Page 118 - International guidelines for groin hernia management

Hernia

This question is not adequately answered by a randomized Groin hernia in women
controlled trial, since the potential number of factors, Inguinal hernia is less common in women, and subse-
environmental and patient-related, are multifactorial and quently little evidence supports one technique over another.
not well defined. Some of these questions might be Since there are so little women with an inguinal hernia, we
answered from a well-designed register, including risk suggest a large registry study with propensity score
factors of importance and having a high coverage. More matching comparing laparo-endoscopic versus open groin
important than making more studies on fine-tuning indi- hernia repair in women to answer this question: Which
cations for the use of antibiotic prophylaxis would be to technique is preferred in women?
implement the current guidelines on antibiotic prophylaxis
and register the outcomes. Complications, prevention and treatment
Adverse events after inguinal hernia repair include recur-
Anesthesia rence and chronic postoperative pain. Postoperative pain
Inguinal hernia repair can very well be performed under reduces quality of life significantly. With the use of dif-
local anesthesia. Still very few surgeons offer this tech- ferent definitions of chronic postoperative inguinal pain
nique as an option. Optimization of local anesthesia tech- (CPIP) it is hard to compare the outcomes of different
nique is still to be determined. Should local anesthesia be studies and extract the preferred treatment. Therefore,
achieved by a nerve block, local ‘‘en route’’ infiltration or a worldwide consensus should be reached on a clear defini-
combination of the two? And in which dilution? tion of CPIP and a uniform assessment of CPIP should be
formulated. Subsequently, the impact of CPIP on daily
Postoperative pain, prevention and management activities can be analyzed, which is unknown until now.
Postoperative pain is an adverse outcome of inguinal hernia The long-term outcomes of treatment of CPIP remain
repair. Even though the incidence is low, the impact on the unknown as well, and future registry analysis is recom-
patient’s quality of life can be significant. A transversus mended. Further on, a prediction model calculating the risk
abdominis plane (TAP) block placed by ultrasonography is of developing CPIP would be helpful to a hernia surgeon to
a promising technique in the management of postoperative identify patients with an increased risk and tailor treatment.
pain after inguinal hernia repair. Its value could be evalu- We recommend future researchers to develop such a model
ated in a randomized controlled trial comparing the use of based on existing literature regarding this subject.
TAP block pre-, per- and postoperatively to prevent and Severe complications after inguinal hernia surgery are
manage postoperative pain. rare. However, some hernia surgeons suggest that there
Another treatment option is laparoscopic extraperitoneal might be an increased severe complication rate after
neurectomy. Its value needs to be evaluated in both open laparo-endoscopic inguinal hernia, such as death. This
and laparoscopic repairs. We suggest a randomized con- severe complication rate might be underestimated due to
trolled trial comparing the effect of laparoscopic insufficient number of included patients in trials and the
extraperitoneal neurectomy versus open peripheral associated surgical expertise in trial participating surgical
neurectomy and total mesh removal for chronic pain after centers. We therefore recommend to initiate a large registry
both open and laparoscopic mesh repair. study in countries where registration is obligatory to
investigate the severe complication rate after laparoscopic
Convalescence inguinal hernia surgery.
Postoperative instructions on when to resume specific
activities vary largely depending on the preferences of the Emergency groin hernia treatment
surgeon, surgical technique and cultural environment. Medical evidence on treatment of acute groin hernias is
Stimulation of activities leads to earlier return to normal limited and of poor quality. Future research should focus
activities and improved quality of life, without an increase on identifying risk factors for developing incarceration and
in adverse events, such as recurrence or postoperative pain. strangulation, diagnostic modalities, optimal timing and
However, which physical activity can be regained at what surgical approach. Nevertheless, in some of these aspects
moment postoperatively after inguinal hernia repair (la- RCTs would be difficult, if not frankly impossible, to
paroscopic or open, mesh or non-mesh) remains unknown. perform. Large-scale epidemiological studies based on
And also, what is the socio-economic consequence of national or international registries might further improve
surgeons’ recommendation for postoperative physical surgical decision making on this crucial issue.
activity and sick leave duration?

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