required to determine the long-term effects of these surgical procedures as well as the most effective open preperitoneal repair technique in terms of both clinical efficacy and costs.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014013510.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

ULTRAPRO Hernia System versus lichtenstein repair in treatment of primary inguinal hernias: a prospective randomized controlled study

The Lichtenstein repair has been recommended as the gold standard for inguinal hernia repair. However, postoperative discomfort still constitutes a concern and an area for improvement. New mesh materials have been continuously introduced to achieve this goal. The goal of the present study was to investigate the outcomes of ULTRAPRO Hernia System (UHS) compared with Lichtenstein mesh repair. A total of 99 male patients with primary unilateral inguinal hernia were included in the study during the period of September 2010-January 2012. Patients with body mass index>30, comorbid diseases, and anesthetic risk of ASA-III and ASA-IV were excluded. The patients were randomly allocated to operation with the Lichtenstein technique (group L) or UHS. Demographics, operative and postoperative/recovery data, and short- and medium-term outcomes of the patients were recorded. A total of 50 patients in group L and 49 patients in group UHS were analyzed. The median follow-up time for the study was 33 months. There were no significant differences regarding demographics, complications, and rehabilitation between the groups. Overall, there was a prolonged operation time in the UHS group compared with the L group (UHS: 53.7±5.7 minutes; L: 44.5±5.5 minutes; P<0.001). UHS may provide results similar to those for the Lichtenstein technique in open repair of inguinal hernias regarding perioperative course, complications, recovery, and recurrence rates. However, because of reduced costs and the lack of need for the exploration of the preperitoneal space, we conclude that the Lichtenstein technique should be recommended as the first choice.

Comparative Study of Prolene Hernia System and Lichtenstein Method for Open Inguinal Hernia Repair

BACKGROUND

Prolene Hernia System (PHS) is a bi-layered polypropylene mesh with a connector that combines the anterior and posterior inguinal hernia repair, but still not very popular in this part of the country. Hence a prospective & randomized comparative study was undertaken to compare PHS with the already popular Lichtenstein Hernia Repair (LHR) and determine the post-operative outcome.

MATERIALS AND METHODS

Total 67 inguinal hernia repairs were randomly assigned to either PHS or LHR method, and data was collected regarding various outcome measures like duration of surgery, post-operative pain, requirement of analgesia, return to normal activity, and early and late complications.

RESULTS

Mean duration of surgery was significantly higher for PHS group than LHR group (65.4 min vs 51.26 min, p-value <0.0001). Significant difference was noted between the PHS and LHR group in terms of moderate to severe post-operative pain (15.15% vs 41.18%,p-value 0.018), time of requirement of analgesia (3.7 vs 4.6 days, p-value 0.024), and time to return to normal activity (2.7 vs 3.4 days, p-value 0.023), all in favour of the former technique. No intra-operative complication was noted in either of the groups. 5 patients had early complications in PHS group and 6 in LHR group, but this was statistically not significant. The average time of follow-up for the study was 7.8 month, ranging from 1 to 18 months. Chronic inguinal pain was noted in 1 and 2 patients respectively in PHS and LHR group, again statistically not significant. No recurrence was noted in both the groups till the time of follow-up.

CONCLUSION

PHS is a safe and better alternative to the time honored Lichtenstein hernia repair with the added advantage of strengthening whole of myopectineal orifice, and virtually eliminating any risk of recurrence.

Cost-utility analysis comparing heavy-weight and light-weight mesh in laparoscopic surgery for unilateral inguinal hernias

BACKGROUND

Hernioplasty is one of the most frequent surgeries in the UK. Light-weight mesh (LWM) has the potential to reduce chronic groin pain but its cost-effectiveness compared with heavy-weight mesh (HWM) is unknown.

OBJECTIVE

Our objective was to conduct a cost-utility analysis between laparoscopic hernioplasty with HWM and LWM for unilateral inguinal hernias.

METHODS

A Markov model simulated costs and health outcomes over a period of 1 year (2012) from the societal and National Health Service (NHS) perspective (England). The main outcome was cost per quality-adjusted life-year (QALY) gained. Surgery results were gleaned from the randomized control trial by Bittner et al. Other input parameters were drawn from the literature and public sources of the NHS.

