Page 116 - International guidelines for groin hernia management

Hernia

Incidence and epidemiology • What is the true recurrence rate and risk for chronic
Large epidemiologic studies or registry analysis could pain after Shouldice repair?
result in new insights in the incidence of groin hernia. The • Is only SAC resection in young patients with an L1
identification of modifiable life style and socio-occupa- inguinal hernia a safe procedure in terms of recurrence
tional factors contributing to development of primary and rate?
recurrent inguinal hernia could help hernia surgeons in the • Is there a significant difference in results of tissue
future to further tailor surgical management. (Shouldice) repair between an indirect and a direct
hernia?
Pathophysiology • Are the outcomes after repair with a self-adhesive mesh
It is becoming increasingly clear that the extracellular comparable with a repair with a flat mesh for
matrix and matrix metalloproteinases play a significant role Lichtenstein?
in the pathogenesis of abdominal wall hernias. Further • Do TEP and TAPP truly have equal results to each
investigation into biomarkers which mirror its activities as other?
well as strategies and methodologies to correct abnormal- • What are the advantages of the use of Prolene Hernia
ities could dramatically affect the incidence and treatment System (PHS) or UltraPro Hernia System (UHS)
of abdominal wall pathologies. Interdisciplinary collabo- compared to Lichtenstein and TEP, TAPP?
rative research with basic science will be necessary to • What are the long-term recurrence rates after inguinal
properly investigate this complex environment. hernia repair with PHS or UHS? Are these results
significantly better to justify the use and subsequent
Classification scarring of both the anterior and posterior
compartment?
Hernia classifications contribute to the possibility to com-
• There is a need to design a large RCT comparing
pare and evaluate study outcomes and subsequent man-
laparo-endoscopic and Lichtenstein repair in primary
agement strategy. Which classification system are the most
unilateral inguinal hernia repair in male patients by
suitable remains unknown. The EHS classification system
surgeons who are experts in both these respective
is a simple system and easy to use. Future research should
techniques.
evaluate what the relevance of the EHS groin hernia clas-
sification is.
Individualization in treatment options
Indications for surgery For many years now, the gold standard for inguinal hernia
Watchful waiting (WW) has been a suggested management surgical treatment is a mesh repair. The mesh repair can be
strategy in male patients with a minimal or asymptomatic performed open or laparoscopically. Whether there is still
inguinal hernia. Some aspects of WW need to be analyzed an indication for non-mesh repair, or when a mesh repair
to fully establish its true value. Is a watchful waiting needs to be done open or laparoscopically remains to be
strategy ultimately cost-effective, considering high cross- definitely determined. There is no uniform technique
over rates due to symptom development? What are the risk applicable to all patients. Hernia surgeons individualize,
factors for developing symptoms such as pain or incar- based mostly on their own experience. Scientific founda-
ceration in untreated male patients with a minimal symp- tion is lacking. The essential question is: When do we
tomatic or asymptomatic inguinal hernia? What is the best individualize and does a tailored approach result in
timing for male patients with a minimal symptomatic or improved quality and outcomes? Scenarios where indi-
asymptomatic inguinal hernia to plan surgical repair in vidualization might be in place are:
terms of cost-effectiveness? A large randomized controlled
trial with long follow-up would be appropriate to answer • Which surgical technique should be used in patients
with an inguinal hernia with the following character-
this question.
istics: high preoperative pain, smoking, collagen dis-
ease, obesity, ascites, physical active or elderly?
Surgical treatment of inguinal hernia
• Which surgical technique should be used in patients
There are many of studies performed on surgical tech-
with an inguinal hernia with the following character-
niques in inguinal hernia. However, not all techniques are
istics: small indirect, (large) medial or large lateral
equally well evaluated and there is still need for further
hernias, non-reducible hernias, incarcerated hernias or
research. Randomized controlled trials in centers where the
strangulated hernias?
various surgical techniques are mastered are ideal to
address the following issues:

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