Page 28 - International guidelines for groin hernia management

Hernia

work, it was more expensive and had a higher complication There has been little new evidence on the preferred
rate. There was no significant difference regarding recur- surgical approach for primary unilateral inguinal hernia.
rences at 1 year in the three groups (3% overall). Another The outcomes for TEP and TAPP, when comparing uni-
small four-arm randomized trial of 100 patients studied lateral versus bilateral, are similar, especially when taking
laparoscopic TAPP and TEP as well as open pre-peritoneal into account the number of hernias repaired. 297–299 One
repair and Lichtenstein repair. 211 The laparoscopic repair prospective non-randomized clinical study compared 53
groups showed less postoperative pain and achieved sig- patients undergoing bilateral Lichtenstein with 75 patients
nificantly faster return-to-normal domestic activities and undergoing bilateral TEP repair. The authors reported that
to-work compared to Lichtenstein repair patients. How- the TEP group had a shorter operation time, lower post-
300
ever, this study is of low methodological value according operative complication rate and shorter hospital stay.
to SIGN criteria. The 2009 EHS guidelines concluded with only moderate
The currently available literature does not allow us to evidence that bilateral hernia is preferably treated by a
provide any recommendation about whether laparoscopic laparo-endoscopic method provided expertise is available. 3
mesh placement in the pre-peritoneal plane is superior to This seems self-evident as the advantages of laparo-endo-
open pre-peritoneal techniques. Further research is neces- scopic repair (faster recovery, lower risk of chronic pain
sary. The learning curve of pre-peritoneal techniques needs and cost effectiveness) are increased when performing two
to be evaluated and the theoretical advantage of a better hernia repairs via the same three key hole incisions. No
visualization in laparo-endoscopic repair techniques new high-level research was found, so the recommendation
(against potential higher cost and complications) must be of the EHS guidelines have been used in the HerniaSurge
researched. guidelines. The EAES guidelines concluded that, espe-
cially in bilateral groin hernia, an endoscopic approach is
6
KQ06.h What is the preferred technique in bilateral an excellent choice (level 1B consensus 96%). (see also
hernia? Chapter 7 individualization). HerniaSurge by consensus
A. C. de Beaux, M. P. Simons decided to upgrade the level of recommendation.

Evidence in literature
The 2009 EHS guidelines, recommended for bilateral pri-
mary inguinal hernia repair, either a bilateral Lichtenstein
3
or endoscopic approach. The socio-economic benefits of Chapter 7
the endoscopic approach over the Lichtenstein approach
led to a suggestion, that the endoscopic repair was pre-
ferred, especially in younger patients. As for a primary Individualization of treatment options
unilateral hernia, the local/national hernia expertise in open
versus endoscopic techniques will have a big influence in B. van den Heuvel, M. P. Simons and U. Klinge
293–296
surgical approach chosen. In addition, the relative
contra-indications to an endoscopic approach, such as fit- Introduction
ness for general anesthesia, previous lower abdominal Inguinal hernia treatment has changed markedly over the
surgery and size of each hernia will influence individual past seven decades. Prior to the 1950s, hernia surgery
surgeon choice of surgical approach (see Chapter 7). involved an anatomical reconstruction of the inguinal canal
Another question in helping to decide the surgical approach with sutures. 3, 5, 200, 211, 226, 256, 258, 282, 283, 288, 301–322
is whether both hernias need to be repaired at the same When the tension-free mesh repair was introduced it
time? A large symptomatic hernia on one side, and a small resulted in a hernia repair revolution. Many new mesh
asymptomatic hernia on the other in an elderly man may applications and variations were developed including open,
only justify a unilateral repair under local anesthetic on the anterior and posterior approaches, and endoscopic tech-
symptomatic side. niques (Fig. 2). 3, 5, 200, 211, 226, 256, 258, 282, 283, 288, 301–322

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