RESULTS

From the societal perspective, LWM induces lower incremental costs (-£88.85) than HWM but yields a slightly smaller incremental effect (-0.00094 QALYs). The deterministic incremental cost-effectiveness ratio (ICER) for HWM compared with LWM amounts to £94,899 per QALY, while the probabilistic ICER is £118,750 (95 % confidence interval [CI] £57,603-180,920). Owing to the withdrawal of productivity losses from the NHS perspective, LWM causes higher incremental costs (£13.09) and an inferior incremental effect (-0.00093), resulting in a dominance of HWM over LWM (ICER 95 % CI -£12,382 to -£21,590).

CONCLUSIONS

There is no support for the adoption of LWM as standard treatment from an NHS perspective. However, given the small differences between HWM and LWM, LWM has at least the potential of improving patient outcomes and reducing expenditure from the societal perspective.

Short- and long-term outcomes of open inguinal hernia repair: comparison of the Prolene Hernia System and the Mesh Plug method

PURPOSE

Tension-free mesh repair of adult inguinal hernias has become a standard procedure, but there have been few comparisons of the postoperative outcome after hernia repair using the Prolene Hernia System (PHS) vs. the Mesh Plug (MP) method in a large number of patients from a single institution.

METHODS

We reviewed the medical records of patients to investigate the short- and long-term outcomes of the different types of hernia repair. Late symptoms were evaluated by questionnaire. A total of 1,141 repairs performed from 1999 to 2008 (PHS in 957 and MP in 184 repairs) were evaluated.

RESULTS

There were 93 early postoperative complications (8.2%). A subcutaneous hematoma was found more frequently after MP repair compared with after PHS repair (3.8 vs. 1.3%, P = 0.013). Seven hundred and ten patients (62.2%) could be followed up for more than 2 years. Recurrence was detected in 14 patients with PHS repair and two patients with MP repair (1.5 vs. 1.1%, P = 0.956). Wound infections occurred in three patients (0.3%) with PHS repair vs. none with MP repair (P > 0.999). Patients with PHS and MP repair showed no significant differences in the long-term wound pain.

CONCLUSIONS

The recurrence and wound infection rates were similar after hernia repair using the PHS and MP methods. Patients undergoing PHS repair developed fewer subcutaneous hematomas. An older age (≥65 years) was a significant independent risk factor for recurrence.

Improved outcomes with the Prolene Hernia System mesh compared with the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair

BACKGROUND

Inguinal hernia repairs are commonly performed operations. Recently, Neumayer et al examined the gold standard Lichtenstein onlay mesh repair (LMR) against laparoscopic inguinal hernia repair and showed that the recurrence rates are higher for laparoscopic mesh repairs when compared with the open onlay mesh repair (laparoscopic = 10.1% versus open = 4.9%). In 1998, the Prolene Hernia System (PHS) mesh, consisting of an onlay and an underlay patch attached with a connector, was introduced as an option for tension-free open repair of inguinal hernias combining the benefits of a posterior and anterior repair from an open approach. Our objective was to evaluate the PHS mesh repair versus the LMR for inguinal hernias. We hypothesized that the recurrence rate of PHS mesh would be lower compared with the LMR with overall similar complication rates.

METHODS

PHS mesh hernia repairs performed from January 2003 to July 2005 and LMR repairs from January 2000 to July 2002 were included. Demographic data such as age, race, and gender as well as comorbid conditions such as chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, diabetes, hypertension, prostatism, and chronic cough were collected. Complications such as cord injury, seroma, hematoma, urinary retention, urinary tract infection, orchitis, and wound infection were recorded. Recurrences in each group were also recorded. A student t test and chi-square analysis were used for statistical analysis.

RESULTS

Six hundred twenty-two charts were reviewed during the 2 time periods (PHS mesh = 321, LMR = 302). The median follow-up for the study was 17 months. There was no significant difference with regards to age, race, gender, or comorbidities between the 2 groups. Overall, there was a trend toward decreased complications in the PHS mesh group compared with the LMR group (PHS mesh = 17%, LMR = 23%, P = .07), with a significant difference in the hematoma/seroma rates (PHS mesh = 6.9%, LMR = 12.6%, P = .015). Finally, there was a significant decrease in the recurrence rate for the PHS mesh group when compared with the LMR group (PHS mesh = 0.6%, LMR = 2.7%, P = .04).

