Page 117 - International guidelines for groin hernia management

Hernia

• What is the best management strategy in elderly • What are the molecular details of the wound healing
patients with a minimal or asymptomatic inguinal process around a foreign body?
hernia, watchful waiting or surgery? • Mesh related complications manifest with a consider-
• Is there an indication in certain cases (low risk for able delay, the incidence rises with time and is higher
recurrence, high risk for pain) to perform non-mesh for younger patients. Should there be a limitation by the
repair? patients’ age to perform a mesh procedure? What is the
• Should open repair under local be promoted? impact of age on the risk–benefit ratio of meshes or
mesh procedures?
• There is a need for a propensity score matching of large
Occult hernia and bilateral repair
data from registries comparing the use of different
Some suggest that a prophylactic mesh repair on the con-
kinds of meshes (e.g., large-pore versus small-pore) in
tralateral side is indicated in older male patients with a
primary unilateral inguinal hernia repair in male
medial inguinal hernia. The appropriateness of this strategy
patients.
needs to be assessed. In which cases is prophylactic bilat-
eral implementation of mesh indicated in unilateral ingu-
inal hernia as a management strategy? Similarly, when an Clinical outcome
asymptomatic defect is found on the contralateral side Clinical outcomes are influenced by the patients’ biology,
during laparoscopic repair of a unilateral symptomatic the surgical technique and surgical skills and the quality
inguinal hernia, is immediate treatment with mesh indi- and characteristics of the mesh. It is unknown which of
cated? What is the natural course of such asymptomatic these factors dominates the clinical outcomes, or whether
defects? There is a need for a prospective registry-based they all contribute equally. It is necessary to analyze the
study of unilateral TEP and TAPP cases (with adequate impact of these factors separately. A prediction model
follow-up) to investigate the true risk of lifetime bilateral could be designed to optimize clinical outcomes in indi-
(symptomatic and asymptomatic) IH. vidual cases.

Day surgery Mesh fixation
We suggest to perform a registry study analyzing the safety Mesh fixation remains subject of debate. Is mesh fixation
of day surgery of the different types of inguinal hernia necessary to minimize the risk of recurrence, or only in
repair compared to short stay surgery with regards to specific cases? And if fixation is needed, which fixation
severe bleeding, unnoticed visceral injury and technique is to be used? And what are the disadvantages of
thromboembolism. fixation? The majority of the randomized controlled trials
on mesh fixation include a follow-up of 1 or 2 years, which
Meshes is the most severe drawback of these studies. Therefore,
The gold standard for many types of hernia repair is the use registry-based studies with a high number of patients and
of mesh. The long-run effect and interaction between mesh long-term follow-up are of additional value to the current
and bodily tissue still needs to be understood. The mesh has randomized controlled trials on mesh fixations.
to fulfill many requirements and the ideal mesh has yet to
be designed. The following research questions address Antibiotic prophylaxis
these issues. As HerniaSurge we would like to emphasize The indication to use antibiotic prophylaxis is ruled by
that future in vivo research on mesh is of great importance three factors; the varying standard of environment, patients
to further improve quality after hernia surgery. risk factors and operative technique. A 5% wound infection
rate in patients not receiving antibiotic prophylaxis is
• How are the physiological requirements of mesh with
defined as a low-risk environment. There is convincing
focus on strength and elasticity to meet its functional
evidence not to administer antibiotic prophylaxis in an
needs defined?
average risk patients/low-risk environment and in any
• Which mesh material or design avoids scar entrapment
patient in any risk environment when using endoscopic/
or erosion?
• What is the value of bioactive meshes with drug release laparoscopic repair.
There are very limited data on high-risk patients in a
to avoid chronic pain, adhesions, or infection?
low-risk environment and no consensus exists on how to
• What are the characteristics of the mesh surfaces to
define these conditions. However, common surgical prac-
minimize the risk for bacterial adherence and for
tice includes antibiotic prophylaxis for increased-risk
infection in contaminated wounds or surroundings?
patients and these currently also include those undergoing
inguinal hernia repair. This is an area for further studies.
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