Page 32 - International guidelines for groin hernia management

Hernia

Evidence in literature underwent unilateral repair and contralateral exploration
and are therefore not representative of most hernia sur-
Evidence for the recommendations and statements in this geon’s practices. A second cohort study with 38-month
chapter is largely derived from retrospective case series median follow-up (range 10–82 months) reported a 1.1%
involving relatively small numbers of patients. Some RCTs incidence of contralateral overt hernia formation following
address certain aspects of the topics presented. unilateral TEP repair with contralateral exploration. 326
A number of studies have reported on the incidence of Thirty percent of the study population had already under-
occult contralateral hernias at the time of bilateral TEP gone bilateral repair.
exploration for a clinically diagnosed unilateral hernia. Two studies address the subject of contralateral (pre-
These studies report incidence rates ranging from 5 to peritoneal) exploration at the time of unilateral primary IH
58%. 323–331 In TAPP exploration, clinically occult con- TAPP repair. In one, the presence of a so-called incipient
tralateral hernias are observed in 13–22% of hernia was identified during TAPP contralateral explo-
325, 332, 333 332
patients. However, the laparoscopic parameters ration in 5% of patients. An incipient occult hernia was
for contralateral hernia presence or absence are not well defined as a looming or beginning hernia with a defect too
defined in these studies, so it is difficult to know how such small to allow protrusion. After a mean follow-up of
variation may account for the large variation in occult 112 months (range 16–218 months) 21% of patients (13
hernias reported. Additionally, the natural history of these patients) developed a symptomatic hernia. In the same
small incidentally discovered defects is poorly understood study, a true contralateral occult hernia had been identified
and the clinical relevance of repair is unknown. 323 and repaired in 8% of patients during their initial surgery.
In those with primary unilateral IHs, the lifetime risk of Another study reported that with a 12-month median fol-
developing a contralateral IH is not known exactly. One low-up, six of 21 patients (29%) with a contralateral ‘‘in-
study reported a 48% incidence of overt contralateral her- cidental hernia defect’’ seen on TAPP exploration
nia development following TEP repair at 13 years follow- developed an overt (i.e. symptomatic) IH. 338
up. 57 Others report the incidence of subsequent contralat- Routine contralateral exploration or ‘‘preventive’’ mesh
eral hernia repair after primary unilateral TEP repair as: placement in a normal groin is controversial. Visualization
3.2% at 3 years, 3.5% at 5 years, and 3.8% at of the contralateral side in TAPP repair for an overt uni-
10 years. 334–336 lateral hernia is easily done without additional dissection of
Several RCTs involving patients who have undergone the contralateral side. However, without dissection of the
repair of unilateral primary IHs have reported on con- contralateral side, some cases of lipoma of the cord will be
tralateral hernia formation during various follow-up peri- missed. Unlike the TAPP approach, the TEP repair requires
ods. One study reported a 5-year 10% contralateral hernia additional dissection to diagnose a contralateral hernia.
incidence. 138 An RCT with a nearly 11-year follow-up Bilateral repair proponents cite a number of advantages to
compared open-suture to open-mesh repair of unilateral their approach including: poor clinical accuracy in hernia
primary IHs and found contralateral hernia formation in diagnosis especially in obese patients, the benefits to the
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21% of non-mesh patients and 25% of mesh patients. patient and the healthcare system of one operation, and
Another RCT of TEP vs open-mesh repair, reported that possible prevention of a hernia-related complications dur-
10.7% of the TEP repair group and 7.3% of the open-repair ing future contralateral side surgery. Opponents focus on
group developed contralateral hernias at 5 years. 337 the potential to do harm to a normal or near-normal groin
Some surgeons perform contralateral exploration at the and the associated risk of chronic pain following surgery
time of unilateral primary IH TEP repair. Two retrospec- on a normal groin. There is a lack of evidence to allow
tive cohort studies address this subject. Notably, the good decision-making on this issue. The decision to pro-
laparoscopic features of a normal groin versus an occult ceed with routine bilateral repair mandates appropriate
hernia are not defined nor are the nature and completeness informed consent and a high level of surgical skill.
of follow-up. One study, with a 5.9-year median follow-up, A number of surgeons now perform ‘‘preventive’’
reported that 8.1% of patients developed a contralateral IH bilateral laparoscopic hernia repair in the majority of
after unilateral TEP repair with negative contralateral patients with symptomatic unilateral hernias. 327, 339 Others
exploration. 328 The annual calculated risk was 1.2% for advocate routine contralateral exploration with mesh repair
contralateral hernia formation after a previously negative in those in whom a ‘‘hernia defect’’ is found. 325, 332, 333 The
TEP exploration (1.6% at 1 year, 5.9% at 5 years and decision to explore a potentially normal groin may be
11.8% at 10 years). The median time to contralateral hernia influenced by the surgeon’s mind-set, his operative exper-
development was 3.7 years (range 0–12 years). However, tise and his complication rate. However, the medical evi-
almost 60% of the study population had already undergone dence to support this decision is either lacking or weak at
bilateral repair. The remaining 40% (409 patients) present.

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