Page 16 - International guidelines for groin hernia management

Hernia

Introduction discussion, the authors conclude that the review is flawed
The 2009 European Guidelines opined that the Shouldice by: the inclusion of low-quality RCTs, non-blinded out-
3
inguinal hernia repair was the best non-mesh technique. comes assessments, lack of external validity by patient
Since then, no studies have offered new evidence con- selection (only healthy patients were included), high lost-
cerning a comparison between non-mesh techniques. to-follow-up rates, no patient-oriented outcomes and the
Questions remain concerning the value of a non-mesh above-mentioned potential bias. Nevertheless, the large
technique in certain cases like indirect hernias (EHS L1 number of patients and consistent results do make the
and L2) in young male patients. There are questions con- results useable in clinical practice. The level of the review
cerning the results of Shouldice when performed in spe- with RCTs is downgraded to moderate. Since this sys-
cialist centers or by specialist hernia surgeons. There are no tematic review was done, no new RCT comparing Shoul-
RCTs performed in these centers. There are also regions dice with other non-mesh techniques has been
(low-resource countries in particular) where mesh is not published. 142 The level of recommendation is strong.
available and surgeons must use the best non-mesh tech- Other non-mesh techniques
nique. Also some patients refuse a mesh implant. Which A 2012 RCT, in which 208 patients were randomized,
non-mesh technique is best therefore remains an important described the Desarda technique compared with a Licht-
question. enstein technique. 144 Follow-up at 36 months found

Evidence in literature recurrence rates in each group of 1.9% and no significant
Systematic Review Cochrane 2012 differences in pain. As this is a new technique with some
A 2012 review covered all prior RCTs (until September non-randomized studies showing promising results, it is
2011) concerning results of the Shouldice technique versus worthy of mention in the guidelines. The level of the RCT
other open techniques (mesh and non-mesh). 142 Eight is moderate and no recommendations can be formulated.
RCTs with 2865 patients are contained, comparing mesh The Desarda technique needs further investigation.
versus non-mesh IH repair. Most of these trials had inad- Large database studies
equate randomization methods, did not mention dropouts The large databases from Denmark and Sweden indicate
and did not blind patients and surgeons to the technique results of non-mesh techniques, but cannot differentiate
used. Recurrence rate was a primary outcome in all and between different techniques so conclusions cannot be
pain could only be analyzed in three trials. Pain definitions made concerning the quality of the Shouldice technique. 145
and measurements were not standardized. Studies were In a 2004 questionnaire study, 11, 145, 146 using results from
heterogeneous, with concerns that techniques were not the Danish database, chronic pain was more common after
standardized. The results show that in Shouldice versus primary IH repair in young males, but there was no dif-
other non-mesh (8 studies) the recurrence rate was lower in ference in pain when comparing Lichtenstein with non-
Shouldice (OR 0.62, 95% 0.45–0.85 NNH 40). Six studies mesh Marcy and Shouldice repairs. The databases conclude
reported an OR in favor of the Shouldice technique. One less recurrences after mesh repair, but not at the cost of
included study reported the most data and its weight in the more chronic pain.
analysis was 59.56%. 143 The results reflect different Guidelines
degrees of surgeon’s familiarity with the techniques, The 2009 European Guidelines concluded that the Shoul-
making it impossible to eliminate the ‘‘handcraft’’ variable dice hernia repair technique is the best non-mesh repair
from surgical trials. Shouldice also results in less chronic method with a 1A level of evidence. 3
pain (OR 0.3; 95% CI 0.4–1.22) and lower rates of
hematoma formation (OR 0.84; 95% CI 0.63–1.13), but Discussion, consensus and clarification of grading
slightly higher infection rates (OR 1.34; 95% CI 0.7–2.54). When considering the results from the systematic review,
It is more time consuming and leads to a slightly increased large databases and guideline conclusions, we conclude
hospital stay (WMD 0.25; 95% CI 0.01–0.49). In their that Shouldice is superior to other non-mesh techniques

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