Page 12 - International guidelines for groin hernia management

Hernia

appears that no one classification system can satisfy all for any IH, including asymptomatic IHs because it was
presently. However, an expert panel analyzed the known considered safe, effective, and associated with low mor-
systems to date (Nyhus, Gilbert, Rutkow, Schumpelick, bidity. However, the natural history of untreated IHs—
Harkins, Casten Halverson, McVay, Lichtenstein, Ben- especially the incidence of complications—was unknown.
david, Stoppa, Alexandre and Zollinger) and developed the Current literature suggests the possibility of surgical
EHS system by consensus. 125–132 HerniaSurge suggests overtreatment of men with asymptomatic IHs. Also, the
this system be used since it fulfills most requirements and morbidity of inguinal herniorrhaphy has been re-evaluated
is relatively simple to use. over the last two decades and current evidence suggests
The EHS system was not developed to classify hernia that the incidence of chronic post-herniorrhaphy pain is
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types preoperatively. This is a disadvantage. It is suggested much higher than previously realized.
that complex cases be managed by hernia specialists. A Inguinal herniorrhaphy is one of the most common
classification to inform decision-making about these com- operations performed by general surgeons. Therefore,
plex cases would be helpful. However, many complex considering the number of IH repairs performed worldwide
cases are easy to describe and do not require further clas- annually, the consequences of overtreatment are signifi-
sification (e.g. multiple recurrences and chronic pain). cant. This has spurred recent studies to evaluate a watchful

125 135, 136
For a detailed explanation please see the publication. waiting strategy in men with asymptomatic IHs. A
For now, the classification system for groin hernias is critical appraisal of these studies and previous assumptions
mired in some controversy and disagreement. However, the is presented.
best available evidence and expert opinion supports the Based on the current literature, it is not possible to
adoption of the EHS system as classification system determine if a watchful waiting management strategy is
refinements evolve. safe for symptomatic men with IHs. Similarly, it is
impossible to determine the hernia complication rate
(strangulation or bowel obstruction) in symptomatic
patients. Additionally, watchful waiting raises ethical
Chapter 5 issues about observing symptomatic patients.

Key questions
Indications: treatment options for symptomatic KQ05.a Is a management strategy of watchful waiting safe
and asymptomatic patients for men with symptomatic inguinal hernias?
KQ05.b What is the risk of a hernia complication (stran-
B. van den Heuvel, A. R. Wijsmuller and R. J. Fitzgibbons gulation or bowel obstruction) in this population?
KQ05.c Is a management strategy of watchful waiting safe
Introduction for men with asymptomatic inguinal hernias?
Approximately one-third of inguinal hernia (IH) patients KQ05.d What is the risk of a hernia complication (stran-
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are asymptomatic. Until recently, IH management gulation or bowel obstruction) in this population?
involved surgical repair regardless of the presence of KQ05.e Are emergent inguinal herniorrhaphies associated
symptoms, the rationale being that surgery for asymp- with higher morbidity and mortality?
tomatic IHs prevents hernia complications (incarceration or KQ05.f What is the crossover rate from watchful waiting
strangulation). Surgical management was recommended to surgery?

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