Page 26 - International guidelines for groin hernia management

Hernia

difference in the recurrence rates between open and laparo- reoperation rates differ significantly between the two
endoscopic surgery. techniques (estimated OR 1.356 95% CI 0.960–1.913;
RCTs p = 0.084). TEP was found to have benefits on the post-
For comparison of the laparo-endoscopic (TEP, TAPP) with operative complications rate (estimated OR 2.152 95% CI
the open Lichtenstein technique for male primary unilateral 1.734–2.672; p \ 0.001), pain-at-rest rate (estimated OR
inguinal hernia many studies must be excluded. This is 1.231 95% CI 1.049–1.444; p = 0.011), and pain-on-ex-
because they included female patients, bilateral hernias and/ ertion rate (OR 1.420 95% CI 1.264–1.596; p \ 0.001).
or recurrent hernias or compared TEP and TAPP with other Guidelines
3
open procedures or used too small meshes or combined IH The 2009 EHS guidelines concluded, mainly on the basis
212, 213, 216, 225, 244
repair with laparoscopic cholecystectomy. of the 2005 meta-analysis, that endoscopic IH tech-
228, 246–277
In the comparison of 1237 laparo-endoscopic niques result in a lower incidence of wound infection,
(TEP, TAPP) operations with 1281 Lichtenstein operations hematoma formation and an earlier return-to-normal
from RCTs fulfilling the inclusion criteria, 211, 217, 278–288 no activities or work than the Lichtenstein technique. Laparo-
differences have been observed in the intraoperative or endoscopic IH techniques have a longer operative time and
postoperative complications following primary unilateral IH a higher incidence of seroma formation than the Lichten-
repair in males. Clear advantages have been observed for the stein technique. Endoscopic repair results in a lower inci-
laparo-endoscopic techniques in terms of early postoperative dence of chronic pain/numbness than the Lichtenstein
pain, analgesic consumption, and return to normal daily technique.
activities and to work. When the surgeon had sufficient The learning curve for performing a laparo-endoscopic
experience in the respective technique (i.e. after completing hernia repair, especially TEP, is longer than that for open
the learning curve), no significant difference was detected in Lichtenstein repair, and ranges between 50 and 100 pro-
the recurrence rate (TEP vs Lichtenstein with median follow- cedures, with the first 30–50 being most critical. 3
up of 5.1 years 2.4 vs 1.2%; p = 0.109 and TAPP vs From a hospital perspective, an open mesh procedure is
3
Lichtenstein with median follow-up of 52 months 1.3 vs the most cost-effective operation. In cost-utility analyses
1.2%; ns) 282, 288 between the laparo-endoscopic and Licht- including quality of life, endoscopic techniques may be
enstein techniques. Likewise, chronic pain occurred signif- preferable since they cause less numbness and chronic
icantly less often after laparo-endoscopic than after pain. 3
4
Lichtenstein operation (TEP vs Lichtenstein with follow-up In the 2014 EHS guidelines update, a new meta-anal-
of 5 years 9.4 vs 18.8% and TAPP versus Lichtenstein with ysis was included. It contained studies with a follow-up of
median follow-up of 52 months slight pain 14.8 vs 23.7%, more than 48 months (including two new RCTs on TEP vs
moderate pain 1.2 vs 5.3% and severe pain 0 vs Lichtenstein). There was a non-significant difference in
3.9%). 283, 284, 287 In the three RCTs. 280, 281, 285 with at least severe chronic pain (p = 0.12) and in recurrence when data
100 patients in each arm, the operative time for TEP was from one surgeon in the Eklund trial. 282 were excluded.
either similar to, or shorter than, the Lichtenstein operative This was because of unacceptable recurrence rates in the
time. The direct operative costs for laparo-endoscopic endoscopic group (32%) due to technical failure.
techniques are higher than for the Lichtenstein opera-
tion. 217, 278, 279, 284 However, that difference decreases when Discussion, consensus
all community costs are taken into account. 278, 284 When the surgeon has sufficient experience in the respec-
Large database studies tive techniques, laparo-endoscopic and Lichtenstein tech-
A 2015 analysis of the Herniamed Registry compared the niques have comparable operation times, perioperative
prospective data collected for males undergoing primary complication rates needing reoperation and recurrence
unilateral IH repair using either TEP or open Lichtenstein rates. Endoscopic techniques show advantages in terms of
289
repair. Inclusion criteria were: a minimum age of early and later postoperative pain and speed of recovery. In
16 years, male gender, primary unilateral IH, elective the EHS guidelines update, data were analyzed from
operation and availability of data on 1-year follow-up by a studies with a follow-up of more than 48 months. This
questionnaire of the general practitioner and patient. In analysis yielded a non-significant difference in severe
total, 17,388 patients were enrolled, 10,555 (60.7%) had a chronic pain and long-term recurrence. The direct opera-
Lichtenstein repair and 6833 (39.3%) a TEP repair. tive costs for laparo-endoscopic IH repair are higher, but
On multivariable analyses, surgical technique had no fall to levels comparable with the Lichtenstein repair when
significant effect on the recurrence rate (estimated OR considering quality-of-life aspects and total community
0.775 95% CI 0.549–1.093; p = 0.146) or on the chronic costs. Study quality heterogeneity—lack of clear pain
pain rate needing treatment (estimated OR 1.066 95% CI endpoints, definitions, quality of surgeon’s technique,
0.860–1.321; p = 0.560). Nor did the complication-related

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