Page 121 - International guidelines for groin hernia management

Hernia

70% of men with these hernias will require surgery within Women with groin hernias are advised to undergo
5 years. laparoscopic repair with preperitoneal mesh placement.
Based on current literature it is not possible to determine Again, groin hernia management will be based on sur-
if a watchful waiting management strategy is safe for geon’s expertise, patient- and hernia-related factors,
symptomatic men with IHs. The risk of an IH becoming available resources and logistics.
incarcerated is less than 3% per year. About 5% of men Complications
with groin hernias require emergent repair. In patients with Surgical treatment of an IH is successful in the majority of
symptomatic IHs surgical repair is recommended. cases. Complications of IH repair include: recurrences,
Femoral hernias carry a higher risk of incarceration and chronic postoperative pain, wound infections, urinary and
strangulation than IHs. Approximately 17% of women with sexual dysfunction, hematoma, seroma, visceral and vas-
groin hernias require emergent repair. Therefore, timely cular injury (uncommon), late postoperative complications
repair is recommended in women with groin hernias. In and mortality.
femoral hernia patients, even if symptoms are vague or Risk factors for recurrent IHs are: incorrect surgical
absent, timely surgery is recommended. technique, female gender, direct IHs, a sliding hernia,
At all times surgeons will tailor their treatment based on collagen metabolism disorders and obesity. Recurrence
their expertise, patient- and hernia-related characteristics, necessitates reoperation in 5–15% of cases.
local/national resources and logistics. Ten to twelve percent of IH repair patients experience at
Surgical treatment least a bothersome level of moderate pain that impacts
Worldwide, more than 20 million patients undergo groin daily activities. Risk factors for chronic postoperative
hernia repair yearly. A generally accepted technique, inguinal pain include: young age, female gender, high
suitable for all IHs, does not exist. There are many different preoperative pain and, early high postoperative pain. Long-
techniques in routine use with varying advantages and term disability due to chronic pain occurs in 10–12% of
disadvantages. Surgical repair of a groin hernia can be patients.
performed with or without mesh, using either an open The incidence of urinary retention following IH repair
approach or a laparo-endoscopic one. The surgeon will varies from less than 1 to 20%. The most common pre-
discuss the advantages and disadvantages of each tech- disposing factor is the use of general or regional anesthesia.
nique with the patient. This is dependent upon the sur- The incidence of sexual dysfunction causing symptoms of
geon’s expertise, local and regional resources and patient a moderate to severe degree is around 5–6%. Impairment
preferences. of testicular function and fertility occurs in less than 1%.
Eighty-five percent of all IH repairs are performed using Hematoma incidence is reduced after endoscopic IH
an open approach. In high-resource settings, 15–55% are repair compared with open repair. Most hematomas resolve
performed laparo-endoscopically. It is recommended that spontaneously over 2–4 weeks and can be managed
patients with symptomatic IHs be treated with a mesh- expectantly. Those with large, symptomatic or infected
based repair technique. The Lichtenstein technique with hematomas should be urgently referred back to their
the onlay placement of a flat mesh is the criterion standard surgeons.
in open hernia repair and most frequently used. Trans-ab- The reported incidence of seroma formation after IH
dominal preperitoneal (TAPP) and total extraperitoneal repair varies between 0.5 and 12%. Seroma formation risk
(TEP) are laparo-endoscopic techniques in which a mesh is factors are: coagulopathy, congestive liver diseases and
inserted in the preperitoneal plane. In TEP a totally cardiac insufficiency. There is no evidence that binders and
preperitoneal approach is used with or without the help of a other compression devices prevent hematoma and seroma
dissection balloon. In TAPP a laparoscopy is performed. formation. Most seroma resolve spontaneously over
TAPP and TEP have similar operative times, overall 6–8 weeks. Since infections following seroma aspiration
complication risks, postoperative acute and chronic pain are regularly described, only symptomatic seromas need to
incidence and recurrence rates. When a mesh is not be treated.
available, the Shouldice technique is the first choice in non- Serious complications, such as bowel, bladder and vas-
mesh IH repair. The Shouldice technique has lower cular injuries, rarely occur during hernia surgery. They are
recurrence rates that other suture repairs. more common (although still rare) during endoscopic
A simple IH operation can be performed on a day sur- versus open repair.
gery basis, unless the patient’s comorbidities require clin- Death in the 30 days following IH repair is very rare and
ical observation. Day surgery does require that adequate mainly associated with emergent repair or related to
aftercare is organized. Day surgery of patients with com- medical comorbidities.
plex IHs is suggested only in selected cases.

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