Page 2 - International guidelines for groin hernia management

Hernia

or herniography may be needed. The EHS classification technique. General anesthesia is suggested over regional in
system is suggested to stratify IH patients for tailored patients aged 65 and older as it might be associated with
treatment, research and audit. Symptomatic groin hernias fewer complications like myocardial infarction, pneumonia
should be treated surgically. Asymptomatic or minimally and thromboembolism. Perioperative field blocks and/or
symptomatic male IH patients may be managed with subfascial/subcutaneous infiltrations are recommended in
‘‘watchful waiting’’ since their risk of hernia-related all cases of open repair. Patients are recommended to
emergencies is low. The majority of these individuals will resume normal activities without restrictions as soon as
eventually require surgery; therefore, surgical risks and the they feel comfortable. Provided expertise is available, it is
watchful waiting strategy should be discussed with suggested that women with groin hernias undergo laparo-
patients. Surgical treatment should be tailored to the sur- endoscopic repair in order to decrease the risk of chronic
geon’s expertise, patient- and hernia-related characteristics pain and avoid missing a femoral hernia. Watchful waiting
and local/national resources. Furthermore, patient health- is suggested in pregnant women as groin swelling most
related, life style and social factors should all influence the often consists of self-limited round ligament varicosities.
shared decision-making process leading up to hernia Timely mesh repair by a laparo-endoscopic approach is
management. Mesh repair is recommended as first choice, suggested for femoral hernias provided expertise is avail-
either by an open procedure or a laparo-endoscopic repair able. All complications of groin hernia management are
technique. One standard repair technique for all groin discussed in an extensive chapter on the topic. Overall, the
hernias does not exist. It is recommended that sur- incidence of clinically significant chronic pain is in the
geons/surgical services provide both anterior and posterior 10–12% range, decreasing over time. Debilitating chronic
approach options. Lichtenstein and laparo-endoscopic pain affecting normal daily activities or work ranges from
repair are best evaluated. Many other techniques need 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is
further evaluation. Provided that resources and expertise defined as bothersome moderate pain impacting daily
are available, laparo-endoscopic techniques have faster activities lasting at least 3 months postoperatively and
recovery times, lower chronic pain risk and are cost decreasing over time. CPIP risk factors include: young age,
effective. There is discussion concerning laparo-endo- female gender, high preoperative pain, early high postop-
scopic management of potential bilateral hernias (occult erative pain, recurrent hernia and open repair. For CPIP the
hernia issue). After patient consent, during TAPP, the focus should be on nerve recognition in open surgery and,
contra-lateral side should be inspected. This is not sug- in selected cases, prophylactic pragmatic nerve resection
gested during unilateral TEP repair. After appropriate (planned resection is not suggested). It is suggested that
discussions with patients concerning results tissue repair CPIP management be performed by multi-disciplinary
(first choice is the Shouldice technique) can be offered. teams. It is also suggested that CPIP be managed by a
Day surgery is recommended for the majority of groin combination of pharmacological and interventional mea-
hernia repair provided aftercare is organized. Surgeons sures and, if this is unsuccessful, followed by, in selected
should be aware of the intrinsic characteristics of the cases (triple) neurectomy and (in selected cases) mesh
meshes they use. Use of so-called low-weight mesh may removal. For recurrent hernia after anterior repair, posterior
have slight short-term benefits like reduced postoperative repair is recommended. If recurrence occurs after a pos-
pain and shorter convalescence, but are not associated with terior repair, an anterior repair is recommended. After a
better longer-term outcomes like recurrence and chronic failed anterior and posterior approach, management by a
pain. Mesh selection on weight alone is not recommended. specialist hernia surgeon is recommended. Risk factors for
The incidence of erosion seems higher with plug versus flat hernia incarceration/strangulation include: female gender,
mesh. It is suggested not to use plug repair techniques. The femoral hernia and a history of hospitalization related to
use of other implants to replace the standard flat mesh in groin hernia. It is suggested that treatment of emergencies
the Lichtenstein technique is currently not recommended. be tailored according to patient- and hernia-related factors,
In almost all cases, mesh fixation in TEP is unnecessary. In local expertise and resources. Learning curves vary
both TEP and TAPP it is recommended to fix mesh in M3 between different techniques. Probably about 100 super-
hernias (large medial) to reduce recurrence risk. Antibiotic vised laparo-endoscopic repairs are needed to achieve the
prophylaxis in average-risk patients in low-risk environ- same results as open mesh surgery like Lichtenstein. It is
ments is not recommended in open surgery. In laparo-en- suggested that case load per surgeon is more important than
doscopic repair it is never recommended. Local anesthesia center volume. It is recommended that minimum require-
in open repair has many advantages, and its use is rec- ments be developed to certify individuals as expert hernia
ommended provided the surgeon is experienced in this surgeon. The same is true for the designation ‘‘Hernia

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