Page 33 - International guidelines for groin hernia management

Hernia

Most studies comparing the outcomes of unilateral sided symptomatic IH, perhaps identifying high-risk
versus bilateral TAPP repair, report a longer operation time groups of early contralateral hernia development. Until
(in the region of 25 min), but no differences in morbidity, evidence is available to further inform this dilemma, it is
time to recovery, reoperation and recurrence rate. 333, 340 recommended to discuss the possible surgical options with
One national cohort study reported a significant difference patients before surgery as part of individualized treatment.
in the rate of postoperative surgical complications occur-
ring within 30 days (such as hematoma, seroma and wound
infection) between unilateral and bilateral IH repair by Chapter 9
TAPP. The postoperative complications necessitated
reoperation in 0.9% of patients after unilateral, and in 1.9%
of patients after bilateral, IH repair. However, this study Day surgery
reported that these differences in intraoperative and post-
operative complications between unilateral and bilateral W.M.J. Reinpold, H. Niebuhr and D. Lomanto
repair decreased in experienced high-volume hernia cen-
ters. 297 Furthermore, there is no evidence that exploration Introduction
of a contralateral groin and mesh placement at TAPP when
no hernia is present has the same risk as that of a true Day surgery for IH repair has become increasingly com-
hernia repair. mon over the past several decades. Synonyms for ‘‘day
In TEP repair, operation time is reported to be 7–10 min surgery’’ include: outpatient surgery, ambulatory surgery,
longer for a bilateral, compared to a unilateral, repair. No same-day surgery, day case, and short-stay surgery and
difference in recurrence rate, postoperative complications, indicate that patient discharge occurs the day of operation.
conversion rate and time to recovery were reported by It is commonly known that day surgery is safe and feasible
3
several studies. 324, 327, 328, 330, 341–343 One study did report for many IH repairs. Several studies prove that day sur-
a slightly increased risk of intra-abdominal complications gery is cost effective when compared with inpatient treat-
(specific complications were not described) and surgical ment. However, it is unclear which complex IHs should not
postoperative complications (hematoma and wound infec- be repaired as day cases. In these Guidelines, ‘‘complex
tion) in the bilateral TEP group compared to the unilateral cases’’ include:
TEP group. 299 Again, it is unknown if exploration of a
1. Groin hernias with signs of incarceration, strangula-
normal groin carries the same risk as exploration of a groin
tion, infection, relevant preoperative chronic pain,
with a hernia, although two studies have reported no sig-
nificant morbidity from such a practice. 326, 328 difficult local findings in the groin such as large
(irreducible) scrotal hernias, (multiple) recurrence(s), a
Discussion
relevant history of lower abdominal surgery, radiation,
Almost all the studies cited in this chapter suffer from data
and comparable problems;
heterogeneity and lack of a uniform definition of an ‘‘occult
2. Groin hernias in patients with relevant comorbidities:
hernia’’. Therefore, the category ‘‘occult hernia’’ might
cardiovascular, respiratory, endocrine, hepatic, renal
include those with: actual protrusion of normally intra-
and gastrointestinal pathologies, mental disorders,
abdominal contents, a ‘‘beginning’’ hernia, or even just a
anxiety, immune deficiencies, post-transplantation sta-
patent processus vaginalis without herniation. A patent
tus, coagulopathies and anti-thrombotic medications;
processus vaginalis is observed in 12% of patients, but
3. Difficult intraoperative findings (severe adhesions,
only 12% of these develop an indirect hernia within
abnormal anatomy, excessive bleeding) and intraoper-
5 years. This compares with 3% of patients with an oblit- ative complications such as damage to viscera, blood
erated processus vaginalis. 20, 344
vessels, nerves and genitals;
Many of the important clinical questions on the subject
4. Symptoms and signs of postoperative local complica-
of a proper approach to occult hernias cannot be defini-
tions: bleeding, hematoma, thromboembolism, urinary
tively answered by the currently available evidence.
retention, bowel obstruction, peritonitis, sepsis, infec-
However, it is likely that up to 50% of patients who
tion, orchitis and/or general complications (cardiovas-
develop an IH, will either present with clinically evident
cular, respiratory, renal, hepatic, gastrointestinal,
bilateral IHs, or develop a contralateral IH in their lifetime.
cerebral organ failure, anxiety, psychic and mental
Risk factors to identify this group of patients and to inform
distress).
the decision on bilateral repair should be areas of future
research. HerniaSurge recommends a trial with long-term The current evidence on ambulatory surgery for IH
follow-up specifically addressing the question whether repair is presented.
there is a need for bilateral repair in patients with a one-
123