Page 18 - International guidelines for groin hernia management

Hernia

each group was 1.9% and no significant differences in pain young male patients with lateral (L1) inguinal hernia. One
were found. The Desarda technique is new and the subject important study with long-term follow-up after Shouldice
of some non-randomized studies showing promising indicated that hernia type (indirect versus direct) was not
results, but the technique needs further investigation. The an independent risk factor. 154 Recurrence after Shouldice
2012 RCT is graded as moderate. No recommendations after 2 and 5 years was, respectively, 4.3 and 6.7%. Out of
about its use can be made at this point. 21 recurrences 20 were direct. Out of 20 recurrences 7 were
Large database studies after an indirect hernia with an enlarged internal ring, 6
Two publications from the Danish Hernia Database after indirect with a weakened posterior wall and 7 after a
describe recurrence after 96 months following open non- direct hernia (n.s.). There are cohort studies concerning
mesh versus Lichtenstein. The recurrence rate after open Shouldice that indicate that classification matters and the
non-mesh repair was 8 versus 3% for Lichten- risk of recurrence is higher after a direct non-mesh repair. 80
stein. 11, 151, 152 These studies are flawed because the An analysis of the location of the hernial gap revealed 83
Shouldice group consisted of only 13% of all suture repairs lateral hernias (48.5%) and 88 medial hernias (medial or
and that reoperation rather than recurrence rates were used. combined, 51.5%). The recurrence rate was 13.6% for
However, they do offer insights though about outcomes in medial or combined hernias and 8.4% for pure lateral
a general population being treated by general surgeons (see hernias. This was not significant. Furthermore, it is
Chapter 25 concerning the value of database studies). A unknown whether a high ligation and sac resection (her-
2004 questionnaire study of the Danish database found that niotomy) has comparable results to Shouldice in these
chronic pain occurred more commonly after primary IH patient groups.
repair in young males. But, no differences in pain occurred
when comparing Lichtenstein with Marcy and Shouldice Discussion, consensus and grading clarification
non-mesh repair techniques. The database studies also Compared to non-mesh techniques mesh-based techniques
found fewer recurrences after mesh repair. have a lower recurrence rate and an equal risk of postop-
Guidelines erative pain. Despite the mentioned limitations of the 2012
The European Guidelines concluded that all male adults review, the large number of patients and consistent results
over the age of 30 years with a symptomatic IH should be make available evidence reliable and useable in practice.
3
operated on using a mesh technique (grade A). They also There is no conclusive evidence that mesh causes more
recommend that a mesh technique be used for inguinal chronic pain. It remains to be seen whether a mesh-based
hernia correction in young men (18–30 years of age and technique is indicated in all cases such as small lateral
irrespective of the type of inguinal hernia). The conclusion hernias (EHS L1 and L2) (see Chapter 7 on
was based on a lack of evidence that the recurrence risk individualization).
after L1–2 IH in younger men is acceptably lower than in It is unclear whether it is appropriate to compare the
men above 30. This question is not being researched results of the Shouldice technique, usually performed by
probably due to the fact that almost all male patients are highly trained surgeons and/or in specialized centers, to the
now treated with mesh techniques. open mesh repair techniques which tend to be performed
Cohort studies by generalists. Specialized centers have not published their
There is lower level evidence that the Shouldice technique results in a reliable manner. Many cohort studies contain
has a recurrence rate of less than 2% especially when bias and thus lack external validity. It is necessary to
performed in high-volume expert settings like the Shoul- improve knowledge concerning this question concerning
dice Hospital. 153 These data come primarily from expert the value of non-mesh techniques especially for long-term
centers. Often the studies suffer from inadequate follow-up recurrence rate and chronic pain. Although the level of
and there is patient selection bias in some. This gives rise evidence seems only moderate, by consensus in Her-
to a dispute between open non-mesh surgeons and surgeons niaSurge the recommendation to use a mesh-based tech-
advocating mesh repair on the true value of the Shouldice nique in inguinal hernia repair is upgraded to ‘‘strong’’.
repair. Resolution is unlikely unless an RCT is performed
KQ06.c Which is the preferred mesh for open inguinal
with adequate methods truly comparing techniques by
hernia repair: anterior flat mesh, self-gripping mesh or
surgeons qualified and experienced in both approaches.
three-dimensional implants (plug-and-patch and bilayer)
This might be possible using large databases provided
via an anterior approach?
identification of Shouldice technique is done. It is clear
M. Miserez, J. Conze and M. Simons
from all high-level studies though that in general practice,
mesh is superior to non-mesh especially when measuring
recurrence rate. It is absolutely recommended that studies
be performed into the value of Shouldice versus mesh in

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