Page 17 - International guidelines for groin hernia management

Hernia

especially when considering recurrence rates. In the sys- Evidence in literature
tematic review the level of evidence was downgraded to Systematic Review Cochrane 2012
moderate. But combining all the evidence, and after con- A 2012 systematic review covered all prior RCTs (until
sensus by HerniaSurge, we concluded that a recommen- September 2011) concerning results of Shouldice versus
dation, upgraded to ‘‘strong’’ was supportable. In other other open techniques. 142 The review contains 6 RCTs
words, in non-mesh repair, perform a Shouldice. including 1565 patients and compared Shouldice versus
Although no studies exist on a comparison of the open mesh (Lichtenstein in all studies except one with plug
learning curves of the different non-mesh techniques, the and patch) for IH repair. The overall RCT quality is low.
HerniaSurge group agrees that the Shouldice technique is Recurrence rates were the primary outcome. Pain defini-
not easy to learn. In The Shouldice Hospital, surgeons are tions and measurements were not standardized. Studies
only considered qualified after 300 cases! It is well known were heterogeneous. There are concerns that techniques
that in many (mainly low resource) countries a (modified) were not standardized and no classification was applied.
Bassini is still performed. The results show, that in Shouldice versus mesh Licht-
Another matter is a discussion concerning the results of enstein, recurrence rate were higher in Shouldice (5 stud-
only high ligation and sac resection versus Shouldice in ies) (OR 3.65, 95% 1.79–7.47, NNH 36). Although not the
young adults with L1 and L2 IH. HerniaSurge is of the primary endpoint in most trials, there were no significant
opinion that this issue needs further research. We are differences between Shouldice and Lichtenstein for post-
unable to formulate a statement on it at this time. operative stay, chronic pain, seroma/hematoma and wound
infection, but operative time was shorter for mesh repair
KQ06.b Which is the preferred repair method for inguinal
(WMD 9.64 min; 95% CI 6.96–12.32).
hernias: mesh or non-mesh?
The authors concluded that the review is flawed by low-
M. P. Simons, J. Conze and M. Miserez
quality RCTs, non-blinded outcomes assessment, external
validity concerns due to patient selection (generally healthy
Introduction
patients were studied), high lost-to-follow-up rates, lack of
The 2009 European Guidelines concluded that all male
patient-oriented outcomes and the above-mentioned
adults over the age of 30 with a symptomatic IH should be
3
operated on using a mesh-based technique (grade A). In potential bias concerning surgical technique. Nevertheless,
the large number of patients and consistent results do make
most countries, the use of mesh has been accepted by the
the results useful.
majority of surgeons as the best approach to decrease risk
Other RCTs since the systematic review
of recurrence. There are concerns about mesh causing more
Since September 2011, three RCTs have been published
chronic pain. Other reasons not to use mesh include: higher
describing a non-mesh versus mesh repair but they were
cost or non-availability of meshes in low-resource settings,
excluded because they either did not include Shouldice
lack of surgical expertise with mesh, and patient refusal of 147–149 147, 150
repairs, Lichtenstein repairs, or had a very
a mesh repair. It remains to be seen whether a mesh-based 148–150
short follow-up.
technique is indicated in all cases (see also Chapter 7 on
One 2012 RCT, in which 208 patients were randomized,
individualization).
compared the Desarda technique with a Lichtenstein
technique. At 36-month follow-up, the recurrence rate in

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