CONCLUSION

Our study shows, during a median follow-up of 17 months, improved outcomes by using the PHS mesh compared with the gold standard Lichtenstein onlay mesh for inguinal hernias with significantly lower recurrence rates. Additionally, in the PHS mesh group, there was a trend toward decreased overall complication rates with significantly less seroma/hematoma rates. Therefore, the PHS mesh repair may represent a superior alternative for the repair of inguinal hernias.

Inguinal hernia treatment with the Prolene Hernia System in a Dutch regional training hospital

INTRODUCTION

In this retrospective study results from inguinal hernia repair with the Prolene Hernia System (PHS) in a regional training hospital were analysed.

PATIENTS AND METHODS

One-hundred and seventy-eight primary inguinal hernias and thirty-nine recurrent hernias (initial non-mesh repair) were treated with the PHS. The primary endpoint was the recurrence rate. Secondary endpoints were short-term and long-term complications. Pain was evaluated by use of a visual analog scale (VAS, 0-100), and a short-form 36-item questionnaire was used to assess postoperation quality of life. All patients visited the outpatient clinic for a physical examination (100% follow-up).

RESULTS

After a median follow-up of 32 months four patients were diagnosed with recurrent herniation (1.8%), three after primary hernia repair (1.6%) and one after recurrent hernia repair (2.6%). Three superficial wound infections (1.3%), three haematomas needing surgical evacuation (1.3%), and two lesions of the spermatic cord (0.9%) were diagnosed. Seven patients (3.2%) suffered from persistent pain (VAS > 40). Average VAS score was 13 (0-80) >24 months after surgery.

CONCLUSION

In a regional training hospital, primary and recurrent inguinal hernias were treated with low recurrence and few complications by use of the PHS.

RANDOMIZED CONTROLLED TRIAL COMPARING PROLENE HERNIA SYSTEM AND LICHTENSTEIN METHOD FOR INGUINAL HERNIA REPAIR

BACKGROUND

There are no data regarding the long-term outcomes of prolene hernia system (PHS) mesh in the published reports. The aim of the study was to compare the short-term and long-term outcomes of the PHS mesh with the Lichtenstein mesh technique.

METHODS

Sixty-four patients with inguinal hernia were randomized to undergo either a PHS or a Lichtenstein repair under local anaesthesia as a day case. Early outcome measures were duration of surgery, pain scores, analgesic requirements, time to return to work, driving and full activity. Long-term outcome measures were chronic groin pain and recurrence.

RESULTS

Mean duration of surgery in the PHS group was 36 min (SD +/- 11) versus 34 min in the Lichtenstein group (SD +/- 8; P = 0.3). There was no significant difference in analgesic requirements (P = 0.65). Overall mean pain score was 3.5/10 versus 2.5/10 (P = 0.1). Mean time to return to work was 42 versus 30 days (P = 0.3), returning to driving was 20 versus 14 days (P = 0.2) and full activity was 21 versus 22 days (P = 0.8). Chronic groin pain developed in four patients in the PHS group (12.9%) and in five patients in the Lichtenstein group (15.1%; P > 0.05). One patient developed recurrent herniation in the PHS group. The median follow up was 4.2 years (range, 4-4.6 years). Patient satisfaction was very high with both the techniques.

CONCLUSION

There is no significant difference in the early and long-term outcomes between PHS and Lichtenstein hernia repairs. The PHS technique involving preperitoneal dissection is well tolerated and easy to carry out under local anaesthesia.

Current approaches to inguinal hernia repair

The repair of a simple inguinal hernia or a complicated incisional hernia no longer involves just the sewing together of a defect in the musculature. Present-day hernia operations require that the surgeon more fully understand the functional anatomy and pathophysiology of the abdominal wall and groin. Hernia surgeons must be familiar with a myriad of surgical techniques, ranging from the traditional tissue repairs with suture to the mesh-based "tension-free" open and laparoscopic techniques. Furthermore, the surgeon must comprehend outcome analysis in evaluating differing therapies. Several approaches have been used for repair of groin hernias and have included tissue repairs (later termed "tension" repairs), as well as mesh or tension-free repairs and laparoscopy. Although each of these repairs boasts its successes, there are advantages and disadvantages to each approach. This article highlights each of these repairs through review of the literature.