Page 27 - International guidelines for groin hernia management

Hernia

caseload per surgeon, and lack of hernia classification— patients. Additionally, logistical and financial constraints
make the evaluation of complication risks difficult. Fur- may limit the availability of quality laparo-endoscopic
thermore, there is a well-documented difference in learning repairs, especially in lower resource settings.
curve and initial costs favoring Lichtenstein.
Large RCTs with good external validity and large-scale
database studies are urgently needed to compare endo-

scopic with Lichtenstein operations for primary unilateral Evidence in literature
IHs in males. These studies must carefully select partici- The literature comparing laparo-endoscopic techniques
pating surgeons, to ensure that the learning curve has been with open pre-peritoneal mesh placement for primary
completed for the respective surgical technique. A major unilateral IHs is extremely limited and heterogeneous.
investment is needed worldwide to make the learning curve A 2002 meta-analysis compared laparo-endoscopic IH
for (laparo-endoscopic) hernia surgery as smooth as possible repair with open IH repair techniques. 290 However, the
by ensuring optimal training facilities and circumstances. early laparo-endoscopic trials control groups included in
HerniaSurge recommends a standardization of the this meta-analysis were poorly standardized; and often
laparo-endoscopic and Lichtenstein techniques, structured included only suture repairs such as the Bassini, McVay, or
training programs and continuous supervision of trainees Shouldice. In later studies, plug-and-patch repairs were the
and surgeons within the learning curve. main cohort in the groups that considered open pre-peri-
toneal mesh techniques.
KQ06.g In males with unilateral primary inguinal hernias Although the authors concluded that open pre-peritoneal
which is the preferred repair technique, laparo-endoscopic hernia repair provides equivalent outcomes at lower costs
(TEP/TAPP) or open pre-peritoneal? and has potentially less severe complications compared with
F. Berrevoet, M. Misra and D. Chen laparoscopic techniques, the included studies and available
literature do not address our key question adequately.
Introduction An RCT of 49 patients compared open pre-peritoneal
Evidence suggests that pre-peritoneal mesh placement is repair and TAPP. 291 This small study concluded that the
preferred over anterior mesh placement because of the open repairs were associated with fewer complications and
physiologic mesh location and placement of the mesh away recurrences and that laparoscopic TAPP was associated
from the groin nerves. There is clinical interest about with higher costs but no advantage in median time to
whether the various surgical approaches to achieve pre- return-to-work.
peritoneal mesh positioning leads to different patient out- The SCUR Hernia repair study, 292 which compared 613
comes. Laparo-endoscopic IH repair has been studied in patients randomized to three groups (open suture repair,
detail with good results, but has a rather long learning open pre-peritoneal repair with polypropylene mesh and
curve, potentially higher procedure costs and potential risks TAPP) demonstrated that although TAPP resulted in both
associated with general anesthesia in certain types of shorter time to full recovery and shorter time to return-to-

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