Page 15 - International guidelines for groin hernia management

Hernia

General introduction In the 2009 European Guidelines, raw data were used to
Choosing the best or most suitable groin hernia repair conclude that laparo-endoscopic and open repair were
technique is a true challenge. The best operative technique comparable in long-term follow-up of a minimum of
should have the following attributes: low risk of compli- 48 months. 3, 142
cations (pain and recurrence), (relatively) easy to learn, fast When reading this chapter, we should realize that
recovery, reproducible results and cost effectiveness. The potential biases exist and these are caused by: lack of a
decision is also dependent upon many factors like: hernia clear chronic pain definition, variations in duration of
characteristics, anesthesia type, the surgeon’s preference, chronic pain, age differences for the risk of chronic pain,
training, capabilities and logistics. The patient’s wishes lack of a generally agreed-upon classification system
must be considered. There are cultural differences between describing the type of hernias, differences in level of sur-
surgeons, countries and regions. Emotions may play a role gical expertise, differences in case load needed to maintain
as well. a certain technique, safety issues regarding training of the
Accordingly, the HerniaSurge Group had some pas- surgeons/residents in the world in difficult techniques like
sionate discussions when developing this chapter. One the TEP and TAPP, and costs of procedures, amongst
single standard technique for all hernias does not exist (see others. In fact, all these factors must be considered when
also Chapter 7 on individualization). studying the evidence presented in the different chapters.
In most situations a mesh repair is preferred. However, a The chapters were researched and written by different
minority of surgeons hold the opinion that mesh use should teams, but the statements and recommendations were
be avoided as much as possible. There is an ongoing dis- agreed upon by the whole HerniaSurge Group. Many lively
cussion concerning the results of specialist centers like The discussions during the meetings and via email led to an
Lichtenstein Hernia Clinic and The Shouldice Hospital. internet consensus vote. There are recommendations that
There are low-resource settings where mesh cannot be have been upgraded. The support for these decisions is at
afforded. There are high-volume laparo-endoscopic sur- the end of each chapter.
geons who passionately advocate a TEP or TAPP in almost
all cases. There are special mesh implants (often expen- Key questions
sive) used by surgeons who have been successful with them KQ06.a Which non-mesh technique is the preferred repair
for many years. How then can one reconcile these opinions method for inguinal hernias?
and conflicts? KQ06.b Which is the preferred repair method for inguinal
Although accurate and recent facts are not available, in hernias: mesh or non-mesh?
most countries the Lichtenstein repair is probably the first KQ06.c Which is the preferred open mesh technique for
choice in a majority of cases. It is a very good technique, inguinal hernias: Lichtenstein or other open flat mesh and
but its outcomes may be bettered by a more difficult implants via an anterior approach?
technique like the TEP when early postoperative recovery KQ06.d Which is preferred open mesh technique: Licht-
and the occurrence of chronic pain are considered. It is enstein versus open pre-peritoneal?
self-evident that a surgeon performing a technique and KQ06.e Is TEP or TAPP the preferred laparo-endoscopic
striving for optimal results should know the technique very technique for inguinal hernias?
well. Excellent training and a high caseload are the foun- KQ06.f When considering recurrence, pain, learning
dations of good surgery. curve, postoperative recovery and costs which is preferred
When comparing the best Lichtenstein outcomes with technique for inguinal hernias: best open mesh (Lichten-
the best TEP/TAPP, it is noted that the differences are very stein) or a laparo-endoscopic (TEP and TAPP) technique?
small. It is challenging though when examining results KQ06.g In males with unilateral primary inguinal hernias
reported in the literature because often the techniques being which is the preferred repair technique, laparo-endoscopic
compared are not performed in a standardized manner by (TEP/TAPP) or open pre-peritoneal?
equally skilled and experienced surgeons. Therefore, this KQ06.h Which is the preferred technique in bilateral
might not be true when comparing an average Lichtenstein inguinal hernias? Open mesh or laparo-endoscopic
to an average TEP/TAPP or Shouldice because of the approach?
former’s lower complexity. Furthermore, applying research
results to the approach for an individual patient is prob- Key question
lematic as well. It is often far from clear whether the results KQ06.a Which non-mesh technique is the preferred repair
of an RCT can be generalized to one’s practice setting or method for inguinal hernias?
patients within that setting.

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