Page 19 - International guidelines for groin hernia management

Hernia

Introduction assess recurrence rates and chronic pain after a median
The Lichtenstein technique with the onlay placement of a follow-up of 7.6 years (n = 180, 81% follow-up rate). 161
155
flat mesh is the criterion standard in open IH repair. Recurrence rates for Lichtenstein and plug-and-patch were
Many alternatives to the original Lichtenstein technique 5.6 and 9.9%, respectively (p = 0.770). Moderate or sev-
have been described. The plug-and-patch (or mesh-plug) ere pain was reported in 5.6 and 5.5%, respectively
technique was the first, 156 followed by the Trabucco (p = 0.785). The second study—which also included
Ò
technique. 157 and the Prolene Hernia System (PHS). 158 recurrent hernias—evaluated patients by means of physical
In the Trabucco technique, a polypropylene plug is examination after a 6.5-year median follow-up and had
combined with a semi-rigid flat pre-shaped polypropylene similar findings (n = 528, 76% follow-up rate). 162 Recur-
mesh. Neither implant is fixed. The spermatic cord is rence rates for Lichtenstein and plug-and-patch were 8.1
placed subcutaneously. At the time of the first EHS and 7.8%, respectively (OR 0.92 n.s.) and chronic persis-
guidelines on the treatment of IH in adults, no long-term tent pain (VAS [ 3). More reoperations occurred in the
comparative follow-up data were available on any of these Lichtenstein group (OR 0.43, p = 0.016).
3 Ò
techniques, but this changed at the time of the update with Prolene Hernia System (PHS)
level 1 studies of the 2009 EHS guidelines. In addition, At the time of the EHS update, two meta-analyses of six
self-gripping meshes have been designed in an attempt to RCTs were published comparing PHS and Lichtenstein
reduce or abandon the need for traumatic mesh fixation in (follow-up ranging from 12 to 48 months). 159, 163 In
Lichtenstein repair and decrease the risk for acute and addition, one long-term follow-up study (5-year follow-up)
164
chronic pain. was available. No differences in recurrence or chronic

Evidence in literature pain were found. The data on operative times and periop-
Plug-and-patch erative complications were contradictory in the meta-
4
The recent 2014 EHS guidelines update, with level 1 analyses, although no differences were seen for postoper-
studies, included data on the comparison between plug- ative wound hematoma formation or infection in either.
and-patch versus Lichtenstein from two meta-analyses of A 2014 long-term outcome study (mean follow-up of
159, 160
seven RCTs. These showed shorter operative times 7.6 years) also include a PHS arm and these data are
for the plug-and-patch (by 5–10 min), but otherwise com- reported below, 161 confirming earlier results. The recur-
parable outcomes in the short- and long-term (follow-up rence rates for Lichtenstein and PHS were 5.6 and 3.3%,
ranging from 0.5 to 73 months). respectively (p = 0.770). The incidence of chronic pain
Long-term follow-up data from two of the RCTs were (moderate or severe) was 5.6 and 6.7%, respectively
published in 2014. The first study used a questionnaire to (p = 0.785).

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